**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 04/18/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to protect residents with exit seeking behaviors. Resident #1 wandered and had exit seeking behaviors, got out of the facility on 02/16/25 and again on 04/09/25. On 04/09/25 Resident #1 eloped and was located a half mile away from the facility on a four-lane busy road. Resident #1's care plan did not address interventions of exit seeking behaviors on 02/16/25 and was not updated until 04/09/25 with interventions. Based on observation, record review, and interview, the facility failed to provide supervision and interventions to prevent elopement for 1 (#1) of 3 sampled residents reviewed for wandering and elopement. The DON identified two residents with a high risk for wandering and elopement. Findings: Upon entrance to the facility on [DATE] at 8:50 a.m., the front main doors were locked and signs were placed on the door informing anyone leaving to check with the nurse before letting anyone out of the facility. An elopement book was observed at the nurse's station with two residents identified as at risk of elopement. On 04/18/25 at 9:15 a.m. through 10:15 a.m., all exit doors were observed to be secured with a 15 second egress release and a secondary alarm. Staff demonstrated opening the exit doors and the primary alarm and a secondary alarm sounded. The sound was loud enough to be heard at the nurse's station. On 04/18/25 at 9:20 a.m., 9:37 a.m., 11:25 a.m., and 2:30 p.m., Resident #1 was observed ambulating through the facility with staff providing one-on-one supervision. A policy titled Safety and Supervision of Residents, revised July 2023, read in part, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities.Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. An undated admission summary for Resident #1 showed they were admitted to the facility on [DATE] and had diagnoses which included dementia, impulse disorder, schizophrenia, and abnormalities of gait and mobility. Resident #1's wandering risk scale, dated 10/21/24, showed they were at high risk for wandering with a score of 14. A score of 11 and above showed a high risk for wandering. Resident #1's care plan, created on 10/23/24, did not address the high risk for wandering and elopement. Resident #1's admission Minimum Data Set assessment, with an assessment reference date of 10/25/24, showed they had long term and short-term memory problems. The assessment showed Resident #1 wandered and the resident's wandering placed them at risk for getting into potentially dangerous places. The assessment showed Resident #1 had no limitation on their range of motion. Resident #1's care plan was not updated to address their wandering that placed them at risk for danger. An incident progress note, dated 10/31/24 at 9:31 p.m., showed Resident #1 was ambulating up and down the halls attempting to exit seek. Resident #1's wandering risk scale, dated 11/23/24 and 12/12/24, showed they were at a high risk for wandering with a score of 16. A score of 11 and above showed a high risk for wandering. Resident #1's care plan was not updated to address the known exit seeking and high risk for wandering and elopement. Resident #1's care plan, updated 01/10/25, showed they had interventions in place of providing diversionary activities for wandering and elopement. Resident #1's wandering risk scale, dated 01/14/25, showed they were at high risk for wandering with a score of 12. A score of 11 and above showed a high risk for wandering. Resident #1's incident progress note, dated 02/16/25 at 5:45 p.m., read in part, Dietary staff reported to this nurse that resident was seen going outside through front door. This nurse and CNA immediately headed outside. Resident noted walking in facility parking lot. Resident #1's wandering risk scale, dated 02/16/25, showed they were at high risk for wandering with a score of 16. A score of 11 and above showed a high risk for wandering. Resident #1's care plan was not updated after they were found outside by the dietary staff on 02/16/25 and to address the high risk for wandering. Resident #1's quarterly minimum data set, with an assessment reference date of 03/14/25, showed they had no behaviors of wandering, was severely impaired in cognitive skills for daily decision making with a brief interview for mental status score of 00, and ambulated without any assistive devices. Resident #1's incident progress note, dated 04/09/25 at 11:13 a.m., read in part, Resident was found outside in front of the museum in [name withheld] by a staff member. Resident was returned to building without any issue. Resident #1's wandering risk scale, dated 04/09/25, showed they were a high risk for wandering with a score of 20. A score of 11 and above showed a high risk for wandering. A care plan revision, dated 04/09/25, read in part, 4/9 wander risk is a 20.Goal Resident eloped 4/9/2025. Interventions have been actively trying to get resident into a locked unit for [name withheld] safety. Identify pattern of wandering is aimless. Intervene as appropriate. May need to redirect resident as needed.Most recent wander score 20 on 4/9/2025. Resident placed one-on-one d/t elopement. A signed statement from the maintenance director, dated 04/09/25, read in part, After the incident had occurred, I checked that all the doors were in proper working condition and checked the batteries on all door alarms that we not connected to the system. All systems were secured and working properly. A review of Resident #1's one-on-one documentation sheets, dated 04/09/25 through 04/18/25, showed they were one-on-one continuously since the elopement on 04/09/25. A review of the in-service documentation showed the facility started in-services related to elopement and securing exit door on 04/09/25 with the last in-service being provided on 04/16/25. A review of the wandering and elopement assessments for all residents showed the facility completed all assessments on 04/09/25. A review of the quality assurance notes showed the facility addressed elopement and exit doors on 04/09/25 and 04/16/25. On 04/18/25 at 9:49 a.m., LPN #1 stated Resident #1 left the facility a week ago. LPN #1 stated prior to that they did not know Resident #1 was at risk for wandering and elopement. LPN #1 stated this was the only time Resident #1 attempted to get out and left the building. LPN #1 stated they had an in-service on elopement, the elopement book, and to make sure all doors were secured, and alarms working. LPN #1 stated Resident #1 was placed with one-on-one supervision since they got out. On 04/18/25 at 9:55 a.m., dietary aide #1 stated they were not aware of any resident leaving the facility without staff knowing. Dietary Aide #1 stated Resident #1 was observed leaving out the front door a few months ago and the nursing staff was alerted. They stated they were not sure where Resident #1 was located when nursing staff went to get them. Dietary Aide #1 stated they had an in-service about a week ago on elopement and to make sure doors were secured, and Resident #1 was placed with staff supervision all the time. On 04/18/25 at 10:00 a.m., housekeeper #1 stated on 04/10/25 they received training on listening for door alarms and observing residents attempting to leave. Housekeeper #1 stated staff were not allowed to let any residents out. On 04/18/25 at 10:05 a.m., CNA #1 stated Resident #1 had been one-on-one for a week and they were provided an in-service on 04/10/25 to make sure all doors were secured. They stated they documented on the form, 1:1 Monitoring for Resident Safety, the whole time they were directly working one-on-one every 15 minutes. CNA #1 stated they were not aware Resident #1 was an elopement risk until they left and was found about a half mile away. On 04/18/25 at 11:57 a.m. CNA #2 stated they knew Resident #1 was an elopement risk when their employment started over two months ago and everyone knew they were. CNA#2 stated Resident #1 got out of the building recently even when they always kept a close eye on them. CNA #2 stated a close eye meant you could see their location every two hours. CNA#2 stated they were working the day of the elopement and Resident #1 was found on a busy road with a lot of traffic. CNA #2 stated they did not know the resident was missing until they were returned to the facility and Resident #1 was placed on direct supervision all day long. CNA #2 stated they were assisting another resident when Resident #1 left and they were not sure how long they were gone. CNA#2 stated they had an in-service over elopement, making sure doors were secure, and how to ensure the alarms were set right on the exit doors. On 04/18/25 at 12:05 p.m., CNA #3 identified Resident #1 as an elopement risk and they did not know how long they had been at risk. CNA #3 stated they did not know how Resident #1 got out and was not aware until they were returned. CNA#3 stated they did not hear any alarms go off and was not sure how they exited the building. CNA #3 stated they had been in-serviced on elopement, Resident #1 being one-on-one, the elopement book, and how to check and make sure the alarms were working correctly. CNA #3 stated Resident #1 was located at the museum on a very busy road. On 04/18/25 at 12:13 p.m., CMA #1 stated Resident #1 was at risk for elopement and was on one-on-one supervision. CMA #1 stated Resident #1 was not an exit seeker prior to the incident on 04/09/25. Certified Medication Aide #1 stated Resident #1 was placed in the elopement book and they received an in-service on elopement and exit doors. On 04/18/25 at 12:24 p.m., CNA #4 stated they had worked at the facility for six months and Resident #1 was not at risk for wandering and elopement when they started. CNA #4 stated they had been in-serviced on elopement, the elopement book, and Resident #1 being placed on one-on-one supervision. CNA#4 stated they did not know how Resident #1 got out of the facility, but thought it was because the alarms were not working right. On 04/18/25 at 12:35 p.m., LPN #2 stated they were the charge nurse assigned to Resident #1's hall when they eloped. LPN #2 stated they were not aware of Resident #1 missing until they were located outside the museum, about a half mile away, on a route with a lot of traffic. LPN #2 stated the alarms were malfunctioning, and they did not go off, and did not know where Resident #1 exited the facility from. LPN #2 stated they had been trained on elopement and checking and setting the alarms correctly on the doors. LPN #2 then stated Resident #1 was placed on direct one-on-one supervision. On 04/18/25 at 12:45 p.m., maintenance supervisor stated Resident #1 got out of the facility and they thought the lock was not reset on the doors. The maintenance supervisor stated they checked all doors when Resident #1 had returned and found all alarms to be working and the doors secured. The maintenance supervisor stated they checked all exit doors six times a day during rounds to ensure alarms were set and doors were secured. On 04/18/25 at 1:05 p.m., CNA #5 stated Resident #1 wandered a lot and they never received any training on the wandering until the elopement on 04/09/25. CNA #5 stated they received training on checking the doors and making sure they knew who was in the elopement book. On 04/18/25 at 1:08 p.m., LPN #3 stated they had worked at the facility for two months and was responsible for the care plans. LPN #3 stated Resident #1 was a high risk for wandering and elopement and the only interventions on the care plan were for diversionary activities and there were no care plan changes until 04/09/25. On 04/18/25 at 1:21 p.m., the DON stated Resident #1 had been at a high risk for elopement since their admission. The DON stated there had been no intervention changes and care plan updates until 04/09/25 because the facility had no care plan coordinator. The DON stated Resident #1 was found by the dietary manager on 04/09/25 near the museum located about a half mile from the facility. The DON stated no one knew for 20 minutes Resident #1 was gone and the alarms did not sound on the doors. The DON stated every day in standup elopement was discussed because of Resident #1. On 04/18/25 at 2:15 p.m., the administrator stated no one knew how Resident #1 got out of the facility and it was anticipated they were gone 20 to 30 minutes. The administrator stated Resident #1 was located about a half mile away near the museum located on a very busy road. The administrator stated Resident #1 wandered and got out of the building once into the parking lot when dietary staff watched them go out in February. The administrator stated they in-serviced all staff, started monitoring the doors, and Resident #1 was placed one-on-one starting on 04/09/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 09/16/24 at 2:47 p.m., OSDH identified the presence of an immediate jeopardy related to the facility failed to provide supervision for Res #1 to prevent recurring elopements. Res #1 was admitted to the facility on [DATE]. Res #1 was identified by family to be an elopement risk at the time of admit. Res #1 was assessed to be at risk for elopement. A care plan was not initiated until 06/11/24 with referrals to locked units and a gero-psych unit. Res #1 was placed on one on one supervision with every 15 minute visual checks. On 07/09/24, Res #1 eloped from the building and was found several blocks from the facility. The care plan was not updated until 08/16/24. No new information was added to the care plan. On 09/08/24 at 4:10 p.m., Res #1 remained with 15 minute checks, but was last observed by staff at 4:20 p.m. Staff were unable to locate Res #1 at 4:43 p.m. Res #1 was located approximately 0.4 miles east of facility. Res #1 had to cross one set of rail road tracks and a four lane business freeway. Res #1 was and continues on every 15 minutes checks. The care plan documented on 09/08/24 the resident was to be monitored one on one. Following the incident on 09/08/24, staff were not educated to ensure reocurrence. There were multiple areas on the monitoring tool that did not document Res #1 had been monitored as stated in the interventions of the care plan, including and entire day shift on 09/12/24. On 09/16/24 at 2:50 p.m., the corporate consultant and DON were notified of the presence of an immediate jeopardy related to elopement of Res #1, without the supervision and monitoring per care plan, no interventions placed to prevent further occurrence, and not following the facility policy to include the IDT in decision making of interventions to prevent elopement. On 09/17/24 at 9:09 a.m., the following POR for elopement was submitted to OSDH for review: Corrective Action: Plan of Removal On, 9/16/2024, elopement risk assessments were initiated on all residents with care plans updated to identify any at risk residents. 1. A notification sign has been placed on front door and service door to alert visitors and vendors to not let anyone out without notifying/asking facility staff first. 2. All staff In-Serviced on elopement risk policy, ensuring that identified elopement risk residents are redirected away from doors, properly performing 1:1 monitoring, and location of list of wandering/elopement risk residents and to check list at beginning of shift. 3. MDS Coordinator in-serviced on completion of care plans on all new admissions to include but not limited to potential for risk of elopement and updating care plans if an event occurs. 4. HR/BOM in-serviced on all newly hired personnel will be educated on elopement policy, location of list of at risk for elopement residents with an acknowledgement page. 5. Nursing Administration In-Serviced on reviewing elopement risk resident list/any new admissions and updating list accordingly 5 times weekly during clinical meeting. 6. DON/Designee will report any negative findings quarterly to QAPI. 7. Any employee that can't be reached for In-Service will be inactive and taken off of schedule until education is provided. 8. Resident #1 has been placed on continuous 1:1 monitoring and will remain on 1:1 continuous monitoring until more secure placement is found. Completed by 10 a.m. 9/17/2024 On 09/17/24 at 10:57 a.m., the facility was notified the POR was approved. On 09/17/24 at 3:49 p.m., the corporate consultant and DON were notified all components of the POR had been met. The deficiency remains at an isolated level with a potential for harm. Based on observation, record review, and interview, the facility failed to: a. provide supervision to a resident with a hx of elopement; b. update and implement care plan to protect resident safety; and c. failed to follow policy by not including IDT in decision making of interventions to prevent elopement for one (#1) of three sampled residents reviewed for elopement. The DON identified the census was 32. The DON indentifed four residents were high risk to wander and two residents were at risk to wander. Findings: A Safety and Supervision of Residents policy, last revised on July 2023, read in parts, .The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents .target interventions to reduce individual risks .including adequate supervision .Ensure that interventions are implemented .Documenting interventions .Safety monitoring .1:1 for 8 hours: 15 minute checks for 8 hours, 30 minute checks for 8 hours .If any issue arise in the monitoring window .begin back at the recent level of monitoring again until not new or continuing behaviors are exhibited or physician recommendation is received .Monitoring the effectiveness of interventions shall include .Ensuring that interventions are implemented correctly and consistently .Evaluating the effectiveness of interventions .Modifying or replacing interventions as needed .Resident supervision is a core component of the systems approach to safety .type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards .type and frequency of resident supervision may vary .Resident Risks .Unsafe Wandering . Res #1 was admitted to the facility on [DATE] with diagnoses to include dementia, Alzheimer's disease, delusional disorder, anxiety disorder, and bipolar type schizoaffective disorder. A Care Plan, initiated 06/11/24, documented Res #1 was an elopement risk/wanderer and had a history to leave the facility unattended. Interventions included: a. assess for fall risk, b. distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book, c. identify pattern of wandering. Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate, d. monitor for fatigue and weight loss, e. provide structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes, f. resident is one on one with every 15 minute visual/supervision for resident safety, and g. the resident's triggers for wandering/eloping are when they run out of cigarettes and want to go home to get more cigarettes. Ensure that resident has cigarettes in the facility. Wandering Risk Scales, dated 06/14/24, 07/09/24, and 07/26/24., documented the resident was at high risk for wandering and elopement. The care plan was not updated or additional interventions placed to monitor or supervise Res #1 to ensure their safety. A Progress Note, dated 07/09/24 at 3:00 p.m., read in part, .doing our normal look out for resident and could not locate [Res #1] in the building search moved to outside, resident's [family member] was notified as was local police .located [Res #1] .brought back to the facility . The care plan was not updated to include additional interventions to monitor Res #1 or interventions to ensure the safety of the resident. On 08/11/24, the elopement care plan was reviewed. There were no updates to include additional goals, monitoring, or interventions for Res #1's risks of elopement, or the events Res #1 had left the facility unattended. A [One on One] Monitoring for Resident Safety form, dated 09/07/24, documented Res #1 had been monitored with initials of a staff member every 15 minutes. A [One on One] Monitoring or Resident Safety form, dated 09/08/24, documented the resident had been monitored with initials of a staff member every 15 minutes and included: a. at 4:10 p.m., it was documented Res #1 was in the lobby and had requested a cigarette, b. at 4:30 p.m., an initial was documented with a line drawn through the time and initial, and c. at 4:45 p.m., there was no initial and the entry had a line drawn through the full line. There was a hand written note which documented, .pt found @ [4:40 p.m.] on 17th street. A Progress Note, dated 09/08/24 at 5:21 p.m., read in part, .requested a cigarette at [4:10 p.m.] .was told it was too early for the smoke break. @ [4:20 p.m.] all pt were getting together for their smoke break .[Res #1] was not located in room staff sent to locate pt .located at [4:43 p.m.] .5 minutes walk from bldg . Incident Report Form submitted to OSDH for the incident dated 09/08/24, did not contain documentation the local law enforcement was notified to assist in the search of a missing resident. The investigative packet did not contain investigative notes to ensure Res #1's risk factors had been fully assessed. A [One on One] Monitoring for Resident Safety form, dated 09/09/24, did not contain documentation at 7:15 a.m., 7:30 a.m., 8:00 a.m., or 8:15 a.m. A Wandering Risk Scale, dated 09/09/24, documented Res #1 was a high risk for wandering and elopement. A care plan revision, dated 09/09/24, documented Res #1 had eloped on 09/08/24. One on One supervision was put into place at this time. The care plan revision, dated 09/09/24, documented Res #1 was to be monitored one on one by staff. It was clarified Res #1 was one on one or to be monitored every 15 minutes as documented in the original care plan dated on 06/11/24. The clinical records did not contain documentation the IDT had been involved in the risk assessment, analysis of risks and interventions, or consulted for interventions to be put into place. A One on One Monitoring for Resident Safety form, dated 09/10/24, contained staff initials every 15 minutes. A hand written entry near the 12:15 p.m. entry, read in part, .15 min checks 09/10/24 starting 12:30. A One on One Monitoring for Resident Safety form, dated 09/12/24, had times entered every 15 minutes from 7:00 a.m. through 6:45 p.m. The entries did not contain documentation of where the resident was or staff initials the monitoring had been completed. On 09/13/24 at 10:50 a.m., CNA #1 was asked if they were aware of any residents that had eloped. CNA #1 identified Res #1 as having a history of elopement and recently was to be monitored one on one due to elopement risk. They stated there were not enough staff to do one on one staffing. They stated the resident got away when staff were in rooms helping each other with other residents. On 09/13/24 at 10:55 a.m., LPN #1 was asked if the facility had any residents that had eloped. They identified Res #1 and they stated the resident was on every 15 minute visual checks. They stated they were working the day Res #1 eloped on 09/08/24. They stated Res #1 was believed to have exited the building when another resident's family left the building. LPN #1 was asked where staff located Res #1. They stated five minutes away. They were asked if Res #1 had gone past a nearby railroad track and a divided four lane freeway. They stated, Yes. On 09/13/24 at 12:50 p.m., a tour from the facility to 17th Street was conducted. The path was across a single railroad track and beyond a divided four lane freeway. The distance was 0.4 miles away from the nursing facility. On 09/16/24 at 12:19 p.m., the DON was asked when was Res #1 first placed on one on one monitoring and the reason. They stated the resident had been on every 15 minute monitoring until the elopement incident on 09/08/24. They stated it was then changed to one on one monitoring. They were asked when was the resident placed on the one on one monitoring. They stated immediately upon return to the facility after the elopement. The DON was asked if the resident was currently on one on one monitoring or every 15 minutes. They stated Res #1 was monitored one on one until 09/10/24 at 12:30 p.m. due to no further attempts to leave, but left on every 15 minutes monitoring due to high risk of wandering and elopement. The DON stated the facility policy was followed for the instruction to change from one on one to every 15 minute monitoring. They were asked who was involved with the determination Res #1 could be monitored every 15 minutes rather than one on one. They stated they made the decision per the facility policy. The DON was asked if the IDT had been consulted prior to the resident monitoring being changed to a longer period of time. They stated, No. They were asked how was Res #1 monitored for elopement risk and safety in the early morning of 09/09/24 and the day shift on 09/12/24. They stated there was nothing documented. They stated all documentation entries on the monitoring tool should have included where the resident was, what the resident was doing, and a staff initial. The DON was asked how it was determined by documentation a resident was to be one on one or every 15 minutes if the same tool was used and there was little documentation to indicate how often a resident was to be monitored. No information was provided. They were asked what interventions had been placed to prevent elopement from the known elopement on 07/09/24 to prevent the elopement on 09/08/24. They stated they were not an employee at those times and was not aware Res #1 had a history of elopement from the facility. The DON was asked how staff ensured adequate supervision for a resident with a high risk for elopement and a history of elopement. They stated the forms were to be reviewed by the administrator. They were asked if the interventions of monitoring every 15 minutes had been effective if Res #1 was monitored every 15 minutes at the time of the elopement on 09/08/24. No additional information was provided. On 09/16/24 at 12:39 p.m., the DON was asked to review the care plan and explain the intervention for Res #1's risk for elopement to include one on one with every 15 minute visual supervision of the resident for safety. They stated they did not understand the interventions. The DON was asked if they were aware of the multiple times Res #1 had eloped and had been assessed as a high risk for continued elopement. They stated they were not aware the resident had eloped prior to 09/08/24. They stated the care plan should have been more clear and updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident # 8 had diagnoses which included Alzheimer's, schizoaffective bipolar type, and mood disorder. A Brief Interview for Mental Status assessment, dated 07/21/23, documented Resident # 8's cognition was moderately impaired. A Progress Note, dated 08/01/23, at 9:00 p.m., documented Resident #14 hit Resident #8 two times on the right side of Resident #8's face. An Incident Report, dated 08/02/23, documented Resident # 8 was hit by Resident #14. The clinical health record did not document the physician or police had been notified. On 08/28/23 at 4:16 p.m., the DON was asked about the incident, on 08/01/23. The DON reviewed the clinical health record and stated Resident #8 notified the police on 08/02/23 at 9:59 p.m. The DON was asked if the physician was notified of the incident. The DON stated they did not see any documentation in the clinical health record the physician was notified. 6. Resident #151 had diagnoses which included schizophrenia, hypertension, manic episode, alcoholism, and drug addiction. A Brief Interview for Mental Status, document dated 07/19/23 documented Resident #151's cognition was severely impaired. A Progress Note, dated 06/29/23 at 6:36 a.m., read in part, .resident throwing things and cussing at staff and other residents . A Progress Note, dated 06/29/23 at 9:17 p.m., read in parts, .resident spit out all their medication's .Attempted to hit staff and threw a coke can at staff .Resident then grabbed stethoscope that was around my neck and pulled both ends, I stepped back and the hold on my stethoscope was broke . A Progress Note, dated 06/30/23 12:27 p.m., read in part, .resident spit all medication onto the floor and through pop can at acma . A Progress Note, dated 08/05/23 at 1:09 p.m., read in part, .resident spit up morning medication. Attempted to give resident medication a second time, resident refused due to believing [they] were currently with child . A Progress Note, dated 08/05/23 at 9:34 p.m., read in part, .resident grabbed CNA ' s crotch and told [them] they had a nice rack . A Progress Note, dated 08/08/23 at 12:00 p.m., read in parts, .resident was yelling and screaming in the dining room. Resident going up to other residents tables and grabbing other residents food. Redirected resident out, resident continue to be restless and screaming . A Progress Note, dated 08/10/23 at 5:22 p.m., read in parts, Resident has been wandering around the facility, trying to eat other residents food, resident tried to swing at another resident and told [them] to shut the .and stop talking. Resident went to another table while another resident had family and tried to take their food and was swinging at the little kid. Resident also has been drinking staff drinks and resident drinks .resident yelled out, [they] had not slept in two days . A Progress Note, dated 08/10/23 at 6:25 p.m., read in part, .resident still wandering in facility, trying to hit residents and yelling throughout facility . A Progress Note, dated 08/10/23 at 6:40 p.m., documented Resident was throwing cups in the dining room and was yelling. A Progress Note, dated 08/10/23 at 7:41 p.m., read in part, .Resident screaming and yelling at staff. Resident spit out all medication . A Progress Note, dated 08/10/23 at 8:58 p.m., read in part, .Resident is being very aggressive to others . A Progress Note, dated 08/11/23, at 12:45 p.m.,, read in parts, .Resident requested something to eat, and was given a piece of cake that [they] took a bite and then threw on the floor .Had to be redirected multiple times from other residents rooms .Made several attempts to undress in common area .Trying to take other peoples belongings . There was no care-plan in the electronic health record for interventions. On 08/30/23 at 10:25 a.m., CNA #5 stated Resident #151 refused medication, took off clothes, took other residents' food, would throw cups, touched other residents, and hit residents. The CNA was asked if they ever witnessed Resident #151 being violent towards other residents. CNA #5 stated Resident #151 would yell and curse in the dining room, throw plates, food, and shatter glasses. CNA #5 was asked how often Resident #151 had behaviors. The CNA stated the resident had behaviors daily. CNA #5 was asked what interventions were used. The CNA stated redirect and tell the nurse. On 08/30/23 at 11:46 a.m., Corporate Nurse #1 was asked to review Resident #151's progress notes and state reportable. They were asked how many incidents were reported for Resident #151 and what dates they were reported. Corporate Nurse #1 stated there were no state reportables. Corporate Nurse #1 reviewed the progress notes and stated incidents on 06/29/23, 08/08/23, 08/10/23, and 08/11/23 involving aggression and behaviors that would affect unidentified residents should have been investigated and reported to OSDH. Corporate nurse # 1 was asked to review Resident #151's care plan to discuss interventions put in place for the residents behaviors. Corporate Nurse #1 stated there was no care plan in the electronic health record. 3. Resident #10 had diagnoses which included, chronic pain, ankylosing spondylitis of multiple sites in spine, and kyphosis thoracic region. An admission Assessment, dated 06/08/23, documented Resident #10 had mild cognitive impairment, and required extensive assistance of one staff for personal hygiene, and dressing and used a wheelchair. An initial OSDH Incident Report Form dated 08/14/23, read in parts, .When [Resident #14] walking down hallway [Resident #10] yelled something at [Resident #14]. [Resident #14] shoved employee out of the way and struck [Resident #10] and pulled [Resident #10's] hair .[Resident #14] is on 1:1 until other placement is found Full body assessment was done on [Resident #10], no concerns noted Resident #14's 1:1 Supervision form, was dated 08/13/23 at 11:30 p.m. through 08/15/23 at 12:30 p.m., documented resident wherabouts, but there was no staff signatures from 08/14/23 at 8:00 a.m., through 08/15/23 at 12:30 p.m. An Incident Note dated 08/14/23 at 10:26 p.m., read in parts, .Staff responded to yelling in room [ROOM NUMBER]. This resident stated, 'I was in room [ROOM NUMBER] visiting when [resident #14] came in the room an I started yelling at [them] and telling [them] to leave. [Resident #14] grabbed by arm and I got away from [them] then [they] tried to grab it again so I threw ice water on [them] which I probably shouldn't have done because [Resident #14] started hitting me. The staff had to get him away from me. 1:1 initiated with other resident . An Incident Note, dated 08/14/23 at 10:26 p.m., read in parts, .Resident voiced c/o pain in back and neck. Also voiced c/o decreased movement in right thumb. Resident requested to file a police report and be sent to ER. Three officers came and took report then resident transported to ER for eval . There was no documentation in the clinical health record an assessment had been completed on Resident #14 after the altercation. On 08/16/23 at 9:59 a.m., Resident #10 stated about two and half weeks ago, Resident #14 had come up behind them and struck them in the back of the head. They stated, they notified the nurse, but they did not do anything about it. They were asked if they had been assessed by the nurse. They stated no, and nursing said they would write it down. Resident #10 stated, I came back to my room and I cried. Resident #10 stated After [they] hit me in the head the first time I had double vision and headaches, I told staff but they didn't do anything. There was no documentation in the clinical health record regarding Resident #10 being hit in the head by Resident #14. Resident #10 stated, I was in another residents room and the other resident came up and was standing at the door. I asked [them] to go away and leave us alone. [Resident #14] then grabbed my arm and tried to pull me out of my wheelchair. I told [them] to let go of me, [they] wouldn't. [They] hit me then hit me again and I threw ice on [them]. [Resident #14] then started wailing on me. The resident stated, I started yelling then next thing I know I woke up half way in the chair and half way on the floor. My shoulder was hurting and my left thumb was sore. I urinated on myself. I asked to call the police and wanted to go to the hospital. No staff ever came in and assessed me. The resident was asked if there was a staff member 1:1 with the other resident. They stated, No. On 08/21/23 at 3:55 p.m., Resident #54 was asked if they were present when the altercation happened with Resident #10 and #14. They stated Yes. They stated, Resident #14 tried to come into their room and Resident #10 told Resident #14 they could not come in the room and Resident #14 just started hitting Resident #10. On 08/24/23 at 10:27 a.m., the Administrator provided documentation that Resident #14 was 1:1 at the time of the incident. The Administrator was asked what was done after the altercation was over. They stated the nurse went to assess the resident and they refused. Resident #14 was placed on 1:1, Resident #10 wanted to file a police report then be sent to the hospital. The Administrator was asked where it was documented Resident #10 had refused to be assessed. The clinical health record did not document the resident refused an assessment. The Administrator was asked what was done to ensure other residents were safe. They stated Resident #14 was placed on 1:1. They were asked who was the employee that was doing 1:1 when the incident occurred. They stated they were unsure. The Administrator was asked if they had filed a final state report on the incident. They stated, they had not filed it yet. The Administrator was asked if Resident #10 had reported personal property was broken by Resident #14. The Administrator stated yes, a phone had been broken but had been replaced. They were asked if they filed a state report on the incident. They stated, no because the phone was replaced a couple of days later. On 08/29/23 at 4:15 p.m., CMA #1 stated, When Resident #14 was hitting Resident #10 I had to get [them] off. CMA #1 stated Those times on the day for 1:1 are not my time documented. The Administrator told me to sign it and I refused. 4. Resident #22 had diagnose which included, convulsions, anxiety, depression, paraplegia, pressure ulcer or left and right buttock, and pressure ulcer of right and left heel. On 08/16/23 at 9:06 a.m., Resident #22's electric wheelchair was observed in the Resident's room. On 08/16/23 at 4:04 p.m., Resident #22 was asked about their wheelchair. Resident #22 stated the nursing home had broke their electric wheelchair and charger. They broke my chair and the charger, the Administrator said [they] would fix the charger but not the chair. They were asked if someone had looked at it. They stated yes. They were asked when they noticed the chair was broken what happened. Resident #22 stated, I was laying in bed it was a staff member, [they] took out a knife and cut the cord that goes to the wheelchair. They were asked if the facility conducted an investigation. They stated the facility did not do anything. On 08/21/23 at 3:36 p.m., the regional director was asked why Resident #22's wheelchair was still in their room. They stated Two different maintenance men have looked at it, there was a fray in it. We are going to change the cord. On 08/30/23 at 12:18 p.m., the regional director was asked for documentation the facility had started to repair the chair. They stated they would get it. They were asked if a grievance had been filed that staff broke her chair. They stated they were unsure. They were asked when the facility was notified of the allegation. The regional director stated the Administrator had notified them someone had broke the resident's chair, but nothing had been emailed to them. They were asked if there was an investigation regarding the allegation. They stated, they would need to call the Administrator. On 08/30/23 at 2:00 p.m., the regional director stated the Administrator had notified the maintance about the wheelchair and they determined it was wear and tear. There was no grievance filed. They were asked if a grievance should have been filed on behalf of the resident. They stated, Yes. They were asked if Resident #22 had reported an allegation that staff had broke their chair. They stated, I think they told [the administrator]. They were asked was it investigated. They stated they were unsure. On 08/30/23 at 2:42 p.m., the regional director stated there was no documentation in the clinical health record. The regional director was asked what should have been done. They stated an investigation should have been started to see if staff had done it or it was normal wear and tear. On 08/30/23 at 2:50 p.m., Maintenance #1 stated they had just looked at the chair. They stated they had looked at it before and had reported it to the Administrator. They had two pictures one was a frayed cord and one was a cut cord. They were asked when had they taken those photos. They stated, just now. They were asked if anything had been done since the initial time it was reported. They stated they were unsure. On 08/25/23, an IJ situation was determined to exist related to the facility's failure to implement their abuse policy to ensure: a. Allegations of abuse were fully investigated, b. Residents were protected during an investigation, c. Interventions were placed to prevent further allegations or abuse, and d. Allegations of abuse were reported in the time frame set by state and federal regulations. This resulted in Resident #21 to report to the surveyor, an event of an unidentified male in their room that had their hand in Resident #21's pants. Resident #21 recognized the male as another resident that currently resides in the facility. The resident record documented staff were aware of the situation on 07/29/23 at 2:31 a.m. Additional documentation of the event documented on 07/29/23 at 6:38 p.m., and 7:45 p.m., staff were aware of the allegation, and the Administrator had been notified on 07/29/23 at 6:38 p.m. There was no documentation of any intervention placed to protect Resident #21 during the investigation. Resident #21 was not interviewed during the investigation. An initial state report was submitted on 07/30/23 at 8:30 p.m., and a follow up/final report was submitted on 08/07/23 at 10:35 a.m. The investigative notes provided by the administrator documented, on 08/01/23, residents were asked Have you seen a strange man walk in the facility. A staff roster documented staff were asked Have you ever seen a man wearing sweatpants and braces in the building in the last week. The investigative notes contained documentation that six core staff were not interviewed and no agency staff were interviewed. No further documentation supported additional investigation was conducted. The administrator was interviewed and stated they did nothing to protect the resident, and did not conduct a thorough investigation. Additional findings include patterns of resident to resident altercations that have not been reported. Residents identified include Residents #14, #10, #1, and many unidentified residents documented in progress notes of sampled residents. On 08/25/23 at 2:29 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 2:48 p.m., the Administrator and Regional Nurse were notified of the IJ situation. On 08/29/23 at 10:23 a.m., an acceptable plan of removal was provided. The plan of removal documented: .Administrator was in-serviced on timely submission of reportables as well as facility abuse policy on 08/25/23. Administrator was also in-serviced on what incidents are reportable to the state on 08/25/23. The staff that were previously not interviewed were interviewed on 08/25/23. Agency provider does not allow access to provider phone numbers after a shift is assigned. Agency staff phone numbers will be obtained by the end of the shift that they work for record keeping and HR office. Staff was in-serviced on abuse and neglect policy and 1:1 protocol on 08/25/23 . .Trauma assessments were completed for all residents on 08/25/23. MMS has been contacted for counseling services on all affected residents. All residents were interviewed r/t their safety in the facility. 10 residents of 34 stated they had concerns with former resident [#14] and [#23]. RNC and RDO spoke with nephew of the resident. He stated incident occurred around 1700-1800 on 07/29/23. Upon investigation, it was noted that the night of 07/29/23 an african american male cna wearing a head covering was working the hall providing resident care on the 7a-7p shift. RNC interviewed resident #21. [They] states that the man that came in her room had long hair that was in a bun. Continue 1:1 with resident #21. Administrator .continues suspension pending investigation r/t failure to report .08/28/23 [at 6:30 p.m.] 1830. On 08/29/23, interviews were conducted with staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. Staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On 08/29/23 at 11:16 a.m., the IJ was lifted when all components of the plan of removal had been completed. This is effective as of 08/28/23 at 6:30 p.m. The deficiency remained at a level of actual harm at a pattern. Based on record review, observation and interview, the facility failed to implement their abuse policy to ensure: a. Allegations of abuse were fully investigated, b. Residents were protected during an investigation, c. Interventions were placed to prevent further allegations or abuse, and d. Allegations of abuse were reported in the time frame set by state and federal regulations for seven (#8. 9, 10, 14, 21, 22 and #151) of 10 sampled residents reviewed for abuse and/or resident to resident altercations. The Resident Census and Condition of Residents, form dated 08/16/23, documented the 37 residents resided in the facility. Findings: An undated, Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention policy, read in parts, .Prevention .Identify, correct and intervene in situations in which abuse .is more likely to occur .supervision of staff to identify inappropriate behaviors .derogatory language, rough handling .assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict .history of aggressive behaviors .entering other residents' rooms .initial reporting, investigation of alleged violations and reporting of results to the proper authorities .Protect residents from harm during the investigation .Protect other residents who might be at risk .Report all alleged violations and all substantiated incidents to the state agency and to all other agencies .all alleged violations involving abuse, neglect .are reported immediately, but not later than 2 hours after the allegation is made .Have evidence that all alleged violations are thoroughly investigated .Prevent further potential abuse .or mistreatment while the investigation is in progress .Report the results of all investigations .including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken . An undated, Behaviors Protocol form documented: Initiate 1:1 with resident x 8 hours then Q15m checks x 8 hours then Q30m checks x8 hours then Q1h checks x8 hours. At this time if there are no further behaviors, checks will end. If at any point resident has a behavior, 1:1 will restart. 1. Resident #21 had diagnoses to include bacteremia, diabetes mellitus, respiratory failure, and dysphagia following a cerebrovascular event. A Progress Note, dated 07/29/23 at 2:30 a.m., read in parts, .Two officers from [local police department] here and spoke with this nurse regarding a report from a third party that resident [#21] had stated that there was a man that came into [their] room wearing gray sweatpants and had braces that had pulled [Resident #21's] pants down .resident is very hard of hearing and is sleep most of night. Officer stated that they would pass it on to the day shift . A Progress Note, dated 07/29/23 at 6:38 p.m., documented the allegation of abuse from Resident #21 had been reported the DON and Administrator. The clinical record contained no documentation Resident #21 had been monitored, or interventions had been placed to protect the resident. An investigation had not been initiated at this time. An initial Incident Report Form, documented on 07/30/21 at 8:30 p.m., the incident report had been submitted to OSDH regarding Resident #21's abuse allegation. The State Report form had not been initiated from 07/29/23 at 2:30 a.m., until 07/30/23 at 8:30 p.m., 42 hours after staff documented the facility was aware of an allegation of sexual abuse. The facility's investigative notes, dated 08/01/23, documented 29 residents were asked one, Have you seen a strange man walk in the facility . There were no additional documentation for the resident interviews during the investigation. An employee list documented from 7/30/23 to 08/01/23 An employee list, dated 07/30/23 and 08/01/23, documented 31 staff members were asked one question, .Have you ever seen a man wearing sweatpants and braces in the building in the last week . There were no additional interviews were conducted and agency staff utilized in the facility had not been interviewed. A Final Incident Report form dated 08/07/23 at 10:35 a.m., documented the final Incident Report Form, had been submitted to OSDH, four days after the required time to report. The report documented Resident #21 had been placed on hourly visual checks to ensure the resident's safety. The investigative notes or clinical record did not contain documentation Resident #21 had been on hourly checks. On 08/18/23 at 2:08 p.m., Resident #21 was asked if they were afraid of anyone at the facility. Resident #21 stated, That one [person] that walks around here. [They] came in my room. I heard [my roommate] hollering. [They] had [their] hand in my pants. [They] went walking out real quick. Resident #21 stated the person was still in the facility, continued to be afraid, heard the facility was not going to do anything, and wanted to move out to live with family. An admission Assessment, dated 08/21/23, documented Resident #21 had adequate hearing and did not wear a hearing aide, usually understands, had moderate cognitive impairment, required extensive assistance of two staff for transfers, dressing, and toilet use, required extensive assist of one staff for personal hygiene, required total assistance of one staff for bathing, and was always incontinent of bowel and bladder. On 08/25/23 at 11:25 a.m., the Administrator stated the allegation of sexual abuse should have been investigated further, the resident should have been placed on one on one supervision for safety, and the Incident Reports should have been more timely. 2. Resident #14 was had diagnoses which include dementia with psychotic disturbance, cerebral vascular disease, tobacco use, hypo-osmolality and hyponatremia, alcohol dependence, and bipolar disorder. A Progress Note, dated 05/20/23 at 4:30 p.m., documented Resident #14 was placed on one on one supervision due to an elopement. The clinical record contained no documentation Resident #14 had been supervised with one on one staff as indicated in the progress note. The facility did not provide additional information. During May 2023, Resident #14 had eight events of elopement/missing person, wandering into other resident rooms, resident to resident altercation, and agitation/aggressive behavior toward staff in common areas where other residents were present. The record contained no incident report or a report to OSDH for three events that met criteria to be reported to OSDH. There was no documentation Resident #14 had received one on one supervision per facility protocol. No further information was provided by the facility. A Progress Note, dated 06/03/23 at 2:42 p.m., documented Resident #14 had an altercation with Resident #9. A Initial Report, dated 06/04/23 at 7:34 p.m., documented an initial report for Allegations of Abuse/Mistreatment had not been submitted for more than 24 hours. During June 2023, Resident #14 had fourteen events of elopement/missing person, wandering into other resident rooms, resident to resident altercation, and agitation/aggressive behavior toward staff in common areas where other residents were present. The record contained no incident report or a report to OSDH for nine events that met criteria to be reported to OSDH. No further information was provided by the facility. Five of the residents involved in resident to resident altercations could not be identified. During July 2023, Resident #14 had twelve events of elopement/missing person, wandering into other resident rooms, resident to resident altercation, taking/destroying other resident's property, and agitation/aggressive behavior toward staff in common areas where other residents were present. The record contained no incident report or a report to OSDH for two events that met criteria to be reported to OSDH. No further information was provided by the facility. Two of the residents involved in resident to resident altercations could not be identified. During August 2023, Resident #14 had thirteen events of elopement/missing person, wandering into other resident rooms, resident to resident altercation, taking/destroying other resident's property, and agitation/aggressive behavior toward staff in common areas where other residents were present. Three events that met criteria to be reported to OSDH were not reported within the required time. The record contained no incident report or a report to OSDH for three events that met criteria to be reported to OSDH. Two of the reported events did not include a 5-day follow-up report as required by state and federal guidelines. Two of the residents involved in resident to resident altercations could not be identified. A resident to resident occurrence on 8/14/23 was not doucmented in the clinical record. No further information was provided by the facility. On 08/24/23 at 2:25 p.m., the Administrator was asked to review the identified progress notes documented in May, June, July, and August 2023, and asked if incident reports had been completed on all of the events or behaviors presented by Resident #14. They stated, No. The administrator was asked to identify the residents involved with resident to resident altercations and those affected by Resident #14 to wander into the other resident's rooms. They stated they did not know who the other residents were. The administrator was asked what interventions were placed to prevent repeated behaviors from Resident #14. They stated there were no interventions. On 08/24/23 at 2:40 p.m., the Administrator was asked if the incident report for the resident to resident altercation between Residents #14 and #9 had been submitted within the required time frame. They stated, No. On 08/24/23 at 3:30 p.m., the Administrator was not able to identify all of the residents who had been affected by Resident #14's behaviors. The Administrator could only identify two of four residents involved in resident to resident altercations with Resident #14. The Administrator was asked what interventions were put into place to prevent continued behaviors by Resident #14. No information was provided. The Corporate Nurse stated Resident #14 should have been on the one on one supervision from the time the resident was admitted in May 2023 until they were transferred on 08/15/23. 3. Resident #9 had diagnoses to include muscle wasting and atrophy, acquired absence of right leg above the knee, mild cognitive impairment, and muscle weakness. An Annual Assessment, dated 04/20/23, documented Resident #9 had mild cognitive impairment, required assistance with transfers, and toileting, had not displaced behaviors or rejection of care, was occasionally incontinent of urine and frequently incontinent of bowels, and not on a toileting plan. On 08/16/23 at 5:00 p.m., very loud, forceful, and harsh tones of a female voice were heard in the hallway. Resident #9 was observed to be propelling wheelchair toward their room and CNA #1 walked behind the resident. CNA #1 continued to repeat, with loud and forceful tones, telling Resident #9 You're wet, turn around, and Go change your pants, now! Resident #9 was dressed in lounge pants and a T-shirt, both which were obviously wet, and a trail of moisture was left on the floor behind where Resident #9 had propelled themselves toward their room. Upon entry into the resident room, CNA #1 closed the door, continued to use loud, forceful and harsh tones to instruct the resident to undress from wet clothing and to clean themselves, as CNA #1 provided Resident #9 with premoistened wipes. Resident #9 appeared to be fidgety, unable to follow-commands, would stand up from wheelchair and sit down in the wheelchair. Resident #9 attempted to wash the front areas as instructed and was told, No, wash your backside, followed by harsh tones to go into the bathroom. Resident #9 went into the bathroom, and transferred self onto the toilet. CNA #1 instructed Resident #9 to remove their wet clothing, then began to hand pre-moistened wipes, one at a time, to the resident. Resident #9 attempted to wash broad areas that had been wet with urine on the front of their body. After Resident #9 had dressed themselves into dry clothing, CNA #1 instructed Resident #9 to stand up and provided one swipe to the anal area before instructing the resident to pull up their pants and sit in the wheel chair. No staff followed the loud, forceful, harsh tones to ensure the safety of Resident #9. On 08/16/23 at 5:10 p.m., the Administrator and BOM were asked if they had heard CNA #1 address Resident #9 regarding having wet pants. The BOM stated, I heard it and it was awful. The Administrator denied knowledge of the event. They were asked if the tones were acceptable. The administrator stated, No, it is not. The BOM was asked if they had reported to anyone. They stated, No. The administrator stated, We will initiate our abuse protocol. On 08/22/23 at 2:40 p.m., the Administrator was asked to provide documentation where CNA #1 had been r[TRUNCATED]

3. Resident # 8 had diagnoses which included Alzheimer, schizoaffective bipolar type, and mood disorder. A Brief Interview for Mental Status, dated 07/21/23, documented Resident #8's cognition was moderately impaired. A Wandering Risk Scale, dated 07/21/23, documented, Resident #8 was a low risk for wandering. On 08/16/23 at 12:36 p.m., Resident #8 was observed with a purse at the front door. Resident #8 went out the door and sat on the bench. The ADON went out and sat with resident one on one until the resident came back in. On 08/16/23 at 12:41 p.m., the ADON was asked what was going on with Resident #8. They stated, Resident #8 refuses to come back inside and wants to leave against medical advice. The ADON stated Resident #8 was very confused. They stated Resident # 8 could be out front but we keep an eye on her to make sure she does not walk away. They stated that the behavior is a daily occurrence. On 08/18/23 at 1:48 p.m., the ADON was shown a wandering assessment, dated 07/21/23, and asked if it was correct due to a score of 2.0 (low risk) for wandering. The ADON reviewed the resident's diagnosis in the clinical health care record and stated the wandering assessment was not correct due to the resident having a diagnosis of Alzheimer's. On 08/18/23 at 3:51 p.m., the ADON was asked if Resident #8 had been reassessed for wandering. The ADON stated Resident #8 was reassessed on 08/18/23, and was a high risk for wandering. On 08/18/23 at 2:41 p.m., the OSDH confirmed the existence of an immediate jeopardy related to the facility failed to ensure supervision to prevent elopement for Resident #24 and Resident #8. Resident #24 was at risk to wander and was observed to leave the facility with no staff supervision. Resident #8 was observed to exit the automatic door at the front exit and sat on a bench. The ADON was asked why Resident #8 was outside. The ADON stated Resident #8 wanted to leave AMA, and the behavior is a daily occurrence for the resident wanting to leave. There was no care plan for Resident #8 to be at risk for elopement. The facility failed to implement interventions, and provide supervision to ensure Residents who were at risk for elopement did not leave the facility without supervision. On 08/18/23 at 4:35 p.m., the The Administrator and Corporate Nurse were notified of the presence of an Immediate Jeopardy. On 08/22/23 at 4:02 p.m., the facility provided an acceptable plan of removal and is as follows: .IJ Plan of Removal 08/18/2023 1621 Front doors will be locked at all times electronically and all other doors will have an alarm in place until our lock down unit is open. At that time all residents who are at risk or high risk will be moved to the lockdown unit. A doorbell/two way radio system will be placed outside the front entrance for visitors to notify staff of their presence on 08/18. DON or designee will complete updated elopement assessments on all residents on 08/18, upon admission, quarterly and as needed. Care Plans will be updated on all residents with a change in elopement assessment status. Care Plans will be update on 08/18, quarterly and as needed with any significant changes. A list of all residents who are elopement risks will be posted at the nurses station and on the PCC dashboard. Residents who are at risk will be supervised by clinical/non-clinical staff while outside. All staff will be in-serviced on 08/18 r/t elopement risks, doors, care plans and the supervision of residents. A binder with in-service information will be left at the nurses station and the charge nurse on duty will in-service the staff that was unavailable and new agency staff. This POR will be complete on 08/18 at 2000. Staff was inserviced again on 08/21/23 regarding the names of the residents who are at risk for elopement. The list of residents who are at risk for elopement are located on the PCC home page on the dashboard as well as behind the nurses desk. All staff with non working phone numbers will be in-serviced by the charge nurse prior to their shift. A binder with the in-service information will be left at the nurses station for those staff members as well as any agency staff. The POR will be complete on 08/21 at 1215 Wooden double doors between the dining room and hallway will be and remain locked. The Fire retardant double doors will be locked. The fire monitoring company has been notified to come and evaluate the door and place a key pad on doors to keep them locked and residents safe. The double doors in the kitchen will also be evaluated by the fire monitoring company for a key pad as well. Business office will be moved to the front desk to monitor the door for resident safety. 8-21-2023 at 16:00 Wooden double doors between the dining room and hallway will be and remain locked. The fire retardant double doors will have an alarm. The fire monitoring company will be on site to install keypads and locks on both doors on Friday 08/25/23. The double doors in the kitchen will also be evaluated by the fire monitoring company for a key pad as well. Resident MR will be supervised outside during daylight hours by clinical/non-clinical staff . 08/22/23 1330 The fire retardant double have an alarm in place. Glass double doors in dining room area also have an alarm in place. Wooden double doors between the dining room and hallway will be and remain locked. [Resident #24] . and all residents at risk for wandering will be supervised outside during daylight hours by clinical/non clinical staff . On 08/22/23 at 4:10 p.m., the immediacy was lifted after all components of the POR had been completed. It remained at a pattern with actual harm. The Administrator and Corporate Nurse were informed. Based on observation, record review, and interview, the facility failed to provide supervision to prevent elopement for three (#24, #3 and #14) of three sampled residents reviewed for elopement behaviors. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility, and one residents at a high risk to wander, and seven residents at risk to wander. Findings: An undated, Elopement policy, read in part, .Elopement includes when a resident leaves the premises or a safe area without authorization and/or necessary supervision placing the resident at risk for harm or injury . 1. Resident #24 had diagnoses which included altered mental status, Alzheimer's disease, and weakness. A Wandering Risk Scale, dated 01/06/23, documented Resident #24 had a history of wandering, a medical diagnosis of dementia or cognitive impairment, and was at risk to wander. Resident #24's care plan, dated 02/06/23, read in parts, .[Resident #24] is a wanderer, [they] propels [themselves] around facility in [their] wheelchair, [they stays inside facility, staff keep in sight as much as possible and round more often .Assess for fall risk .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Monitor for fatigue and weight loss . The care plan did not document Resident #24 was at risk for elopement. Resident #24's five day admission assessment, dated 03/15/23, documented resident #24 was cognitively impaired, was able to respond adequately to simple direct communication and had not wandered. On 08/18/23 at 12:50 p.m., Resident #24 was observed to go outside the double front entrance doors without any staff supervision. LPN #1 was notified and went outside to get the Resident. Resident #24 was observed to have went through a wooden fence and was in the courtyard. LPN #1 attempted to encourage the resident to return into the facility. CMA #2 was observed running into the entry way of the gate and was able to talk Resident #24 into returning inside the facility. On the way in the door CMA #2 was heard to tell LPN #1 that Resident #24 had an alarm on their chair but the batteries were out. On 08/18/23 at 1:07 p.m., CMA #2 was asked to clarify what alarm should Resident #24 have on their chair. They stated Resident #24 usually had an alarm on their chair, but it had expired in June. They were asked what the alarm was used for. They stated if Resident #24 goes out of the facility it will notify the security system. They stated the alarm was in the drawer at the nurse's desk. CMA #2 retrieved a small white plastic box from a drawer at the nurse's desk. CMA #2 was asked how they knew Resident #24 was outside. They stated another resident told them. On 08/18/23 at 1:27 p.m., CMA #4 was asked if Resident #24 had been outside of the facility recently without anyone knowing. They stated, yes. They were asked if Resident #24 should be outside by themself. They stated No. They were asked if the Resident had an alarm. They stated, Sometimes it works and sometimes it doesn't, [the resident] goes out and [they] sit on the bench and see the cats. On 08/18/23 at 1:28 p.m., Resident #24 was observed in their wheelchair opening the restroom door in the common area looked in then moved away and parked their wheelchair. On 08/18/23 at 1:42 p.m., LPN #1 was asked if they were aware Resident #24 was outside the facility door before they were notified. They stated, No. On 08/21/23 at 9:34 a.m., the corporate nurse was asked if Resident #24 was at risk for elopement. They stated the resident had not wandered. They were asked if Resident #24 should be outside unsupervised. They stated, No. On 08/21/23 at 2:33 p.m., Resident #24 was observed sitting in the foyer area near the open front door. Resident #24 was observed to go out the front door. Resident #24 was observed to go down the sidewalk and then was observed shutting the gate to the courtyard behind them. This surveyor returned to the open facility door and observed staff were at the open doors and were informed the resident was out in the courtyard. On 08/21/23 at 2:40 p.m., Resident #24 was observed to be assisted by staff back into the facility. The DM was asked what happened. They stated they had seen the doors were open and the nurse was there, and that this surveyor notified them that Resident #24 was going into the courtyard. On 08/21/23 at 2:44 p.m., the DM stated the temperature in the courtyard was 104.7 degrees. 2. Resident #14 was admitted with diagnoses to include dementia with psychotic disturbance, cerebral vascular disease, tobacco use, hypo-osmolality and hyponatremia, alcohol dependence, and bipolar disorder. A Progress Note, dated 05/20/23 at 4:30 p.m., read in parts, .Received a call from [local police department] that resident was across the street at [another local nursing home] .Staff member from this facility walked over to return resident .Resident will be 1 on 1 till end of shift and will notify oncoming nurse of cont (sic) intervention . The clinical record contained no documentation Resident #14 had been supervised with one on one staff as indicated in the progress note. The record contained no incident report or a report to OSDH for regarding Resident #14's elopement. No further information was provided by the facility. A Progress Note, dated 06/08/23 at 8:33 p.m., read in parts, .attempting to go through exit doors . A Progress Note, dated 07/13/23 at 8:16 p.m., read in parts, .hitting and chasing staff .exit seeking . A Progress Note, dated 07/31/23 at 11:33 p.m., read in parts, .has made multiple elopement attempts. Has gotten outside multiple times . A Progress Note, dated 08/06/23 at 2:30 p.m., read in parts, .nurse was informed that [Resident #14] was observed waling (sic) outside moment prior .resident was no where to be found .the front of the building and observed police cars patient was indeed with the officers .placed on 1 on 1 care . A Progress Note, dated 08/06/23 at 6:30 p.m., read in parts, .observed waling (sic) outside .no where to be found .patient was with the officers .continues to roam around the building while officers are getting statements .placed on 1 on 1 care . A Progress Note, dated 08/06/23 at 8:46 p.m., read in parts, Elopement cursing at other residents . The clinical record did not clarify how many times Resident #14 had eloped from the facility on 08/06/23. A facsimile verification, dated 08/08/23 at 11:38 a.m., documented an initial report for a Missing Resident was submitted to OSDH in regard to Resident #14's elopement on 08/06/23. The report documented Resident #14 was to be placed with one on one staff supervision and will remain with one on one until a placement can be made for transfer of Resident #14. One on One Supervision documentation for Resident #14, documented the resident was to be one on one supervision from 08/03/23 through 08/15/23. There were many blank areas the documentation had not been completed on the form. Resident #14 had documentation of one on one staff supervision as follows: a. On 08/03/23 from 9:30 a.m., through 3:00 p.m., at 4:30 p.m., 8:30 p.m., and 8:50 p.m., b. On 08/04/23 from 7:00 a.m., through 08/06/23 at 1:00 a.m., Resident 14 was supervised with hourly documentation, c. On 08/07/23 from 5:30 p.m., through 10:30 p.m., hourly, d. On 08/09/23 from 7:30 p.m., through 08/13/23 at 3:30 p.m. hourly, and e. On 08/13/23 from 7:30 p.m., through 08/15/23 at 12:30 p.m., hourly. There was no documentation Resident #14 had received one on one supervision prior to 08/03/23. A Care Plan, dated 08/17/23, did not contain interventions for elopement. The care plan had not been initiated or completed until two days after Resident #14 had been discharged from the facility. On 08/24/23 at 2:25 p.m., the Administrator, DON, ADON, and Corporate Nurse were asked if Resident #14 had eloped from the facility on the day of admission. The Administrator stated, Yes. The Administrator was asked if an incident report had been completed and submitted to OSDH. They stated, No. A request was made for the documentation of one on one supervision as indicated in the progress note. The administrator was asked what interventions were placed to prevent repeated behaviors from Resident #14. They stated there is not a baseline care plan. No information was provided regarding one on one supervision on 05/20/23. On 08/24/23 at 2:55 p.m., the Administrator, DON, ADON, and Corporate Nurse were asked to review the progress notes and incident reports for July 2023. The Administrator was asked if incident reports had been completed for the event on 07/31/23, when Resident #14 had been outside of the facility. They stated, No. The Administrator was asked what interventions were put into place to prevent repeated behaviors from Resident #14. No information was provided. On 08/24/23 at 3:30 p.m., the Administrator, DON, ADON, and Corporate Nurse were asked to review the progress notes and incident reports for August 2023. The Administrator was asked to clarify how many times Resident #14 has eloped on 08/06/23. They stated, I believe it was just once. The Administrator was asked if the incident reports had been completed in the required time frame to report to OSDH and other required agencies regarding the elopement. They stated, No.