On 09/18/25, an IJ situation was determined to exist related to the facility's failure to protect residents from physical abuse.On 09/18/25 at 2:59 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 09/18/25 at 3:06 p.m., the administrator was informed of the existence of an IJ for abuse and the IJ template was provided.On 09/19/25 at 10:39 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Plan of RemovalResident #28 has been referred for inpatient geri-psych services. Until such time that the resident departs the facility, the resident was immediately placed on one-on-one supervision.All staff will receive inservice training regarding abuse prevention including resident to resident abuse. Specifically, staff will receive training to intervene when resident to resident abuse occurs, report abuse immediately to the Administrator, to assess or evaluate the resident who sustained abuse for injury and document those findings in the resident record. An intervention(s) will be established for each episode of resident-to-resident abuse at the time of the occurrence, the intervention will be communicated to the staff and updated to the resident's care plan. An intervention communication form will be used to communicate to staff all new occurrences and interventions.All staff received inservice either in person or by phone call. For any staff member that could not receive inservice in person or by phone, they will be required to receive inservice before their next scheduled shift.Inservice education will be provided by the DON, RN [registered nurse], and Care Plan CoordinatorAll staff will receive inservice training by 11:59 pm on 9.18.2025All above components of the plan will be in place by 11:59 pm on 9.18.2025Resident #28 had no access to any other resident outside of the memory care unit. All residents on the memory care unit were safe from abuse immediately when one on one supervision was established for resident #28. Resident #28 was transferred via EMSA [Emergency Medical Services Authority] from the building for geri-psych services at approximately 7:00 pm on 9.18.2025By 12:00 pm on 9.19.2025 each resident on the memory care unit will receive a head to toe assessment for injury and will be asked about their safety.The Plan of Removal will be completed by 1:00 pm on 9.19.2025The IJ was lifted, effective 09/19/25 at 1:00 p.m., when all components of the plan of removal had been verified as completed. Documentation one on one supervision was provided for Resident #28, staff education regarding abuse and dementia, resident assessments for injury/head to toe assessments were reviewed. Interviews with staff were conducted to ensure education was provided regarding abuse, dementia, and the process for reporting abuse. The deficient practice remained at an isolated level with the potential for more than minimal harm.Based on record review and interview, the facility to ensure residents were protected from physical abuse for 3 residents (#33, 37, and #41) of 3 sampled residents reviewed for abuse.The DON identified 48 residents resided in the facility.Findings:A policy titled Policy and procedure regarding prohibition of resident abuse including corporal punishment, neglect and exploitation, revised 10/11/22, read in part, The facility will implement the seven key components for abuse prohibition which include Screen, Train, Prevent, Identify, Investigate, Protect and Report/Respond in an effort to prevent abuse, neglect and misappropriation from occurring, taking corrective action as needed and monitoring outcomes.Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.Physical abuse which includes but is not limited to hitting, slapping, punching, biting and kicking.Prospective residents will be screened prior to placement to determine if the facility has the capability to provide the necessary care and services to the resident.The Administrator or designee may consult with law enforcement during the course if any investigation.The facility will identify, and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses or anyone who may have knowledge of the allegation. The results of all investigations will be documented, including statements written for or by others and maintained in the administrative offices.Staff will increase supervision of the alleged victim and perpetrator and all other residents that may be impacted. If necessary, the alleged victim or perpetrator may be relocated to another room or part of the facility in an effort to protect the resident.All staff are required to report all allegations of abuse.to the Administrator, OSDH [Oklahoma State Department of Health] and local law enforcement.1. An undated order summary for Resident #28 showed diagnoses of dementia and Alzheimer's. An initial INCIDENT REPORT FORM, dated 07/04/25, showed Resident #28 slapped Resident #37 while trying to push them in their wheelchair. There was no education noted and law enforcement and the resident's family was not contacted. The investigation did not show safe surveys were conducted.A care plan for Resident #28, updated 07/04/25, showed to adjust the environment, determine situation, establish routine, refer to senior psych evaluation, and staff to learn the subtle changes. An admission MDS assessment, dated 07/07/25, showed Resident #28 had a BIMS of 9 indicating moderately impaired cognition, physical behaviors towards others, and verbal behaviors towards others. The assessment showed they were independent with mobility.An initial INCIDENT REPORT FORM, dated 07/12/25, showed Resident #28 started yelling at Resident #33 while they were walking down the hall. The form showed Resident #28 slapped Resident #33 to the floor causing them to hit their head making a knot form. There was no education noted and law enforcement was not contacted. The investigation did not show safe surveys were conducted.An initial INCIDENT REPORT FORM, dated 08/04/25, showed Resident #28 slapped Resident #37 in the face in the hallway. There was no education noted and law enforcement was not contacted. The investigation did not show safe surveys were conducted.A care plan for Resident #28, updated 08/22/25, showed to administer medication as ordered, assess and anticipate resident's needs, give as many choices as possible, when agitated intervene before agitation escalates, document observed behavior and attempt interventions, and physical and verbal cues to alleviate anxiety.An initial INCIDENT REPORT FORM, dated 09/06/25, showed Resident #28 slapped Resident #33 on the left cheek. The form showed redirection, one on one activity with staff, ABH gel, continue medication management, and monitor were the interventions. There was no education noted and law enforcement was not contacted. The investigation did not show safe surveys were conducted.An initial INCIDENT REPORT FORM, dated 09/09/25, showed Resident #28 entered Resident #41's room to attempt to take their walker. The form showed Resident #41 stated to let it go and Resident #28 picked up a shoe and hit Resident #41 in the face with it.The form showed PRN medication for agitation and anxiety was administered. The form showed 15 minute checks were initiated for Resident #28 and Resident #41 was monitored for safety by staff. There was no education noted and law enforcement was not contacted. The investigation did not show safe surveys were conducted.A care plan for Resident #28, updated 09/09/25, showed to apply ABH gel and to give medication. 2. An undated order summary for Resident #33 showed diagnoses of Alzheimer's and dementia.A quarterly MDS assessment, dated 06/15/25, showed Resident #33 had a BIMS of 00 which indicated severe cognitive impairment, no behaviors, and independent with mobility.An Incident Note, dated 07/12/25, showed a CNA alerted the nurse to report to the memory unit where Resident #33 was on the floor lying parallel to the bed in Resident #28's room. The nurse witnessed Resident #28 standing over Resident #33 while they laid on the floor.Resident #33's care plan was not updated to reflect the incident on 07/12/25. 3. An undated order summary for Resident #37 showed diagnosis of Alzheimer's disease.A quarterly MDS assessment, dated 05/28/25, showed Resident #37 had a BIMS of 00, indicating severe cognitive impairment, no behaviors, and independent with mobility.An Incident Note, dated 07/04/25, showed Resident #37 was smacked in the head above their ear by Resident #28.Resident #37's care plan was not updated to reflect the incident on 07/04/25.4. An undated order summary for Resident #41 showed diagnosis of vascular dementia.A quarterly MDS assessment, dated 07/02/25, showed Resident #41 had a BIMS of 9, indicating moderately impaired cognition, no behaviors, and independent with mobility.A care plan, initiated 09/09/25, showed Resident #41 had a physical altercation with Resident #28.A physician visit note, dated 09/10/25, showed Resident #41 was seen by the nurse practitioner and had soreness in their face when they were hit by another resident (Resident #28).On 09/17/25 at 4:20 p.m., CNA #1 stated Resident #28 had punched Resident #33 in the eye. They stated they did not receive any education following the incident. They stated Resident #41 had been smacked with a shoe by Resident #28. They stated they did not receive education following the incident. They were not aware of incidents with Resident #37.On 09/17/25 at 4:32 p.m., LPN #2 stated Resident #41 had been hit in the face with a shoe by Resident #28. They stated Resident #33 had two altercations with Resident #28 in the hallway on the way to the dining room. LPN #2 stated Resident # 28 attempted to kiss Resident #37 in the hallway and they slapped each other.On 09/17/25 at 5:03 p.m., the administrator stated they and the DON completed investigations. They stated the process for investigating resident to resident abuse was the staff always called the administrator and they sent in the state reportable to adult protective services. The administrator stated if there were any objective physical injuries like bleeding or a fracture, they would send out for medical evaluation. The administrator stated they would make sure the residents were separated and them conduct a 30 minute watch. The administrator stated they made sure the nurse called the doctor, family, Adult Protective Services, administration, and the DON. They stated in the memory care they just had slaps, but nothing serious.On 09/17/25 at 5:16 p.m., the administrator stated local law enforcement was notified if a resident to resident altercation resulted in a major injury, missing money, missing something of value, physical abuse, financial abuse, and sexual abuse. The administrator stated they were aware of the rules, and they were informed at a seminar conducted by the Centers or Medicare and Medicaid Service that they did not have to call the police every time as they would not do anything. The administrator stated they made a determination if the incident was significant enough for them to be notified.On 09/17/25 at 5:20 p.m., the administrator was asked where the documentation of local law enforcement being contacted for the resident to resident incident between Resident #28 and #37. They stated if it was a slap on the wrist then most likely not.On 09/17/25 at 5:30 p.m., the administrator stated Resident #41 was slapped on the head. They stated law enforcement was a waste of time and they did not do anything. They stated they did not call on this incident. They stated there were no safe surveys as there was nothing to follow up on as there were no injuries. They stated the safe surveys and education was a nursing thing that they were not sure of was done.On 09/17/25 at 5:46 p.m., the administrator asked LPN #2 if they had educated staff following the incident with Resident #28 and #37. LPN #2 stated they did not document anything and did not know to call law enforcement.On 09/17/25 at 5:52 p.m., the IP stated they did not have a QA for the incident with Resident #28 and #37.On 09/17/25 at 5:58 p.m., the administrator was asked if local law enforcement was contacted for the incident with Resident #28 and #33. They stated apparently not.On 09/17/25 at 6:13 p.m., the administrator stated they did not contact law enforcement. The administrator stated there were no safe surveys, no education, no QA, and no new interventions for the incident with Residents #28 and #37.On 09/17/25 at 6:15 p.m., the administrator stated they did not contact law enforcement. The administrator stated there were no safe surveys, no education, no QA, and no new interventions for the incident with Residents #28 and #33.On 09/17/25 at 6:16 p.m., the administrator stated they did not contact law enforcement. The administrator stated there were no safe surveys, no education, no QA, and no new interventions for the incident with Residents #28 and #41.On 09/17/25 at 6:38 p.m., the administrator stated Resident #28 had not been seen by counseling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 06/25/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent a resident with a cognitive deficit and a history of exit seeking behaviors from eloping from the facility. An order note, dated 03/08/25, showed Resident #1 tried to get out the front door. A quarterly resident assessment, dated 03/15/25, showed Resident #1's BIMS was 06 (severe cognitive impairment). A wander risk assessment, dated 04/12/25, showed Resident #1 was a high risk (score 15) for wandering. An incident note, dated 05/10/25 at 7:35 p.m., showed Resident #1 escaped the facility at approximately 7:00 p.m. Resident #1 made it one block down the road to Cimarron before worker realized they were gone. Staff assisted the resident into their car and drove the resident back to the facility. A care plan for the resident's elopement risk was not created until 05/12/25. A heath status note, dated 05/30/25, showed Resident #1 exhibited exit seeking behaviors. A combined initial and final facility reported incident, dated 06/01/25, showed Resident #1 escaped the building through the front door of the facility. Resident #1 was seen walking down the highway by the nursing home in the opposite direction. On 06/01/25 from 3:53 p.m. to 6:53 p.m., the outside temperature in [NAME] Oklahoma was 84 degrees Fahrenheit. Highway OK-33 is located in front of the facility, approximately 25 feet from the entrance door. The facility is surrounded by residential roads on the other three sides. A behavior note, dated 06/23/25 at 10:38 a.m., showed Resident #1 had attempted to exit the front door. An initial facility reported incident, dated 06/23/25, showed LPN #1 was called to the front door. The reported incident showed Resident #1 was walking across the facility lawn. The reported incident showed LPN #1 and two CNAs went to the resident and directed them back into the facility and into bed. On 06/23/25 from 9:53 a.m. to 12:53 p.m., the outside temperature in [NAME] Oklahoma ranged from 85 to 100 degrees Fahrenheit. The care plan was not updated after the resident's elopement on 06/01/25 and 06/23/25. On 06/25/25 at 4:21 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 06/25/25 at 4:50 p.m., the administrator and DON were notified of the IJ situation. On 06/27/25 at 10:53 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Effective immediately, one on one staff assignment has been made for Resident #1. Staff will remain within 10-15 feet of the resident at all times. Other interventions include prevent resident #1 from exiting the building and engage resident in a meaningful activity. Resident #1's care plan will be updated to reflect each episode of exiting the facility and will reflect the intervention described above. All other residents identified as exit seeking have had their care plan updated to reflect interventions when demonstrating exit seeking behaviors. All current staff on duty will receive inservice training that will include the intervention of one on one for resident #1, the identification of any other current resident who demonstrates exit seeking behavior, how to identify exit seeking behavior in any other current resident, to notify the nurse immediately when any resident demonstrates exit seeking behavior or elopes the facility. Staff were instructed to prevent each resident with exit seeking behavior from leaving the building and to attempt to engage the resident in a meaningful activity. All remaining staff will be inserviced either in person or by phone by 10 pm on 06.25.2025 on the above information. For those staff members inserviced by phone or otherwise unable to contact, those staff members will receive additional in person inservice at the start of their next shift. The IJ was lifted, effective 06/25/25 at 10:00 p.m., when all components of the plan of removal had been verified as completed. This was verified by observing the location of residents at risk for exit seeking behaviors, staff interviews, review of in-service information, and a review of resident records to ensure interventions were in place for residents who exhibited exit seeking behaviors. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to provide supervision to prevent a resident with a cognitive deficit and a history of exit seeking behaviors from eloping from the facility for 1 (#1) of 3 sampled residents reviewed for elopement. The infection control nurse identified six residents at risk for elopement resided in the facility. Findings: 1. On 06/25/25 at 9:03 a.m., as the surveyor was standing in the parking lot of the facility, they observed two semi trucks pass by on the highway that was located approximately 25 feet from the entrance of the facility. There were also a large set of stairs outside the facility entrance door that led to the parking lot. On 06/25/25 at 10:21 a.m., Resident #1 was observed lying in bed, then sat up independently on the side of their bed. Resident #1 started touching their blanket, giggled, then pointed to their gold colored blanket. The resident began to speak, but the words were nonsensical. On 06/25/25 at 10:25 a.m., Resident #1 moved their bedside table to the side and laid back down in their bed independently. There were no staff present in the resident's room. On 06/25/25 at 12:16 p.m., Resident #1 was observed standing in their room. CNA #2 brought the resident their meal tray and asked if the resident wanted to sit in their chair. Resident #1 walked over to the sink and obtained a napkin. On 06/25/25 at 12:17 p.m., CNA #2 opened the bathroom door and Resident #1 walked into the bathroom. CNA #2 opened the resident's meal tray and cut up the enchilada, opened the dessert, and opened the cups of liquids. On 06/25/25 at 12:19 p.m., Resident #1 exited the bathroom walked toward the surveyor and talked about their head. CNA #2 had to direct the resident on how to get soap on their hands and the resident rubbed their hands together and rinsed them in the sink. On 06/25/25 at 12:21 p.m., Resident #1 walked over to the recliner, sat down, and CNA #3 pulled the bedside table over, and put sour cream on the enchilada. The resident thanked CNA #3. CNA #3 cleaned up the resident's room, handed the resident a call light, and told the resident they would be out in the hallway if they needed anything. On 06/25/25 at 12:25 p.m., CNA #2 exited Resident #1's room. An undated procedure for locating and reporting missing residents, read in part, It shall be the plan of this facility to locate a missing client/resident as quickly as possible and return him/her to the facility to prevent an accident or any type of actual harm that might occur .Upon discovery that there is a missing client/resident, this facility will .Make a thorough search of the building for the missing client/resident and request any information from any of client/resident or visitor who may have observed any actions or have any comments concerning the missing client/resident .Make a thorough search of the grounds and land adjacent to the building .If not found, notify administrator if available. If Administrator cannot be located within 30 minutes then the next person in charge will be located and notified .Send one employee as a minimum to search the vicinity .If not found within two hours the police department is to be notified and supplied with the name and description of the client/resident along with the description of the clothing worn by the client/resident when last seen .The next of kin, responsible part, or individual who visits the client/resident shall be notify of the missing client/resident within two hours .When the client/resident is determined to be missing the Oklahoma State Department of Health will be notified by verbal or written report within 24 hours of the approximate time that the client/resident was discovered missing. An order note, dated 03/08/25, showed Resident #1 tried to get out the front door. A quarterly resident assessment, dated 03/15/25, showed Resident #1's BIMS was 06 (severe cognitive impairment). The assessment showed Resident #1 had diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and psychotic disorder. A wander risk assessment, dated 04/12/25, showed Resident #1 was a high risk (score 15) for wandering. An incident note, dated 05/10/25 at 7:35 p.m., showed Resident #1 escaped the facility at approximately 7:00 p.m. The note showed the resident made it down to Cimarron one block down the road before a worker realized they were gone. The note showed CNA #3 brought the resident back in their car and took the resident back down to their room. The note showed no injuries were found. A care plan for the resident's elopement risk was not created until 05/12/25. Resident #1's care plan, dated 05/12/25, showed the resident had the potential for elopement/exit seeking wandering. The approaches showed staff were to complete the wander risk inventory on admission, quarterly, and as needed, and staff were to ensure exit doors were activated/alarmed. The care plan showed if wandering/exit seeking was observed, staff were to remain with Resident #1, engage them in a meaningful activity or redirect the resident. It showed staff would instruct family, visitors, and residents to not open the door for others without checking with nursing staff. The care plan did not document the actual elopement on 05/10/25. A heath status note, dated 05/30/25, showed Resident #1 exhibited exit seeking behaviors. A combined initial and final facility reported incident, dated 06/01/25, showed Resident #1 escaped the building through the front door of the facility. Resident #1 was seen walking down the highway by the nursing home in the opposite direction. The facility reported incident showed the resident was placed on 15 minute checks to ensure safety. On 06/01/25 from 3:53 p.m. to 6:53 p.m., the outside temperature in [NAME] Oklahoma was 84 degrees Fahrenheit. Highway OK-33 is located in front of the facility, approximately 25 feet from the entrance door. The facility is surrounded by residential roads on the other three sides. The care plan was not updated after the resident's elopement 06/01/25. The forms provided to the surveyor for the every 15 minute checks following the incident were: a. one completed status location form dated 06/02/25 from 6:45 a.m. through 11:45 a.m.; b. one completed status location form dated 06/03/25 from 12:00 a.m. to 8:15 a.m.; c. one unlabeled, undated form that started at 5:00 p.m. and went through 11:45 p.m. There were blanks for the 6:30 p.m. and 6:45 p.m. checks; and d. one unlabeled, undated form that started at 12:00 p.m. and went through 11:45 p.m. There were blanks from 3:30 p.m. through 6:45 p.m. for the every 15 minute checks. A behavior note, dated 06/23/25 at 10:38 a.m., showed Resident #1 had attempted to exit the front door. An initial facility reported incident, dated 06/23/25, showed LPN #1 was called to the front door. The facility reported incident showed Resident #1 was walking across the facility lawn. The facility reported incident showed LPN #1 and two CNAs went to the resident and directed them back into the facility and into bed. The form was completed by LPN #1. On 06/23/25 from 9:53 a.m. to 12:53 p.m., the outside temperature in [NAME] Oklahoma ranged from 85 to 100 degrees Fahrenheit. The care plan was not updated after the resident's elopement on 06/23/25. On 06/25/25 at 10:08 a.m., family member #1 stated there were confused residents in the facility who tried to enter their loved one's room. They stated when they visited the facility, residents were in their wheelchairs at the front door, but family member #1 had not experienced them trying to leave the facility when they entered or left the facility. On 06/25/25 at 10:17 a.m., LPN #1 stated Resident #1 was a high elopement risk. They stated the resident had dementia and an altered mental status. They stated Resident #1 walked independently. On 06/25/25 at 1:04 p.m., family member #2 stated Resident #1's mind was not 100 percent. They stated at times, Resident #1 did not know family member #2's name. On 06/25/25 at 1:08 p.m., family member #2 stated they had been called several times over the past month and a half by the facility regarding exit seeking behaviors. They stated on two occasions Resident #1 did get out of the facility. Family Member #2 stated on one occasion Resident #1 went toward the residential neighborhood and someone had brought them back in a car. They stated the other time Resident #1 went right out the front door towards the highway. On 06/25/25 at 1:11 p.m., family member #2 stated the facility told them they were watching for where Resident #1 was at in the building. They stated the facility was doing what they could to care for Resident #1. On 06/25/25 at 1:21 p.m., CNA #1 stated if a resident did go outside the building, they would do their best to try to get them back inside. They stated they would notify the DON and administrator depending on how far they got. On 06/25/25 at 1:26 p.m., CNA #1 stated the facility doors were locked and required a code to open. They stated if you pushed on the door too long, it would open after about 15 seconds. They stated that was probably how the residents were getting out. On 06/25/25 at 1:27 p.m., CNA #1 stated Resident #1's cognition was not the best. They stated the resident was not oriented to person, place or time. They stated the resident would often ask where they were and what was going on. On 06/25/25 at 1:28 p.m., CNA #1 stated they were not working at the time, but had heard Resident #1 had escaped the building a couple of times. They stated staff were to check on the resident every fifteen minutes and document what they were doing. On 06/25/25 at 1:32 p.m., CNA #1 stated Resident #1 walked independently. On 06/25/25 at 1:32 p.m., the administrator stated Resident #1 had severe dementia. They stated in the last month, the resident was smart enough to know if they pushed on the door 15 seconds it would open. The administrator stated they could not afford to have a guard standing at the gate 24 hours a day to guard the door. On 06/25/25 at 1:34 p.m., the administrator took the surveyor down a hall where no residents resided. There was a double door at the end of the hall the administrator explained this was going to be the memory unit at the facility. They stated Resident #1 would be the first resident when it opened and it would be a locked unit. On 06/25/25 at 1:36 p.m., the administrator stated once the facility got the memory unit opened in the next seven to 14 days, Resident #1 would not be able to get out anymore. They stated that was their plan of correction. On 06/25/25 at 1:39 p.m., the administrator stated they were proactively dealing with Resident #1. On 06/25/25 at 2:18 p.m., CNA #2 stated the past couple of times a resident had eloped the facility had completed every fifteen minute checks on Resident #1. They stated they were here when Resident #1 escaped on 06/23/25. CNA #2 stated staff went outside, redirected the resident, sat them outside, and brought them in through the door of the skilled unit. CNA #2 stated Resident #1 had been wandering all morning that day. They stated a coworker redirected the resident to the dining room. CNA #2 stated when they came back from the bathroom, kitchen staff alerted them Resident #1 was outside because they could see them through the windows in the dining room. CNA #2 stated that was when they went and got the resident from outside. On 06/25/25 at 2:22 p.m., CNA #2 stated they took Resident #1 to the bathroom, laid them down, and were completing every fifteen minute checks on the resident to prevent them from eloping again. CNA #2 stated the resident was pretty drained because it was pretty hot outside. CNA #2 stated the resident was near the [NAME] Nursing Home sign by the highway when they got them. On 06/25/25 at 2:25 p.m., CNA #2 stated they had not received training related to elopement. They stated the door was locked and a code was needed to open it. They stated if you held the door long enough, it would open. They stated they believed that was with every door. On 06/25/25 at 2:49 p.m. CNA #3 stated they did not know the policy for elopement. They stated they knew elopement was when a resident was exit seeking. They stated if a resident did exit the building, they would first assess the situation and make sure they were ok. They stated they would speak to them calmly and try to redirect them in the right direction. On 06/25/25 at 2:51 p.m., CNA #3 stated they had not received any training related to elopement. 06/25/25 at 2:52 p.m., CNA #3 stated the facility had doors that locked and required security codes to keep residents from exiting the building. They stated they believed the memory care unit that was opening would help. On 06/25/25 at 2:54 p.m., CNA #3 stated on 05/10/25, they saw Resident #1 walking down the road when they got off work. CNA #3 stated they brought the resident back to the facility in their car. On 06/25/25 at 2:58 p.m., CNA #3 took the surveyor outside and pointed to [NAME] the road directly behind the skilled unit. CNA #3 stated they believed Resident #1 was on Pine and thought Resident #1 got out through the skilled door but no one knew for sure. CNA #3 stated Resident #1 had been trying to go out the skilled door earlier on their shift and they had to redirect them that night before they left. CNA #3 stated Resident #1 made it another block and a half. They stated they picked Resident #1 up at Pine and Cimarron. CNA #3 stated they were doing 15 minute checks on the resident, but was not sure if they were still in place. They stated they were unsure if the resident had gotten out another time but, We all know [the resident] has attempted it. On 06/25/25 at 2:34 p.m., LPN #1 stated the policy for elopement was to get the resident safe and into the facility if possible, notify the physician, DON, administrator and family. They stated they had been completing 15 minute checks and were working on a policy for how long the facility was going to complete the 15 minute checks. They stated staff tried to keep as many eyes on the resident to keep them safe and prevent elopement if possible in the future. On 06/25/25 at 2:36 p.m., LPN #1 stated they did not think they had received specific training on elopement. They stated if a resident exhibited exit seeking behaviors they would try to redirect them with an activity, snack, or some alone time in their room. They stated they would also increase the amount of times they were checking on them. On 06/25/25 at 2:37 p.m., LPN #1 stated the facility had double doors with a lock system on them and staff were at the desk most of the time to keep an eye on the door. On 06/25/25 at 2:38 p.m., LPN #1 stated Resident #1 was only alert and oriented to self. They stated the resident often times looked for their family. They stated the resident was confused and needed help finding their room. They stated the resident walked on their own. On 06/25/25 at 2:39 p.m., LPN #1 stated they were only present for Resident #1's elopement on 06/23/25. They stated prior to the elopement, the resident was exhibiting exit seeking behaviors. LPN #1 stated staff took the resident to their room, changed their clothes, got them a drink in the dining room and took them to the television room. LPN #1 stated Resident #1 seemed comfortable in the dining room. LPN #1 stated they had to go complete blood sugars and heard a scream and observed Resident #1 walking on the lawn. They stated they along with two other staff members got the resident back inside through the side door. LPN #1 stated they believed Resident #1 pushed the door for the 15 seconds and it opened. On 06/25/25 at 2:41 p.m., LPN #1 stated they resident agreed to go to bed because they were tired and wanted to go home. They stated once the resident was able to see their personal belongings, they recognized their room. LPN #1 stated they obtained the resident's vital signs, looked the resident over, and placed the resident on 15 minute checks. On 06/25/25 at 2:45 p.m., LPN #1 stated they were aware of other elopements and believed Resident #1 had eloped two or three times in the past month or two. On 06/25/25 at 3:03 p.m., the infection control nurse stated RN #1 who completed the facility reported incident on 06/01/25 was the former DON. They stated RN #1 had not been at the facility since 06/15/25. On 06/25/25 at 3:06 p.m., the infection control nurse stated to their understanding, if a resident got out of the facility and did not leave the property, they completed an internal incident report and notified the administrator and DON. They stated if the resident left the property including getting to the highway, a State reportable incident should be completed and the administrator, DON, family, and physician should be notified. They stated staff would go and look for the resident, and once located and brought back, then everyone would be notified. On 06/25/25 at 3:08 p.m., the infection control nurse stated they had not received training related to elopement. They stated Resident #1 was always looking for their family member. They stated when Resident #1 left, they were trying to find their family member. On 06/25/25 at 3:09 p.m., the infection control nurse stated the facility had locked doors. They stated if the doors did not shut all the way, an alarm would sound so staff would know it was open. They stated the facility did have a couple exit seeking residents. On 06/25/25 at 3:10 p.m., the infection control nurse stated Resident #1 had full blown dementia and did not know they were in a nursing home. They stated the resident did know their name and knew who their family member was. They stated the resident walked on their own and went to the bathroom on their own. On 06/25.25 at 3:12 p.m., the infection control nurse stated the elopement they knew about for Resident #1 was on 05/10/25. They stated the only way they knew about the one on 06/23/25 was LPN #1 came in and said there was a commotion in the dining room. They stated another resident was hollering for staff because they were in the dining room and saw Resident #1 was outside. They stated Resident #1 was in the front lawn towards the highway. They stated they did not know about the one on the highway, but was told about it. On 06/25/25 at 3:16 p.m., the infection control nurse stated as of now the facility was going to continue the 15 minute checks on Resident #1 until the memory care unit was opened on 07/01/25. On 06/25/25 at 3:19 p.m., the DON stated they had just looked up the elopement policy. They stated staff were to look around the building grounds and if the resident was missing two hours, they were to notify the police. They stated staff were to notify the family immediately. They stated they were to give a description of the resident, complete a State reportable within 24 hours, and complete an incident report. On 06/25/25 at 3:20 p.m., the DON stated they had not received or provided any training related to elopement, but it was on the list. They stated when residents were exhibiting exit seeking behaviors, staff were to redirect or distract them by taking them to the television room, giving them an activity to do, or give them a snack. They stated staff were to be notified when residents exhibited exit seeking behaviors and the information was to be passed on in report. On 06/25/25 at 3:22 p.m., the DON stated the facility had coded doors and a different code to enter and exit the building. They stated they were break away doors and if you held them long enough they would open. The DON stated if a resident did elope, staff were to notify the DON and the administrator, complete a head to toe assessment to make sure there were no injuries, and complete frequent checks. They stated it was not in the policy, but they usually completed every 15 minute checks. On 06/25/25 at 3:23 p.m., the DON stated Resident #1 was very confused and oriented to self only. They stated the resident ambulated independently most of the time. On 06/25/25 at 3:25 p.m., the DON stated they were unable to find the every 15 minute checks for the 05/10/25 or the 06/01/25 elopement of Resident #1. They stated the every fifteen minute checks were to be documented on the status location forms. The DON stated the 06/01/25 facility reported incident did document Resident #1 was on every fifteen minute checks to ensure safety. The DON stated Resident #1 was on 15 minute checks now. On 06/25/25 at 3:28 p.m., the DON stated Resident #1 was on every 15 minute checks for 24 hours, then the facility was completing every 30 minute checks. The DON stated they spoke to the facility nursing specialist who instructed them to go ahead and keep the resident on 15 minute checks because they were such a high risk. On 06/25/25 at 3:30 p.m., the infection control nurse brought in the every 15 minute checks and every 30 minute checks for Resident #1 for the elopement on 05/10/25 and 06/01/25. There were forms dated 05/10/25 through 05/12/25 completed. For the 06/01/25 elopement, they provided two forms with no dates, one form dated 06/02/25 and one form dated 06/03/25. The infection control nurse stated there were no dates on the two pages and if it was not dated they did not know when it was done. The infection control nurse identified the blanks in documentation on one of the undated forms from 3:30 p.m. through 6:45 p.m. On 06/25/25 at 3:32 p.m., the infection control nurse identified the blanks in documentation for 6:30 p.m. and 6:45 p.m. on the other undated form. On 06/25/25 at 3:54 p.m., the DON stated Resident #1's most recent wander risk assessment was completed on 04/12/25 and showed the resident was a high risk to wander. On 06/25/25 at 4:16 p.m., the administrator stated the facility did not have a specific elopement policy. They stated they had a missing persons policy. They stated when staff realized a resident was missing, it was all hands on deck and everyone looked for them. They stated if they could not locate them, they would notify the police and fire department to complete an area search. They stated most of the time they would catch them on the property, bring them back inside and complete every 15-30 minute checks on them to watch them more closely. On 06/25/25 at 4:20 p.m., the administrator stated they completed orientation with new employees and they assumed elopement was discussed in the training procedure. They stated you did not need any formal training, it was common sense if someone was wandering staff needed to keep an eye on them. The administrator stated when Resident #1 first exited the building, the nurse was the former DON. The administrator stated they would think they would know to send something into the State. The administrator stated when they returned to the facility the following Monday after 05/10/25, they asked staff if they completed a report to the state and they said no. The administrator stated they instructed them to complete one. They stated they did not think RN #1 even put anything in the nurses' note. On 06/25/25 at 4:26 p.m., the administrator stated the nurses and aides were busy. They stated they could see Resident #1 one minute and three minutes later they were out the door. They stated they wished they could lock the door where they could not get out, but due to life safety, they could not. They stated they were shocked Resident #1 was cognitive enough to push on the door until it opened. The administrator stated they facility was keeping a close eye on the resident and documenting every 15 minute checks. They stated prior to 05/10/25 they had no problems, and all of a sudden Resident #1 escapes three times. The administrator stated the DON was new, but the infection control nurse would know what assessment they used to identify residents at risk for elopement. The administrator stated they were unable to remember if QAPI was involved in the elopements and to ask the infection control nurse to verify. On 06/25/25 at 4:36 p.m., the infection control nurse stated the facility completed a wandering risk under the assessment tool to determine a resident's elopement risk. They stated they were completed quarterly. On 06/25/25 at 4:38 p.m., the infection control nurse stated QAPI had not had any involvement with the elopements. 2. A quarterly resident assessment, dated 03/30/25, showed Resident #8's BIMS score was 15 (cognitively intact). On 06/25/25 at 10:34 a.m., Resident #8 stated the door to the facility was supposed to be locked. They stated a couple days ago, a resident got out. Resident #8 stated they did not know what the resident was doing playing on the highway. They stated there were two or three residents who liked to get out of the facility because their minds weren't right. Resident #8 stated they did not know the names of the residents. 3. An annual resident assessment, dated 05/29/25, showed Resident #9's BIMS score was 15 (cognitively intact). On 06/25/25 at 10:41 a.m., Resident #9 stated there were residents who wandered in the facility. They stated they had to keep their door to the bathroom locked so Resident #1 and Resident #2 would not wander into Resident #9's room.