**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of the facility policy, the facility failed to ensure a significant medication error did not occur for 1 of 3 residents reviewed for medication administration. Specifically, Resident (R)1 received the medications intended for R6. R1 did not receive any of her prescribed medications. This resulted in R1 experiencing a drop in blood pressure which required hospitalization. On 09/26/23 at 2:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 09/26/23 at 2:00 PM, the survey team provided the Administrator and Director of Nursing (DON) with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 09/17/23. The IJ was related to 42 CFR 483.45 - Pharmacy Services. On 09/26/23 at 2:00 PM, the Administrator and DON were notified that the failure to ensure a resident received the correct medications per physician orders constituted IJ at F760. On 09/26/23 at 4:27 PM, the facility provided an acceptable IJ Removal Plan. The survey team, validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The IJ is considered at past non-compliance dating back to 09/18/23. An extended survey was completed in conjunction with the Complaint Survey for noncompliance at F760, constituting substandard quality of care. Findings include: Review of the facility policy titled, Handling of Non-Controlled Medication, Number 20 states, Identify each resident by name and picture in MAR (Medication Administration Record). Administer medication in accordance with the six (6) rights of Medication Administration: RIGHT RESIDENT, RIGHT DRUG, RIGHT DOSE, RIGHT FORM, RIGHT TIME AND RIGHT ROUTE. Review of R1's, Face Sheet, revealed the facility admitted R1 on 02/06/23, with diagnoses including, but not limited to, urinary retention, cognitive communication deficit, neurogenic bladder, congestive heart failure and chronic kidney disease. Per the medical record, R1 no longer had a diagnosis of hypertension and was receiving Hospice Care and Services for a diagnoses of congestive heart failure. R1 was admitted to hospice on 02/27/23. Review of R1's Physician Orders revealed R1 was supposed to receive the following medications: Zofran disintegrating 4mg 1 po q6 hours prn, Zoloft 50mg 1 po qd, Lorazepam 0.5mg 1 po q6 hours prn, Melatonin 10mg 1 po qhs, Glycopyrrolate 1mg 1 po qid prn, Bisacodyl Suppository 10mg qd as needed, Artificial Tears tid prn, Acetaminophen 650 suppository q4 hours PRN, Albuterol Sulfate duo nebs q4 hours PRN, Hydrocodone - acetaminophen 5-325mg 1 po q6 hors prn. Review of R6's MAR dated 09/17/23 revealed R1 was administered, Acetaminophen 500 mgs, Amlodipine 10 mgs, Aspirin 81 mgs, Carvedilol 6.25 mgs, Gabapentin 400 mgs, Hemocyte Plus 106 mgs, Miralax 17 grams, Plavix 75 mgs, Potassium Chloride 20 milliequivalents (meqs), Prozac 20 mgs, Torsemide 20 mgs and Zyrtec 10 mgs. These medications were intended for R6 and not R1. Review of R1's vital signs recorded on 09/17/23 at 09:30 AM revealed a blood pressure of 101/61. At 9:45 AM revealed a blood pressure of 96/58 and a heart rate of 75. At 10:00 AM the blood pressure was 89/50 and the heart rate was 74. There was no blood pressure charted at 10:15 AM but the heart rate was documented as 68. At 10:30 AM the blood pressure was 92/56 and the heart rate was 65. At 10:33 AM the blood pressure was 85/55 and the heart rate was 65. Review of R1's Progress Notes dated 09/17/23 at 11:40 AM states, Ambulance came to pick up resident at 10:50 AM. Resident is alert and oriented x3, vital signs were taken every 15 minutes and documented, and fluids were pushed prior to leaving via ambulance. Review of R1's hospital records indicated that R1 was received in the emergency room on [DATE] at 11:16 AM. R1 was eventually sent to the Intensive Care Unit (ICU). The reason for admission is listed as hypotension and the report states, A [AGE] year old female presents to the emergency department for evaluation of medication ingestion. Further review of the hospital record revealed R1's blood pressure was recorded as 85/48 with a heart rate of 67. During an interview on 09/26/23 at 10:58 AM, the Director of Nursing (DON) stated that when the nurse reported the incident we started taking the vital signs every 15 minutes and after 45 minutes we sent her out to the hospital. The DON stated that the nurse is a new nurse. The next day we put arm bands on all residents unless they refused to wear them. Residents are care planned for the arm bands and the refusals. During an interview on 09/26/23 at 11:25 AM, LPN1, the nurse that administered the medications in error, stated, I was working on the unit and I did not know the residents. [R1] required her medications to be crushed, so I gave [R1's] roommate her medications first, she takes them whole. So to save time, I pulled [R6']s medications and when I went back to the medication cart, I saw [R1's] picture still green on the screen, indicating that she was to receive the medications I had pulled. So I crushed the medications and carried them into [R1]. I was looking at [R1] on the report sheet. [R1] received the medications that were meant for the resident next door [R6]. I recognized the error immediately, and panicked and called the nursing supervisor. We started taking the vital signs every 15 minutes. The supervisor contacted the physician and the resident's personal representative and then assisted me with taking the vitals and monitoring the resident. When the blood pressure dropped down the supervisor made the decision to send the resident to the hospital. During an interview on 09/26/23 at 2:00 PM, the Administrator stated that the resident had received the wrong medication. She also stated at this time, we have done all the in services and things were put into place to ensure this does not happen again. During an interview on 09/26/23 at 3:35 PM, the Medical Director (MD) stated, I do not know how this resident could have received the wrong medication. I ordered for the staff to monitor her closely and if her blood pressure started to drop to send her to the emergency room. On 09/26/23 at 4:27 PM, the facility provided the following removal plan: Allegation of Compliance 09/26/2023 Medication Administration Error Action Plan 09/18/2023 Root Cause Analysis: New Grad Nurse assigned to a new unit for the first time on Sunday. Following a consecutive line of medication administration/failed to identify resident using the 5 (five) rights. 1. Nurse was provided orientation on hire. (Start Date 06/12/2023) on orientation until 07/14/2023 (1:1). Nurse was re-educated on 09/17/2023 on the 5 Rights and Medication Administration and received a written anecdotal related to her missing patient identification prior to administering medications. a. Nurse will be provided with a re-education action plan where she receives additional orientation from the Nurse Manager/Pharmacy Consultant related to medication administration. (Continues, complete 09/27/2023) b. Supervisor was notified by nurse, MD was notified, RP was notified. Orders obtained to do vital signs Q15 minutes x 2 hours as well as push fluids. (send to ER if condition worsens) c. Resident was sent to the ED related to a BP of 85 systolic. 2. All resident location verified by admissions related to census and ensured door signs accurate 09/18/2023. 3. All nurses received remedial education related to Medication Administration started 09/18/2023. 4. Pharmacy Consultant to continue periodic Med Pass Observations with Nurses. a. Nurse Manager will conduct Med Pass Audits on each unit weekly x 4 weeks (results of those audits will be reviewed by leadership and nurse specific education will be provided to address any concerns.) 5. Pictures in the EMAR were verified by the Unit Secretary. 6. Audits were conducted on all current residents 09/18/2023 to ensure that door labels were correct as well as arm bands were in place. (Completed by Admissions on 09/18/2023) 7. Audit of existing residents for accurate door signs, and picture in the EMAR weekly x 4 weeks by ADON and Unit Managers. 8. Orientation updated to include med pass observation skill check off for new nurses. (Staff Development)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, and interviews, the facility failed to provide necessary care and services for a dialysis resident that was diagnosed with pseudo-aneurysm (a leakage of arterial blood from an artery into the surrounding tissue). Specifically, on [DATE] at 5:15 AM Resident (R)1 was found by Nurse (N)1 lying in bed surrounded by blood with a large amount of blood observed on floor. R1 had no pulse and was unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated and 911 was called. R1 was pronounced dead at 5:54 AM by Emergency Medical Services (EMS). On [DATE] at 4:40 PM, the Administrator was notified that the failure to provide necessary care and services to a resident diagnosed with pseudo-aneurysm constituted Immediate Jeopardy (IJ) at F600. On [DATE] at 4:40 PM, the surveyor provided the Administrator with a copy of the CMS Immediate Jeopardy Template and informed the Administrator that IJ existed as of [DATE]. On [DATE], at 7:40 PM, the facility provided an acceptable IJ removal plan. The immediacy of the IJ was removed on [DATE]. The IJ was lowered to a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy). An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the Facility's policy titled Abuse/Neglect/Misappropriation/ Elder Justice Act with a prepared by date of [DATE] revealed, Residents has the right to be free from abuse, neglect . This also includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Review of the Facility's policy titled Care of the Resident Receiving Hemodialysis with a prepared by date [DATE] revealed, To provide optimal maintenance and preventive care for the resident who is receiving Hemodialysis. Procedure 2. Inspect the access site daily . 4. Upon Return (Post-Treatment) from Dialysis: Review of Residents condition. a. Note information sent from Dialysis Center. b. Document required information on Dialysis Resident Communication Report form. c. Note resident's condition/complaints. e. Check Vascular Access site (Shunt or Central Line): Observe site for bleeding, pain, tenderness, discharge . Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: End Stage Renal Disease, hypertension, major depression, Type 2 Diabetes Mellitus, hypothyroidism and morbid obesity. Further review of R1's Face Sheet revealed, R1 has a Full Code advance directive. Review of R1's unspecified Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating R1 had mildly impaired cognitive status. Review of R1's Physician Orders revealed R1 receives dialysis three times weekly, on Tuesdays, Thursdays, and Saturdays for diagnosis of End Stage Renal Disease. Review of R1's Dialysis Resident Communication Report dated [DATE] revealed, Questions, Problems, Concerns, New Orders: pseudoaneurysm on LUA (Left Upper Arm) access . Physicians office was notified on [DATE]. Further review revealed, R1 was stable, alert and oriented, and access site was clear. Review of R1's Nurses Progress Note dated [DATE] at 5:15 AM revealed, Approximately at 5:15 am, during rounds patient was found lying in bed full of fresh blood, blood on the floor on the left side of the bed and shirt full of blood with blood sitting on her chin; Patient was checked, and the patient was not breathing or responding to name being called or to touch. An interview with Certified Nursing Assistant (CNA)1 on [DATE] at 11:31 AM revealed, CNA1 last checked on R1 around 3:30 AM and gave her a peanut butter and jelly sandwich and a blanket because R1 stated she was hungry and cold. An interview with Registered Nurse (RN)1 on [DATE] at 11:47 AM revealed, RN1 heard the code being called, she got the crash cart, pulled out the back board and began CPR. RN1 further revealed, when she arrived in the room, she observed a lot of blood in R1's bed and on the floor. An interview with the Director of Nursing (DON) on [DATE] at 2:47 PM revealed, the DON did not know what a pseudo- aneurysm was. The DON stated she follows the standard procedures when residents return from dialysis. An interview with Licensed Practical Nurse (LPN)1 on [DATE] at 2:52 PM revealed, LPN1 did not work with R1 the night in question but as an ex-dialysis nurse if she had seen the concern for a pseudo-aneurysm, she knew that was bad and she would have sent the resident to emergency room. An interview with LPN2 on [DATE] at 4:23 PM revealed, LPN2 checked R1 in from dialysis on [DATE]. LPN2 stated she read the concerns on the communication report and was aware pseudo-aneurysm was noted, but she was not aware of anything else that she could do. LPN2 further stated she saw where the dialysis clinic was making a doctor's appointment, so she did not know if there was any monitoring other than what she had already done for the resident. The Facility's Removal Plan included the following: Supplies: Location of Crash Carts - The team evaluated the current location of all facility crash carts which are located at . After discussion the crash cart from [NAME] will be relocated to Crews Point. 1. Units without a crash cart - An adult back board and ambu bag containing a small and adult mask will be placed on those units. These will be placed in a bag within the nursing station. 2. Tourniquet - Will discuss with medical director the recommendation of placing a tourniquet on the crash cart. A. Orders 1. Revise Order Set 2. Revise communication tool between facility/dialysis agency. B. Communication 1. Revised Communication Tool to be between facility and dialysis agency. 2. Communication books to be uniform. A. Notebooks to be with cover to include resident's name, dialysis center, schedule, transport company with pick up time, chair time. B. Content 1. Face Sheet 2. Code Status 3. Physician Order to include dialysis agency, days/week. 4. Daily Communication tool with most recent document forward. D. Education 1. Revised Order Set 2. Revised Communication Tool 3. Location of Crash Carts 4. Care of the dialysis patient a. Observation of AV site daily and after dialysis b. Review of communication forms and orders/Diagnosis/MD consults. E. All current Dialysis patients were reviewed for diagnosis of Dialysis site complications for the past 30 days: a. [R2] no complications b. [R3] no complications c. [R4] no complications d. [R5] no complications e. [R6] no complications f. [R7] no complications g. [R8] no complications F. Dialysis communication sheets and Site assessments will be reviewed weekdays in IDT meeting to ensure no Site complications are evident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the facility policy titled, Standard Policy/Procedure: Fall Prevention Program last revised 2/14/23, revealed The facility will endeavor to reduce resident falls through a comprehensive fall evaluation and prevention program. Residents at risk for accidents and/or falls shall be identified and have care plans and procedures in place to reduce the falls and injuries related to falls. Fall risk observations are to be completed on new admissions, re-admissions, quarterly and annually. R8 was admitted to the facility on [DATE] with diagnoses including; but not limited to; fracture of right femur, unsteadiness on feet, type 2 diabetes, and dementia with behavioral disturbances. Review of the Quarterly MDS with an ARD of 12/6/22, revealed R8 has a BIMS score of 13 out of 15, which indicates she is cognitively intact. R8 requires extensive assistance with most activities of daily living (ADL). Further review revealed R8 has a bed alarm in use daily during this assessment period. An observation and interview on 3/15/23 at 8:30 AM revealed R8 in her room, at the end of the unit, with slight confusion, fall mats noted on both sides of the bed. R8 was attempting to get out of bed during the interview, but was easily redirected. Record review on 3/14/23 at 1:00 PM of a Progress Note dated 12/12/22 at 3:30 AM revealed while in another resident's room, yelling heard from the end of the hall. A Certified Nursing Assistant (CNA) checked on the resident and resident was noted on the floor. I enter the room and noted resident on knees leaning against the bed. Resident stated she was trying to get her pillow, knees red, no open skin. Resident denies hitting contact with head, supervisor called to assess resident. Resident then placed back in bed and personal care provided, bed in the lowest position and call light within reach. Resident Representative notified with voice message and Medical Director. Review of a Care Plan with a revision date of 3/9/23 revealed At increased risk for falls/injury related to history of falls at previously while living at an assisted living facility with a left femoral neck fracture. 12/12/22 fall with no injury; 2/6/23 in room injury; 3/7/23 noted sitting on floor mat. A phone interview on 3/15/23 at 10:00 AM with Resident Representative (RR) for R8 revealed the resident has had numerous falls and has a history of falls. Prior to being admitted to this facility the resident was in assisted living and had fallen there as well, when the resident gets anxious she believes that she is still able to walk and normally falls and hurt herself. When R8 was admitted , I expressed these concerns about her prior history of falling with staff. I visit the resident fairly often and have not witnessed the resident with a fall mat or the bed lowered until the resident broke her femur in February (2/6/23). I don't know why they didn't make any interventions or put any fall mats/protection next to her bed to prevent her from injuring herself until it actually happened. An interview on 3/15/23 at 10:21 AM with RN1 revealed, I assessed R8 after her fall on 2/6/23 and on that day the resident had no complaints of pain at that time. The next day the resident told other staff that she was having knee pain and was later sent and it was determined the resident had a right femur fracture. RN1 further stated our policy for fall prevention is that we start with smaller interventions at first such as lowering the bed or maybe adding a bed alarm then move to bigger interventions such as bed mats or moving the residents' room closer to the nurse's station for more observation. RN1 stated she was not familiar with R8 and was unsure if R8 had previous falls. Review of R8's Progress Note dated 02/06/23 at 5:40 PM revealed, resident found of the floor on the left side of the bed. Per resident, she was attempting to clean crumbs on the nightstand. Fall was not witnessed by staff; resident was assessed, and no visible signs of injuries were noted. Resident noted with no pain or injury and Range of Motion (ROM) is normal for this resident. Fall vital with head contact ordered due to being unwitnessed, supervisor and RR notified. Review of R8's Progress Note dated 02/06/23 at 5:58 PM revealed ,Nurse supervisor called to assess resident in bed after fall, denies any pain and is able to move extremities to her personal limits. States knees hurt, but that they always hurt, respirations even, no sign of distress. Review of R8's Progress Note dated 02/07/23 at 11:13 AM revealed, resident complaining of right knee pain, slight redness noted to the right knee, resident had a fall at 5:15 AM this morning. Resident noted with increased confusion and is a high fall risk due to decreased safety awareness related to dementia. Xray of right knee ordered will obtain urine analysis (UA) and bilateral floor mats have been initiated. RR and Medical Director (MD) notified related to new orders. Review of R8's Progress Note dated 02/07/23 at 5:14 PM revealed, MD notified of Xray results showing fracture of right femur supracondylar (thigh bone broken at the knee) with 14-millimeter displacement. New orders received to send to hospital for further evaluation and treatment. Review of a Progress Note dated 03/07/23 at 10:45 AM revealed, resident found on floor, upon entering the resident's room bed [NAME] [sic] alarming. Observation revealed resident on floor mats on the side of the bed closest to the door. Resident stated I can't get up, and unable to recall how they had fallen or if she hit her head. Resident noted to be incontinence with stool, resident placed back in bed and incontinence care provided. Resident sent to hospital per MD due to unable to complete right femur and right knee Xray, RR notified. Review of a Progress Note dated 03/08/23 at 11:40 AM revealed, resident will be transported back to the facility via transportation, Xray for right knee and right hip results negative of any fractures. An interview on 03/15/23 at 10:35 AM with RN2 revealed, I was not here when the resident fell, but staff reported to me that they found her kneeling by her bedside, but when staff assessed her the resident had no major complaints of pain at the time. The next day when I came to work, the resident complained of knee pain, so we ordered a X-RAY for the resident and confirmed the resident broke her right femur. Interventions we use to prevent a resident from falls with injury is discussed as a team and with family members during care plan meetings We also start with small interventions, such as; more supervision then move other interventions such as floor mats, bed alarms, or room changes for closer supervision o reduce the number of falls with injury. Amended 04/07/23 Based on review of the facility policy, record review, observations, and interviews, the facility failed to ensure adequate supervision was provided to prevent accidents/hazards for 1 of 3 Residents (R)14, reviewed. On 03/12/23, R14 had a successful elopement from the facility. On 03/12/23, at approximately 7:00 AM, R14 eloped from the facility through a gated courtyard between the [NAME] Circle Unit and Camelia Court Unit. At approximately 7:42 AM on 03/12/23, R14 was found alongside the back of the facility, and returned unharmed. R14 was dressed in full street clothing, to include a long-sleeved shirt, pants, and shoes. The weather was noted to be overcast at about 50-60 Degrees Fahrenheit. On 03/14/23, at 12:52 PM, the Administrator was presented with an Immediate Jeopardy (IJ) template indicating IJ existed at F689 with a start date of 03/12/23 and an end date of 03/14/23. The facility presented an acceptable removal plan on 03/14/23. Implementation of the plan was verified through observation, staff interviews, and record reviews. Observation verified that all door alarms were functioning successfully. Documentation review revealed staff was educated on wandering/elopement policy and procedures and immediacy on responding to door alarms. This failure constituted substandard quality of care, resulting in the completion of an extended survey. Additional review revealed the facility failed to provide adequate supervision to protect 1 of 4 Residents, R8 from sustaining injuries during falls within the facility. Findings include: Review of the facility's policy titled, Missing Resident Plan: Code Purple revised on 03/14/23 revealed It is the policy of this facility to respond immediately with emergency procedures when a resident has been identified as missing. R14 was admitted to the facility on [DATE] with diagnoses including but not limited to vascular dementia, muscle weakness and unsteadiness on feet. Review of R14's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/01/23 revealed R14 has a Brief Interview of Mental Status (BIMS) score of 12, indicating mild cognitive impairment. Review of Section E of the MDS related to Behaviors indicated R14 had not exhibited any behaviors of wandering. Review of Section G of the MDS indicated R14 required limited to extensive assistance with locomotion on the unit with the assist of one person, physically. Review of R14's admission Elopement Assessment completed on 02/23/23 revealed R14 to be evaluated as not an elopement risk. Following his successful elopement, a second assessment was completed on 03/13/23, indicating he is now an elopement risk. Review of R14's Physician Orders indicated an order dated 03/14/23 revealing, Secure care bracelet and move to secure unit due to elopement, dementia and per family phone call 3/12, history of wandering. Review of R14's progress notes indicated a nursing note timed and dated 03/12/23 at 7:10 AM which revealed, Nurse supervisor: Notified by staff that resident cannot be found and that it was noted that gate between [NAME] Circle and Camellia Court was open. Code purple immediately called. Administrator called. Public safety at LMC called and 911 called. Additional nursing notes revealed on 03/12/23 at 7:42 AM, Nurse supervisor: Resident has been located at the back of the facility. Pant legs were wet. Resident easily assisted back to his room. Nurse at bedside. An additional note on 03/12/23 at 7:58 AM read, Assess resident. No new injuries noted. Peg tube noted to abd. Dsg to sacrum in placed [sic]. Wet shoes and wet pants to shin noted. Resident stated he accidently stepped in the pond. Took off wet socks and replaced with dry socks. Resident refused to change pants and didn't want hospital pant. An additional note in the medical record dated and timed as 03/12/23 at 08:07 AM read, Resident stated he's going to wait until the sun is up to go outside near the pond to get his car tire air in [sic]. Secure bracelet placed on L ankle. During an interview with the Lead Floor Technician (LFT) on 03/14/23 at 11:34 AM revealed on 03/12/23 at approximately 7:00 AM, he clocked in to work. Shortly after, the nursing supervisor called a code purple. He immediately began searching and later found R14 near the trash compactor, time was unknown/undocumented, but he thinks it was around 8:00 AM. The LFT stated he calmly approached R14 and asked him where he was going. R14 stated to him that he was trying to get back to his shop, but everything was locked up. The LFT stated he then noticed R14's pants to be wet and asked him what happened. R14 stated he was near the pond and stepped in a hole. At this time, R14 began walking back towards the facility with the LFT and he was handed off to the nursing staff, who helped him into the facility and assessed him. During an interview with the Director of Facilities and Property Services (DOFPS) on 03/14/23 at 11:45 AM, he led a tour of the believed trail R14 took to exit and return to the facility. The tour revealed areas that included parking lots, rugged traverse, and muddy areas. The DOFPS revealed he was able to map out the trail due to cameras that were placed alongside the buildings on the facility's property. He also provided copies of the video surveillance to the survey team. During an observation and interview on 03/15/23 at 9:52 AM with R14 revealed him sitting up in his bed with staff present. R14 appeared clean and calm. He stated he was getting ready to go to his shop. When asked where his shop was, he stated, It's down the street, but they have it locked up. When asked if he remembered the incident of the elopement and what happened, he stated, I walked out the building to get to my shop, but every door I went to was locked. I need to go and get back to work, because people are going to be waiting for their cars. He stated he did not get hurt, but he did remember stepping in the pond and when he got back to the facility, they gave him clean and dry clothes. During an interview with Licensed Practical Nurse (LPN)1 on 03/15/23 at 9:58 AM, LPN1 stated he was R14's nurse for today. He stated R14 had not expressed to him any concerns or ideas related to wanting to leave the building at this time. During an interview on 03/15/23 at 10:15 AM, Registered Nurse (RN)1 revealed she was the nurse in charge when the incident occurred. It was right at shift change when she received a call from the unit that said R14 was not in his room. At that time, 2 night shift supervisors got up to assist in locating R14. RN1 stayed in the room to complete the staffing sheets for shift change. She then received a call saying the gate was open. At that time, she immediately activated a Code Purple, called the Administrator, Public Safety and 911. When she remembered she had access to the facility's surveillance cameras, she returned to the office so that she could pinpoint a timeframe of when R14 left. Using the cameras, she was able to determine R14 had gotten out of the building. RN1 stated some staff members had gotten in their cars to drive along the roads to see if they had seen R14. When the staff alerted R14 had been found, a wheelchair was taken to the nearest door to assist in returning R14 to his room to be assessed. RN1 stated after the assessment and when no injuries were noted, the Physician was called to give an update. At that time, she (RN1) received a PRN (as needed) for Ativan. She then began conducting in-services immediately on Code Purple and Elopements. RN1 stated the weather that morning was a little warmer, around the 50s possibly and it was not raining. She stated R14 was properly dressed in a long-sleeved shirt and long pants with sneakers, but he did not have on a jacket. During an interview with the Administrator on 03/15/23 at 10:45 AM, she confirmed again that staff had acted properly upon the facility's policies. She stated she herself had walked the area and path taken by R14 and could not understand how he was able to maneuver without getting hurt. She stated the facility maintains ongoing in-services to ensure this does not happen again to any other residents. The facility's plan revealed: A. Equipment a. Exits- Check all gates daily prior to leaving- started 3/12/23. i. Log to be completed daily by Maintenance. b. Cameras- Aided in locating resident. (Resident located ~40 minutes after he exited the facility) Resident never left the Extended Care property. B. Environment a. Fencing- Ensure fence integrity around body of water- Vendor assessment completed 3/13/23 by Maintenance. C. People a. Code Purple was called 3/12/23 at 6:58 AM, Administrator notified. b. Search conducted-all available staff assisted in the search (~30 people, 911, LMC Public Safety, Medical Director and RP notified). c. Resident- hx of elevated ammonia- repeated labs 3/14/23 completed by Nursing. i. Body audit completed 3/12/23 ~8:07 AM ii. Will repeat Braden skin risk assessment once weekly x 4 weeks. iii. Review activities programming for resident provide 1:1 as needed iv. Code Purple education provided to all staff starting on 3/12/23. v. Staff present during the incident were educated about recognizing residents at risk for elopement where to search, and how to page the alert on 3/12/23. vi. Admin staff were educated on and used the Fishbone Diagram to identify root causes analysis of the incident. Completed on 3/13/23. d. Policy i. Update Code Purple Policy to include LYNX notifications. ii. Elopement risk assessment completed at admission and quarterly and as needed. iii. New admissions for the past 30 days will be re-assessed for elopement risks. This began on 3/14/23. e. Process i. Admissions assessments BIMS score=12 (No indication of elopement risk). Alert and oriented x2, chair alarm implemented due to fall risk. ii. admission Elopement assessment did not indicate a need for wander guard bracelet. (No exit seeking or verbalization of wanting to leave). iii. Care Plan- New process to include assessment of resident during admission for prior substance use, prior elopement history. Completed by Social Services Director iv. Change type of elopement assessment by 3/17/23 to more clearly establish elopement risk f. Other i. Enable staff to enter and exit with a card reader through Camelia Court to ensure they are not using undesignated exits throughout the facility. Completed by Maintenance ii. Continue to use wanderguard notebooks for each unit and both visitor exits to better identify residents who are at risk for elopement. Completed by Nurse Managers and HIM on 3/12/23.