**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident had the right to be free from abuse for seven residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident#15, Resident #20 and Resident #23) of 7 residents reviewed for abuse/neglect. 1. The facility failed to ensure Resident #2 was free from abuse, Resident #2 sustained a right hip fracture from being pushed by Resident #3 on 04/22/25. 2. The facility failed to ensure Residents #2 and #5 were free from abuse, Resident #4 hit Resident #3 in the back of the head causing a bump to her head and pushed Resident #5 that caused him to fall on top of another resident on 06/07/25 at 4:50 PM. 3. The facility failed to ensure Resident #15, Resident #20, and Resident #23 were free from abuse when Resident #15 struck Resident #20 on the back of his head with her phone causing an abrasion; and struck Resident #23 on his face with her phone on 03/24/25. The noncompliance was identified as PNC at an Immediate Jeopardy level. The Immediate Jeopardy event began on 04/22/25 and ended on 04/23/25 when it became PNC. The facility had corrected the noncompliance before the investigation began. These failures have the potential to result in serious injury or death as a result of abuse and neglect. The findings included: Record review of Resident #2's Face Sheet dated 07/01/25 revealed an [AGE] year-old male admitted on [DATE] with the diagnosis of: psychotic (a mental disorder characterized by disconnection of reality) disturbance and hypertension (high blood pressure). Resident #2 resided in the facility's secured unit. Resident #2 was discharged on 04/22/25.Record review of Resident #2's acute care plan dated 04/21/25 reflected he:- had impaired thought processes .- was an elopement risk/wanderer .Interventions: Distract resident from wandering by offering pleasant diversions; Identify pattern of wandering .- needs structured environment in secure unit related to cognitive deficit .- had a resident to resident; female went into resident's room and then told resident to leave her room she then pushed resident causing resident to lose balance and fall . Record review of Resident #2's Minimum Data Set assessment revealed there was no assessment available due to he was recently admitted on [DATE].Record review of Resident #3's Face Sheet dated 07/01/25 revealed a [AGE] year-old female admitted [DATE] with the pertinent diagnoses of: Dementia, Cognitive Communication Deficit (communication difficulties stemming from impairments in cognitive processes), and degenerative disease of nervous system. Resident #3 resided in the facility's secured unit. Resident #3 was discharged on 06/10/25.Record review of Resident #3's comprehensive care plan dated 03/18/25 reflected Resident #3:- has impairment cognitive function/dementia or impaired thought process related to Dementia .- had a behavior problem, she walked into other residents' room, repetitive questions related to Dementia .Interventions: Caregivers to provide opportunity for positive interaction, attention, stop and talk to her when passing by; explain all procedures to resident before starting .; if reasonable, discuss the resident's behavior, explain why behavior is inappropriate; intervene as necessary to protect the rights and safety of others, speak in calm manner and divert attention, remove from situation and take to alternate location; monitor behavior episodes ; provide program of activities .-is an elopement risk .Interventions: Distract resident from wandering; Identify pattern of wandering; redirection; provide structural activities .- needs structural environment in secure unit related to cognitive deficit .- [Resident #3] stated during interview with the social worker that in the past she had traumatic experiences with men .Interventions: Staff to monitor resident for behavior such as pushing, yelling, and cursing at others, staff to redirect as needed .- had a resident to resident, she walked into a male resident's room she then pushed resident causing him to lose his balance and fall .Record review of Resident #3's admission Minimum Data Set assessment dated [DATE] reflected she:-had clear speech-usually made self-understood and usually understood others-her BIMS summary score was 5 (indicating severe cognitive impairment)-did not have potential indicators of psychosis. She had other behavior symptoms not directed to others 1 to 3 days-had wandering behaviors that placed the resident at significant risk of getting to a potentially dangerous place-required partial to moderate assistance for personal care.Record review of the facility's Provider Investigation Report reflected Incident Date/Time: 04/22/25 at 1:10 AM. [Resident #3] was ambulatory, not interviewable, not able to make informed decisions, had no special supervision. Resident #3 was the alleged perpetrator.Resident #2 was ambulatory, interviewable, not able to make informed decisions, had no special supervision. Resident #2 was the alleged victim. Description of allegation: Female resident wandered into male resident room. She believed the room to be hers and yelled at the male resident to get out of her room. The male resident was awake and standing at the end of the bed. She then pushed him and he lost his balance and fell.Record review of Resident #2 Head to toe assessment: 04/22/25 at 1:10 AM - Complained of pain to right side and sent to local hospital.Residents immediately separated and placed on 1:1 monitoring.Investigation Summary: Female resident wandered into male resident room. She believed the room to be hers and yelled at the male resident to get out of her room. She then pushed him and he lost hi balance and fell. At that moment, [CNA A] was in another resident's room and witnessed [Resident #3] with her hands on [Resident #2] shoulders and pushed him. [CNA A] stated Resident #2 lost his balance and fell to the floor. [CNA A] immediately walked [Resident #3] out of the room and called for the nurse. [CNA A] stayed with [Resident #3] while nurse assessed [Resident #2]. Head to toe assessment revealed [Resident #2] complained of pain to right side and was sent to [local hospital]. At approximately 3:30 AM, [local hospital] notified facility of [Resident #2] to be transferred to [another hospital] due to right hip fracture. SW assessed [Resident #3] with a psychosocial assessment and showed no signs of distress. MD notified, UA collected, and antibiotics started for urinary tract infection. Resident to remain on one to one for the duration of antibiotic to monitor for any change in condition or change in behaviors .Pharmacist consultant notified for medication review. Psych referral initiated. Investigation is inconclusive, the residents have diminished capacity to willfully intent any harm. The residents do not have previous history of aggressive behaviors.Action taken post investigation: Resident to remain on one-to-one monitoring for the duration of antibiotic to monitor for any change in condition or change in behaviors. During the one to one, the resident has not shown any change of conditions or increased aggressive behaviors. Inservice conducted on Abuse and Neglect.In an interview on 7/01/25 at 2:42 PM, CNA A said he was providing a resident with personal care in the secured unit when he heard a shout and quickly finished with the resident he was helping and ran into Resident #2's room. CNA A said Resident #3 wandered into Resident #2's room and she was confused yelling at Resident #2 to get out of her room then saw Resident#3 push Resident#2 to the ground. CNA A immediately yelled for the nurse to come and assist him. CNA A stated as the LVN E entered the room, he began to redirect Resident #3 to the doorway away from Resident #2. As other staff began to arrive, he stayed with Resident #3 so that she would not wander into someone else's room. CNA A said he was the only staff member in the locked unit at the time of the incident due to the assigned nurse of the unit was caring for other residents in the facility outside the secured unit. CNA A stated Resident #3 normally paced around the hall all night. CNA A stated approximately one hour earlier, Resident #3 had wandered into another resident room and had to be redirected out. CNA A said Resident #3 also was found sleeping on the floor of another resident room prior to the incident.In an interview on 07/01/25 at 6:10 PM, LVN C stated the night shift consisted of 2 LVN's and 4 CNAs for the entire building with one nurse assigned to the secured unit and Hall A and one CNA assigned to the secured unit. LVN C said he worked the night shift in the secured unit at times and he was usually assigned the secured unit and Hall A. LVN C said while he attended to the residents in Hall A, the CNA remained in the secured unit. LVN C stated he tried to round in the secured unit every 30 min to an hour. LVN C said the secured unit usually approximately 19 residents and several who routinely wandered at night. LVN C stated if she was outside of the secured unit and the CNA was in a resident room providing personal care, there was no one else monitoring the secured unit's halls or residents. LVN C said the CNA should alert the nurse when he was providing care so the nurse could monitor the secured unit hall and residents but that did not always happen if both staff were caring for residents. LVN C said the last time he received abuse/neglect training was about two weeks ago. In an interview on 07/01/25 at 6:30 PM, LVN E said she was the nurse who was in charge of the locked unit the night the incident occurred on 04/22/25 and she responded to the CNA's call for help. LVN E said she saw Resident #3 in the doorway and quickly entered the room and instructed CNA A to escort Resident #3 to her room. LVN E began assessing Resident #2 who was on the floor complaining of pain. LVN E felt Resident #2's leg and the resident complained of pain again, and it felt odd, so she called CNA A to stay in the room with Resident #2 while she went to call an ambulance. LVN E said she could not recall the time or estimated time she was away from the secured unit at the time of the incident. LVN E said she knew Resident #3 routinely wandered the secured unit hall at night but denied knowing if Resident #3 was wandering the secured unit halls or resident rooms the night of the incident. LVN E said Resident #3 did not have any previous aggressive behaviors. LVN E said if she was in Hall A caring for other residents, the CNA assigned to the secured unit could not provide the residents personal care and supervise the hall or other residents at the same time. LVN E said after the incident, she and all the other staff received abuse and neglect in-service training and resident to resident altercation in-service. LVN E said the last abuse and neglect in-service she received prior to the incident was 2 weeks ago. In an interview with the DON on 07/02/25 at 10:15 AM, she said Resident #3 was found in another resident's room at approximately 12:30 AM on the floor asleep. The DON said the CNA took Resident#3 back to her room and put her back into her bed. The DON said CNA A heard someone yelling at approximately 1:10 AM while he was providing another resident incontinent care. The DON said the CNA saw Resident#3 push Resident #2 to the floor. The DON said Resident #3's dementia and sleepiness might have contributed to her confusion regarding where her room was located. The DON said after the incident, Resident #3 was found to have a UTI and that might have been why she was exhibiting aggressive behaviors during the incident. The DON said Resident #3 had not displayed any signs of having a UTI the day prior to the incident. The DON said Resident #3 was placed on one-to-one supervision and was put on antibiotics for the UTI. The DON said all staff were given a training on abuse and neglect, supervision and resident to resident altercation. The DON said all residents had the right to be free from abuse and neglect. The DON said she felt there was no non-compliance identified for the occurrence of the incident. The DON said Resident #3 did push Resident #2 but didn't think it was willfully done because of her dementia and she did not intend to inflict harm. The DON said she felt Resident #3's actions did not meet the definition of a willful act. Willful, as defined at S483.5 in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The DON stated the staff had been able to supervise the residents well at night and did not feel more staff was needed in the secured unit as residents slept most of the night and those that were awake were supervised by the CNA. The DON did not provide a response as to why this incident of resident-to-resident abuse occurred when the CNA was busy providing personal care to one resident and no other staff were monitoring Resident #3 to prevent her from entering Resident #2's room. The training for abuse and neglect was giving either by the DON or the administrator who is also the abuse coordinator and the last one was giving no more than two weeks ago.In an interview on 07/02/2025 at 11:30 AM, the Administrator stated she was made aware of the incident in the early morning of 04/22/25. The Administrator said she began an internal investigation and reported the incident to the state. The Administrator said she ensured Resident #3 was placed on one-to-one supervision for her and the other resident's safety. The Administrator said she did not think Resident #3 acted willfully as the aggressor in the incident due to her dementia and anxiety. Willful, as defined at S483.5 in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The Administrator claimed the UTI as being the reason Resident #3 acted aggressively. The Administrator said her staffing schedule had been the same for some time having one nurse assigned to two halls (secured and Hall A) and one CNA assigned to the secured unit, and felt the current staffing was adequate and did not contribute to any abuse.Resident #4 and Resident #5Record review of Resident #4's Face Sheet dated 07/01/25 revealed a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE] with the diagnoses of: Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows and manic highs), hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there), unspecified intellectual disability, Schizoaffective disorder (a combination of schizophrenia and mood disorder- disorder that affects a person's ability to think, feel, and behave clearly). Resident #4 resided in the facility's secured unit.Record review of Resident #4's acute care plan dated 05/25/25 reflected she: has impaired cognitive function or impaired thought processes related to disease process, diagnoses of schizoaffective disorder .cue, orient and supervise as needed .takes psychotropic medications (Risperidone) related to Bipolar disorder.-has delirium or an acute confusion episode related to change in environment-is an elopement risk/wanderer related to impaired cognition .Interventions: admitted to secure unit; distract resident from wandering by offering pleasant diversions .; identify pattern of wandering .; provide structured activities .-has a behavior problem mood swings related to bipolar disorder. )5/28/25 - Resident had behavior of getting mad and yelling then grabbing and hitting the CNA. Interventions: Assist resident to develop more appropriate methods of coping and interacting; educate resident on successful coping; explain all procedures before initiating .; if reasonable, discuss resident behavior; intervene as necessary to protect the rights and safety of others . Record review of Resident #4's admission MDS assessment dated [DATE] reflected she:-had a BIMS score of 14 (cognitively intact)-displayed verbal behavioral symptoms directed towards others-was independently mobile-had an active diagnosis of Schizophrenia, Bipolar disorder, anxiety Record review of Resident #5's Face Sheet dated 07/01/25 revealed a [AGE] year-old male admitted on [DATE] with the diagnoses of: cognitive communication deficit and unspecified Dementia. Resident #5 resided in the facility's secured unit.Record review of Resident #5's comprehensive care plan dated 04/07/25 reflected he:-is an elopement risk/wanderer related to dementia; he had an elopement through the front door-was involved in a resident to resident altercation. Resident was pushed to the floor by another resident.-had a recent incident involved yelling at female co-resident-has the potential to be verbally/physically aggressive related to dementia. Record review of Resident #5's quarterly MDS assessment dated [DATE] reflected he:-had a BIMS score of 5 (severe cognitive impairment)-displayed physical and verbal behavioral symptoms directed towards others-displayed wandering behaviors-independently ambulated Record review of the facility's Provider Investigation Report completed by the /abuse coordinator reflected Incident Date: 06/07/25 4:50 PM in the secured unit dining: Resident to resident altercation. Persons involved: [Resident #4], independently ambulatory, no special supervision, not interviewable, does not have the capacity to make informed decisions, had history of wandering, alleged aggressor; [Resident #2] independently ambulatory, no special supervision, not interviewable, does not have the capacity to make informed decisions, had history of wandering, alleged victim; [Resident #5] independently ambulatory, no special supervision, interviewable, does not have the capacity to make informed decisions, had history of wandering, alleged victim .Provider Summary: The alleged aggressor had an altercation with [Resident #3] during dinner time in the dining room of the secured unit. Alleged aggressor was agitated and hit female Resident [#3] in the head. Male Resident [#5] tried to intervene during the altercation and stumbled. At approximately 4:60 PM, [Resident #3] became agitated during dining service. [Resident #4] was sitting herself in the corner with her plate in front of her when she accused [Resident #3] of laughing at her. She proceeded to push her plate off the table and started to curse and speaking in jumbled sentences. She then pushed over her table causing it to turn over and quickly went to the table where [Resident #3] was sitting. The Medication Aide immediately approached and positioned herself between the residents to de-escalate the situation. Despite the aide's verbal redirection and physical positioning between the two residents the aggressor was able to strike [Resident #3] on the back of the head with a closed hand. [Resident #5] who was sitting beside [Resident #3] at the table was startled, got up wanting to intervene in the situation. At the time, staff trying to de-escalate the situation with one aide behind him and the medication aide between the two females trying to divert [Resident #5] from going towards the aggressor. The aggressor was able to push [Resident #5] causing him to stumble backwards, bumping into a resident sitting behind him, and then sliding down to the floor. The medication aide was able to redirect the aggressor to her room and a housekeeper remained and nurses staff went to assess the victims. The aggressor continued with her agitated behaviors with staff in her room. MD and police notified; orders obtained for resident to be sent to [local hospital] for further evaluation. She was transferred out at approximately 4:45 PM .[Resident #3] was noted with a bump to the back of her head with complaints of pain. Nurses administered pain medication. [Resident #5] was noted with redness to his right flank(the side of the body between the lower ribs and hip on the right side) and no complaints of pain. A random selection of resident interviews completed with no signs or trends of abuse and neglect. Investigation is unconfirmed. The residents have diminished capacity to willfully intend any harm, the residents in question had no pain, mental anguish or emotional distress. The facility investigation findings were unconfirmed.Provider action taken post-investigation: In-service on abuse and neglect, the alleged aggressor returned from the emergency room at approximately 4:20 PM on 06/08/25 and was placed on 1:1 supervision while the SW worked on additional placement. The alleged victims continued additional monitoring with no signs of emotional distress - none noted by the end of investigation.Observation and interview of Resident #5 on 07/01/25 at 11:20 AM revealed he was alert and oriented to person, place, and time. Resident #5 engaged in conversation. Resident #5 said he recalled the incident and said he witnessed Resident #4 being aggressive to Resident #3 and saw how the staff person who got in between them struggled to keep the residents separated so he thought he could help but got pushed instead. Resident #5 said during the day they have a nurse and two CNAs but at night they only have one nurse and one CNA but the nurse did not count because she worked in the other hall.In an interview on 07/01/25 at 11:30 AM, LVN B stated she was the primary nurse for the lock unit during the day shift. LVN B stated any over stimulate residents who are difficult and confrontational are kept in dining room and the under stimulated residents who can sit and pay attention will be taken to watch television or do projects in the living room. LVN B said the residents are kept occupied and are redirected if they exhibit agitated or exit seeking behaviors from the locked unit. Residents are redirected to a calmer environment or their own room. Staff knowledge of triggers for each resident keeps incidents from happening between residents. LVN B said the staff knew how to intervene in situations where abuse could occur between residents and if needed, they could get the additional staff to help from the other halls. LVN B said the number of staff used for supervision depended on the census of facility. The last training for abuse neglect and supervision was about 2 weeks ago.In an interview on 07/02/25 at 3:30pm, CNA F stated she was escorting Resident #4 to the dining area at approximately 4:50 PM for dinner. CNA F saw that there were no more chairs left so she decided to sit Resident #4 in the corner with a tray. CNA F stated she was handing out dinner plates to the residents when she heard a plate hit the floor and break. CNA F looked to see what had happened when she went to pick up the plate from floor and saw the med aid get between Resident #3 and Resident #4. CNA F stated the med aide tried to keep Resident #4 from Resident #3 when Resident #5 tried to help break up the altercation and was pushed by Resident #4 . CNA F was not part of the staff that broke up the altercation as she was making sure none of the other residents got involved or hurt. CNA F said she received abuse and neglect training this week. In an interview on 07/02/2025 at 1:30 PM, with the DON stated on 06/07/25, Resident #4 was being escorted to the dining room of the secured unit for dinner and was put in a corner with a tray because the dining room was full. The DON said CNA F was passing out trays when she heard a plate hit the floor and break. The DON stated Resident #4 started arguing with Resident#3 and the med aid got in between both residents as other staff began to get there to intervene. The DON stated Resident #5 was sitting next Resident # 3 and tried to help and was pushed by Resident #4 and fell on to a resident that was behind him. The DON said as Resident #4 was being separated from Resident #3, Resident #4 struck her on the head. The DON stated Resident #4 was still being aggressive to the staff as she was escorted to her room. The DON said Resident #3 was administered a head-to-toe assessment and was found to have a bump to her head, she complained of pain to her head and was given meds and was monitored for several days. Resident #5 was given a head-to-toe assessment and was found to have no injuries. Resident #4 was admitted to the hospital for further observation and when she returned on 06/08/2025, she was put on a one-to-one while SW. The DON said Resident #4 had a history of aggressive behavior towards staff and residents. The DON said the staff were given a training on abuse and neglect, supervision, and resident rights. The DON said she did not feel that the facility/staff failed to do anything as they responded to the situation when it occurred. The DON said all residents had the right to be free of abuse and neglect. The DON stated Resident#4 did commit the abuse but didn't think is was done willfully due to her mental illness. The DON's definition of willful was Someone who does not have a mental illness and knows what they are doing and touched or struck someone intentionally.In an interview on 07/02/25at 11:30 AM, the Administrator stated she was made aware of the incident and immediately began an investigation of the incident. The Administrator said Resident #4 continued to be aggressive with the staff and was admitted to the hospital for a Psychiatric evaluation. The Administrator stated she made sure that Resident #4 was put on a one on one when she returned to the hospital. The Administrator stated she did not see the incident as being done willfully since the aggressor had a diagnosis of hallucinations, bipolar disorder, anxiety, and schizoaffective disorder. The Administrator's definition of willful was The aggressor's act was unwilful since the resident did not know what they are doing due to their mental illness. 3. Record review of Resident #15's Face Sheet, dated 07/02/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), schizophrenia (disorder that affects a person's ability to think, feel and behave clearly), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, and major depressive disorder. Resident #15 was discharged to another facility on 05/17/25.Record review of Resident #15's quarterly MDS assessment, dated 02/18/25, revealed Resident #15 had a BIMS score of 13, indicating her cognition was intact. Record review of Resident #15's change of condition for resident to resident incident completed by ADON L on 03/24/25 revealed Resident walked by living area where several resident were sitting, she yelled to male resident you took my stuff and hit male resident on his cheek with her cell phone as she walked by him, she then continued to walk and hit another male resident who was nearby with her cellphone to the back of his head she kept saying my stuff, they took my stuff. She was stopped by Dietary Manager and redirected to her room where she was placed on a 1:1. She continues to have outburst. No injuries and no pain noted. Primary Care Clinician and Family notified. Record review of Resident #15's care plan with dated 07/02/25 revealed [Resident #15] has a behavior of accusing other residents of taking her items when she misplaces her things. Interventions: nurse to notify medical professional of any changes in conditions as needed and staff to redirect resident and document behaviors. [Resident #15] was physically aggressive and had a resident to resident where she struck two residents with her phone related to anger from accusations of misplaced items, dementia, poor impulse control, and disease process. Interventions: Administer medication as ordered, head to toe and pain assessments, MD/RP notified of incident, monitor/document/report any signs/symptoms of resident posing danger to self and others, police called, psychiatric consult as indicated, resident on a one to one. When the resident becomes agitated: intervene before agitation escalates, guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later with an initiation date of 03/24/25.Record review of Resident #15's progress notes dated 03/24/25-03/25/25 revealed a referral was submitted for a behavioral hospital. Resident #15 remained on a 1:1 until she was accepted and transferred to the behavioral hospital on [DATE]. Resident #15 returned to the facility on [DATE] and was transferred to another facility on 05/17/25.4. Record review of Resident #20's Face Sheet, dated 07/02/25, revealed the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: cerebral ischemic attack (stroke), hemiplegia (paralysis of left side), muscle wasting and atrophy (wasting or thinning of muscle mass due to disuse or nerve problems), major depressive disorder, and anxiety disorder.Record review of Resident #20's quarterly MDS assessment, dated 01/03/25, revealed Resident #20 had a BIMS score of 13, indicating his cognition was intact. Record review of Resident #20's change of condition for resident-to-resident incident completed by ADON L on 03/24/25 revealed Resident was sitting in his wheelchair in living room area. When female resident walked by and hit him with her cell phone behind his head causing abrasions to back of head due to resident wearing his cap and cap having plastic fitting. Resident stated no pain or discomfort at this time. No drainage noted. Treatment provided. No distress noted. Neuro checks implemented. Plan of care on going. Primary Care Clinician and Family notified. Record review of Resident #20's care plan with dated 07/02/25 revealed [Resident #20] had a resident to resident and he was struck to the back of the head with a phone. Interventions: administer medications as ordered, head to toe, pain, and skin assessments, MD/RP and all needed personnel informed, and monitor/document/report any signs/symptoms of psychosocial changes to behavior/emotional status and document findings with an initiation date of 03/24/25. Record review of Resident #20's progress notes dated 03/24/25 revealed Resident #20 was monitored for changes or symptoms. Resident #20 had no emotional distress or changes noted.5. Record review of Resident #23's Face Sheet, dated 07/02/25, revealed the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: unspecified fracture of lower end of left leg, unspecified convulsions, muscle wasting and atrophy (wasting or thinning of muscle mass due to disuse or nerve problems), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and dementia (a group of symptoms affecting memory, thinking and social abilities).Record review of Resident #23's quarterly MDS assessment, dated 02/15/25, revealed Resident #23 had a BIMS score of 14, indicating his cognition was intact. Record review of Resident #23's change of condition for resident-to-resident incident completed by ADON L on 03/24/25 revealed Female resident was walking by resident while he was sitting in the dining room, she then hit him on his right cheek with her cell phone, Resident with no complaints of pain or discomfort at this time. No injuries noted at this time. Vital signs assessed, within normal limits. No distress noted. calm demeanor. Plan of care on going. Primary Care Clinician and Family notified. Record review of Resident #23's care plan with dated 07/02/25 revealed [Resident #23] had a resident to resident and he was struck to the side of his face with a phone. Interventions: administer medications as ordered, head to toe, pain, and skin assessments, MD/RP and all needed personnel informed, and monitor/document/report any signs/symptoms of psychosocial changes to behavior/emotional status and document findings with an initiation date of 03/24/25. Record review of Resident #23's progress notes dated 03/24/25 revealed Resident #23 was monitored for changes or symptoms. Resident #23 had no emotional distress or changes noted. Resident #23 did not wish to speak about the incident.On 07/02/25 at 3:45 PM, in an interv

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure residents received adequate supervision to prevent accidents and/or hazards as possible for 1 of 12 residents (Resident #1) reviewed for supervision and accident hazards. The facility failed to ensure Resident #1 received adequate supervision in allowing Resident #1 to exit the facility without the knowledge of staff sometime between 6:30 PM and 7:00 PM on 05/16/25. An IJ was identified on 07/01/25. The IJ template was provided to the facility on [DATE] at 8:15 PM. While the IJ was removed on 07/03/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because new polices implemented to prevent future errors were still in process. This failure could place residents at risk for injuries and a decline in health. 1. Resident #1:Record review of Resident #1's face sheet dated 07/01/25 revealed a [AGE] year-old male with an admission date of 03/28/25. Pertinent diagnoses included Unspecified Dementia, Other Abnormalities of Gait and Mobility, and Other Lack of Coordination. Record review of Resident #1's Comprehensive Care Plan dated 07/02/25 revealed the problem [Resident #1] had an elopement through the front door initiated on 05/16/25. Interventions listed for the problem included: Increase supervision when resident is observing doors for long period of time initiated on 05/17/25. Redirect resident if he is having any wandering or exit seeking behaviors initiated on 05/17/25. Secure Unit initiated on 05/17/25. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 5 (severe impairment). Further review revealed Resident #1 had wandering behaviors one to three days in the last week. Further review revealed Resident #1 had not used a cane, walker, or wheelchair to move in the last seven days. Record review of the provider investigation revealed the following summary: CNA [N] reported at approximately 7:30 to charge the nurse that the resident was missing. Upon interview she stated she clocked in to work at approximately 6:15-6:30pm and began doing her round. During her rounds she noticed that the resident was not in his room. She went to the secure unit and [CNA O] in that hall told her he was not on the unit. CNA [N] then went to the resident's room again to find the resident was not in his room or bathroom. She immediately reported to DON who was the charge nurse at the time. At approximately 7:34 DON reported to Admin they were unable to locate the resident and she was currently searching the outside of the facility. Facility called code for elopement and department managers started searching the vicinity of the town. Admin notified police [case number] of missing resident. At approximately 8:07pm [staff] notified that the resident was with his family at his previous address in [City Name]. Family returned the resident to the facility, and he was admitted to the secure unit at approximately 10:11pm. Resident assessed head to toe and no signs of injury or emotional distress. Investigation to conclude that the resident had walked out the front door during the timeframe of two ambulances coming to the facility. The resident confirmed he went out the front door when it was open. Resident was picked up by a passing citizen and drove the resident to his address on his driver license. All staff in-services on front door engagement and assuring it is locked prior to leaving. Record review of Resident #1's wandering evaluation dated 05/13/25 revealed Resident #1 was deemed to not be a wandering risk In an interview with Resident #1's RP at 11:09 AM on 07/01/25, RP 1 stated he received a phone called from his Resident' #1 neighbor at his old address in [City Name]. RP 1 stated the neighbor told him a gentleman had driven his father to his old house in [City Name]. RP 1 stated the gentleman that drove his father told him he picked Resident #1 up, called the police, and the police told him to drive Resident #1 to the address on his Identification Card. RP 1 stated the address in [City Name] was about 25 minutes away from the facility. RP 1 stated he drove to the address to pick up Resident #1 RP 1 stated his father was physically fine and not in pain. RP 1 stated he drove his father back to the facility and they put him back in the locked unit. In an interview with Resident #1 at 11:35 AM on 07/01/25, Resident #1 was not able to provide any details of the incident due to cognitive deficits. In an interview with the DON at 2:18 PM on 07/01/25, the DON stated she was the charge nurse at the time of Resident #1's elopement. The DON stated it was busy at the front door that evening. The DON stated CNA N told her she could not find Resident #1 at around 7:00 PM and she immediately initiated a head count of all residents. The DON stated she called the administrator and then began searching outside the facility. The DON stated there is no telling what could have happened to Resident #1 during his elopement, especially since he was given a ride by a stranger. The DON stated Resident #1 was admitted to the locked unit on 03/28/25 and had just been let out of the locked unit on 05/13/25. The DON no resident centered plan was put in place to transition residents safely as they go from the locked unit to the general unit . The DON stated she would strike up conversations with Resident #1 and that he never wandered or showed exit seeking behaviors before this incident. The DON stated Resident #1 had been in the locked unit ever since he got back to the facility after his elopement. The DON stated Resident #1 was not allowed out of the facility unsupervised. The DON stated the receptionist started staying until 7:00 PM instead of 5:00 PM to keep staff closer to the door during the busier hours. In an interview with the ADM at 3:30 PM on 07/01/25, the ADM stated she received a call from the DON on 05/16/25 at 7:34 PM telling her Resident #1 was missing. The ADM stated she called the police right after that to notify them Resident #1 was missing. The ADM stated she started driving into the facility, and when she was only a few minutes away, she received a call that Resident #1 had been located. The ADM stated she called RP 1 to confirm that he was with Resident #1. The ADM stated they inspected all locks and alarms at the facility but did not find any deficiency. The ADM stated they interviewed Resident #1 when he got back and he told them he walked out the front door when it was open. The ADM stated before someone comes out of the locked unit the IDT team and regional team have a discussion concerning the safety of that decision. Record review of the facility policy titled Elopements and Wandering Residents implemented on 11/21/22 revealed the following:1. The facility may be equipped with door locks/alarms to help avoid elopements.2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.d. Adequate supervision will be provided to help prevent accidents and elopements. Record review of the facility policy titled Elopements and Wandering Residents implemented on 11/21/22 revealed the following:1. The facility may be equipped with door locks/alarms to help avoid elopements.2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.d. Adequate supervision will be provided to help prevent accidents and elopements. LETTER OF CREDIBLE ALLEGATIONFOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On July 1st, 2025, the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy is as follows: Issue:F 6891. The facility failed to provide adequate supervision of Resident #1. Resident #1 exited the facility through the front door on 05/16/25 around 6:30 PM to 7:00 PM. Resident #1 was found by a passerby who gave him a ride to his old home in [local city]. The facility did not have a transition plan to maintain adequate supervision of the resident outside the locked unit.2. The facility failed to provide adequate supervision to Resident #2. Resident #2 and Resident #3 resided in the locked unit of the facility. Resident #2 entered the room of Resident #3 and pushed him to the floor fracturing his right hip. The facility did not and still does not have enough staffing in the locked unit to maintain adequate supervision of residents inside the locked unitActions for Resident Involved Resident # 1 On 07/02/25 was immediately assessed by the licensed nurse and placed in secure unit. Resident #1's care plan was updated and is current. Resident # 1s till resides on secure unit due to wandering behavior with no further incidents with exit seeking. Resident #2- No longer resides in the facility Resident # 3 - No longer resides in the facility Identify residents who could be affected: On 07/02/25, The DON/Designee conducted an audit of all current residents in the secure unit to confirm that a current quarterly wandering evaluation is documented and reflects each resident's cognitive and behavioral status, including a review of the BIMS score. Residents were deemed to be appropriate for secure unit placement. DON conducted reassessments were completed and the care plan updated if needed. On 07/02/25, an audit was conducted by the DON for any residents who transitioned out of the unit in the last 30 days. None were identified as at risk for elopement. On 07/02/25, The Director of Nursing or designee conducted an audit of all new admissions and readmissions within the past 30 days to verify that wandering evaluations have been completed, interventions have been implemented based on the assessed risk, and these are reflected in the resident's plan of care. On 07/01/25, the Administrator/Social Worker/Director of Nursing/Designee conducted staff interviews to identify any concerns of exiting seeking /wandering behaviors. No issues were identifiedAction Taken/ System Change: On 07/01/25 and completed on 07/02/25 all staff have been educated by DON/Designee on the following 1:1 Education with DON/ADONS/IDT and administrator on Abuse/Neglect/Exploitation and transition from unit to general population process conducted by Regional Clinical Consultant Abuse/Neglect and Exploitation Behavior management Resident behaviors and triggers including resident specific triggers to provide optimal monitoring and prevention on halls. Redirection techniques of walking with residents and/or engage in diversional activities if a resident is agitated or wandering. Elopement Incidents and Accidents Call off from shift procedure Supervision of Residents- Residents must be supervised by staff with appropriate increased supervision or interventions implemented to mitigate further occurrences based on individual residents needs.Any staff who have not received education will do so prior to the start of the next work shift. Staff not in the facility on 07/02/25 and/ or on PTO/ FMLA/ Leave of Absence will have the re-education completed prior to the start of their next scheduled shift.Initiated On 07/02/25 and ongoing, newly hired Nursing staff will receive this training by DON/Designee during orientation prior to providing care to the residents. The training will include the above-stated educational components.Completion date 07/02/25 Initiated on 07/01/25 and going forward, The Facility will provide at a minimum 2 staff members in the secured unit to provide resident supervision to include assignment of one-to-one staff supervision as needed based on Residents behaviors and needs to ensure safety of self/others. Initiated on 07/01/25 and going forward ongoing review of schedule will be completed by the Administrator and the Director of Nursing/Designee to confirm staffing is sufficient to assure resident safety and attain or maintain the highest practical physical, mental and psychosocial wellbeing of each resident, as determined by Resident assessments and individual plans of care and considering the number, acuity and diagnosis of the secure unit population. We will maintain at a minimum 2 staff members on secure unit for continued supervision and monitoring of residents.Initiated on 07/01/25, Nursing staff were educated by DON/Designee when nursing staff take scheduled breaks, a relief must step in and monitor until the staff returns. Nursing staff have been educated to monitor any residents who is out of their room, if one staff member is in the room, additional staff will observe and monitor other residents in common areas. Nursing staff will notify the Charge Nurse so that coverage for assigned residents is maintained and supervision is not interrupted.Completed on 07/02/25Resident-to-resident incidents will continue to be reviewed by DON/Designee during the morning clinical meeting. The Director of Nursing and/or designee will document the review of each incident, including a summary of interventions discussed and any required care plan updates. Any resident who may require one is to one staff supervision will be provided and the plan of care updated.Monitoring: Beginning 07/01/25 and going forward, the Director of Nursing will monitor compliance with staffing plan and supervision. Beginning 07/01/25 and going forward, The Director of Nursing or designee will monitor compliance each morning by reviewing resident and newly identified behaviors during clinical meetings. To confirm that care plans are updated and appropriate interventions are implemented, the DON/designee will document discussions and interventions in the care plan. The Administrator will attend the morning clinical meeting and directly observe that the Director of Nursing and/or designee is reviewing all incident reports and newly documented resident behaviors. On 07/01/25, An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, Regional Clinical Specialist and Regional VP of Operations to review the plan of removal. Administrator/DON/ADON will review residents with the IDT prior to transition from the unit to the general population and verify interventions which may include, but not be limited to, increased supervised time outside the unit during meals and activities, enhanced supervision for wandering or exit-seeking behaviors, frequent visual checks, and 1:1 supervision. Additional interventions may include the use of personalized behavior care plans, environmental modifications to reduce triggers, staff communication handoffs during shift changes, and regular multidisciplinary team reviews to adjust supervision levels as needed. Training with IDT completed on 07/02/25.Completion date 07/02/25 We respectfully submit this action plan for the removal of Immediate Jeopardy.Sincerely,[Administrator], LNFA Verification of Plan of Removal: In interviews beginning at 12:00 PM on 07/03/25 and ending at 4:46 PM on 07/03/25 with staff from all shifts, 12 CNA's, 7 LVN's, 2 Housekeepers, 1 CMA, 1 Maintenance supervisor, 1 Dietary Manager, 2 ADON's, 1 DON, and 1 ADM were able to identify abuse/neglect policies and procedures, providing appropriate supervision, behavior management, elopement policies and procedures.-DON interviewed at 1:30 PM on 07/03/25. The DON stated the facility conducted an audit of all current residents in the locked unit to confirm wandering evaluation and cognitive and behavioral status to determine appropriate placement. The DON stated she conducted an audit of all new admissions and readmissions to ensure a wandering evaluation was completed. The DON stated the facility added an additional CNA to be present on the locked unit during the evening shift moving forward. The DON stated she will monitor compliance with staffing plan moving forward. The DON stated she will monitor newly identified behaviors in residents. The DON stated a QAPI meeting was held to review the plan of removal. The DON stated all staff were retrained on abuse/neglect, behavior management, resident behaviors and triggers, elopement, incidents and accidents, call off procedure, and supervision of residents by the DON, ADON's and ADM from 07/01/25 through 07/03/25. The DON stated the correct definition of abuse and willful.-ADM interviewed at 2:01 PM on 07/03/25. the ADM stated all staff were retrained on abuse/neglect, behavior management, resident behaviors and triggers, elopement, incidents and accidents, call off procedure, and supervision of residents by the DON, ADON's and ADM from 07/01/25 through 07/03/25. The ADM stated a QAPI meeting was held to review the plan of removal. The ADM stated the correct definition of abuse and willful-ADON L interviewed at 2:43 PM on 07/03/25 stated all staff were retrained on abuse/neglect, behavior management, resident behaviors and triggers, elopement, incidents and accidents, call off procedure, and supervision of residents by the DON, ADON's and ADM from 07/01/25 through 07/03/25.-ADON G interviewed at 2:52 PM on 07/03/25 stated all staff were retrained on abuse/neglect, behavior management, resident behaviors and triggers, elopement, incidents and accidents, call off procedure, and supervision of residents by the DON, ADON's and ADM from 07/01/25 through 07/03/25.-Observations of staff supervision of residents throughout the facility including the locked unit by surveyors revealed sufficient supervision of residents at all times after the POR was accepted on 07/03/25. Record review and verification of the corrective action implemented beginning on 07/03/25:- On 07/02/25, the DON conducted an audit of all current residents in the locked unit to confirm wandering evaluation and cognitive and behavioral status to determine appropriate placement - verified by interview of DON and record review of five residents (Resident #1, Resident #6, Resident #7, Resident #8, and Resident #9) residing in the locked unit on 07/03/25. Records revealed wandering and cognitive evaluations had been completed as stated with residents being placed in the locked unit appropriately.- On 07/02/25, the DON conducted an audit of any resident that had left the secured unit in the past 30 days - verified by interview with the DON and record review of affected residents on 07/03/25.- On 07/02/25, the DON conducted an audit of all new admissions and readmissions to ensure a wandering evaluation was completed - Verified by interview with the DON and record review of random sampling of resident EMR's on 07/02/25.- On 07/01/25, staff interviews were conducted to identify wandering and exit seeking behaviors in residents - verified by interviews with ADM and ADON's on 07/03/25.- Completed education of DON/ADONs/IDT and ADM on abuse, neglect, and exploitation - verified by interviews with regional clinical consultant and ADM on 07/03/25.- Completed education of all staff on the following items: abuse/neglect, behavior management, resident behaviors and triggers, elopement, incidents and accidents, call off procedure, and supervision of residents - verified by interviews with various staff on 07/03/25.- Added an additional CNA to be present on the locked unit during the evening shift moving forward - verified by record review of staffing schedules for the next 2 weeks on 07/03/25. Surveyors arrives at the facility at 2:00 AM on 07/02/25 to observe locked unit supervision during night shift. Facility had already implemented the extra CNA in the locked unit at that time. The facility implemented the extra staff immediately after the IJ was called. - Beginning on 07/01/25, the DON will monitor compliance with staffing plan - verified by interview with the DON on 07/03/25.- Beginning on 07/01/25, the DON will monitor newly identified behaviors in residents - verified by interview with the DON on 07/03/25.- On 07/01/25, a QAPI meeting was held to review the plan of removal - verified by record review of the QAPI signature page.- ADM/DON/ADON will review residents with IDT prior to transition from the locked unit and verify interventions once residents were out in the general population. - verified by interview with the ADM and DON on 07/03/25.The ADM was informed the Immediate Jeopardy was removed on 07/03/25 at 4:46 PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of 4 residents reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 was unaccounted for approximately 29 minutes from 4:46 PM to 5:15 PM on 08/17/24 before a 3rd party notified CNA A that Resident #1 was in her wheelchair outside the facility. The noncompliance was identified as PNC. The PNC began on 08/17/24 and ended on 09/04/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm. The findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old female with an original admission date of 12/01/22 and a current admission date of 08/06/23. Pertinent diagnoses included Vascular Dementia with Psychotic Disturbance, muscle wasting and atrophy, and abnormalities of gait and mobility. Record review of Resident #1's Quarterly MDS assessment section C, cognitive patterns, dated 11/27/24 revealed a BIMS score of 3 (severe impairment). Record review of Resident #1's care plan revealed the problem [Resident #1] is an elopement risk/wanderer behavior of exit seeking, wandering, and agitation. 8/17/24 [Resident #1] had an actual elopement episode. Initiated on 10/21/24. Interventions listed for this problem included: -Distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, book. Resident prefers: to have a doll that she was given and she likes to carry it with her. Initiated on 08/17/24 and revised on 08/18/24. -[Resident #1] was admitted to the secured unit. Initiated on 08/17/24 and revised on 08/22/24. -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. Initiated on 12/1/22 and revised on 08/17/24. -Non-pharmacological interventions: Redirection, Offer fluids and snacks, Attend activities of choice. Initiated on 08/18/24. -Wandering evaluation tool completed. Initiated on 08/18/24 and revised on 08/22/24. Record review revealed Resident #1's elopement risk assessment dated [DATE] indicated she was not a wandering risk. Further record review revealed Resident #1's elopement risk assessment dated [DATE] indicated she was a wandering risk. Record review of the provider investigation report dated 08/20/24 revealed the following narrative: On August 17th, 2024, at approximately 5:15pm [CNA A] was notified by a visitor sitting in the front lobby that there was someone at the front door. She opened the door and was told by 3 visitors that there was someone outside who needed help. [CNA A] noticed it was [Resident #1] and immediately went outside to assist the resident. The resident was noted to be at the front of the North end of the building sitting in her wheelchair. [CNA A] immediately called [RN B] to go out to assist the resident. Resident was found to be in no distress and denied any complaints. Resident was not noted to have any s/s of dehydration. Head to toe assessment conducted with no new injuries present. Range of motion within normal limits. Resident unable to explain how she exited the building. Record review of wunderground.com revealed the temperature in [NAME], Texas on 08/07/24 from 4:51 PM to 5:51 PM to be between 94 degrees and 92 degress fahrenheit. In an interview with the DON at 1:01 PM on 12/31/24, the DON stated Resident #1 moved from the locked unit to the C hall on 03/22/24. The DON stated they performed a wandering assessment on all residents every 3 months. The DON stated at the time of the elopement, Resident #1 was not considered an elopement risk. The DON stated Resident #1 would wander the halls, and at times, wander into another resident's room looking for her room. The DON stated they never came to a definitive conclusion as to which exit Resident #1 used to leave the facility. The DON stated Resident #1 was able to propel herself while she was in her wheelchair. The DON stated Resident #1 was found at the corner of the sidewalk and grass on the side of the building in her wheelchair. The DON stated Resident #1's wheelchair was stuck in the grass at the time she was found. The DON stated CNA C noticed the side exit door's alarm was possibly malfunctioning earlier in the day but did not report it to anyone. The DON stated CNA C was suspended immediately after the incident. The DON stated RN B and LVN D performed the assessment on Resident #1 once she was back in the facility and found no signs or symptoms of distress. The DON stated after the incident, Resident #1 was put back in the locked unit before the end of the day. The DON stated if anyone suspected a resident had eloped, they would call a code grey. The DON stated the first person to respond to the alarm would go outside and check the immediate vicinity. The DON stated other nurses and aides would begin a headcount on their respective halls. The DON stated elopement drills were done quarterly before the incident, but since then they have done them monthly. The DON stated they had an elopement binder at the nurse's station containing all of the residents that had been identified as a wandering risk. The DON stated residents were not allowed to go outside the main exit without supervision because the nearby street was very busy. The DON stated they added new alarms known as screamers to the side exits to help prevent another elopement in the future. The DON stated if the resident had not gotten stuck in the grass when she eloped she may have inadvertently rolled into the nearby busy street. During an observation at 1:30 PM on 12/30/24, this state surveyor saw a binder located at the nurse's station with names and pictures of other residents in the facility identified as a wandering risk. During an observation at 1:35 PM on 12/30/24, this state surveyor paced out the distance from the exits to where Resident #1 was found outside the facility. Resident #1 was approximately 180 feet from the front door, 45 feet from the side exit, and 60 feet from a busy street. During an observation at 1:40 PM on 12/30/24, this state surveyor opened the side exit door that CNA C noted had a deficient alarm on the day of the elopement. After opening and closing the door, the screamer alarm went off for approximately 20 seconds and then shut off. The keypad did not have a red light on. The alarm tied to the keypad never sounded during the test. Several nurses and aides responded to the alarm immediately, and a head count was observed to begin on the other side of the facility by another state surveyor. In an interview with the RCNS at 1:40 PM on 12/31/24, the RCNS stated there was an elopement binder at each nursing station and at the front desk. The RCNS stated the elopement binder contained a color photo and information regarding the residents identified as wandering risks. The RCNS stated the SW was responsible for keeping the elopement binders updated. The RCNS stated they perform wandering evaluations on all residents quarterly. The RCNS stated in August the alarm had a malfunction. RCNS stated CNA C saw the door did not have a red light but did not test the alarm. The RCNS stated CNA C should have immediately informed a manager about the door malfunction. The RCNS stated if the door alarm was not working then residents could exit the facility without the knowledge of any employees. In an interview with CNA A at 3:03 PM on 12/31/24, CNA A stated she was working from 6:00 AM to 6:00 PM on the day of the elopement. CNA A stated the incident occurred around the start of dinner. CNA A stated when she let some visitors inside through the front entrance, one of them told her there was somebody in the corner outside. CNA A stated she went outside immediately and recognized the resident as Resident #1. CNA A stated she called RN B to help her get Resident #1 back in the facility. CNA A stated Resident #1's wheelchair was stuck in the grass. CNA A stated she brought Resident #1 back inside the building with the help of RN B. CNA A stated if Resident #1 had not gotten stuck in the grass she may have rolled through the parking lot and into the street. In an interview with the MS at 9:57 AM on 01/02/25, the MS stated he had worked at the facility for approximately two years. The MS stated since the elopement they have added new alarms to each of the side exit doors. The MS stated before the elopement staff were using the side doors as an exit. The MS stated there were two side exit doors in the facility. The MS stated he and the DON had told staff repeatedly to not use the side doors as exits, and to only exit through the main front entrance. The MS stated inputting the code in the keypad disengaged the alarm for 15 seconds before it automatically reengaged. The MS stated a red light on the keypad meant the alarm was engaged. The MS stated the new alarms added to the doors could not be turned on and off via the keypad. The MS stated there was a code that would disengage the alarm indefinitely until someone input the code back into the keypad. The MS stated the code that indefinitely disengaged the alarm was removed from the system. The MS stated the alarm connected to the keypad would disengage at seemingly random times. The MS stated it would disengage itself less than one time per month. The MS stated when the alarm disengaged itself, he would have to input the code to reengage it. The MS stated employees in the past have informed him when they noticed an alarm was disengaged, and that they needed him to renengage it. The MS stated the alarms have periodically disengaged themselves since he has worked at the facility. The MS stated if a resident eloped from the facility without anybody knowing they could fall or hurt themselves and no one would be able to help. The MS stated he checked the door locks twice per day. The MS stated since the elopement they had performed one elopement drill per shift monthly. In an interview with the EC at 12:45 PM on 01/02/25, the EC stated he worked for a local electronics company. The EC stated their company came out quarterly to the facility to inspect the fire alarms, sprinklers, and the kitchen hood. The EC stated the keypad and the handy box for the doors were mismatched. The EC stated the handy box was slightly too small for the keypad. The EC stated the wires had to bend to fit the mismatched parts. The EC stated bending the wires could cause them to break or not have a good connection. The EC stated he was going to fix the keypad alarms later that day. In an interview with RN B at 1:55 PM on 01/02/25, RN B stated on the day of the elopement, CNA A called her to a resident that was outside and needed help. RN B stated she last saw Resident #1 inside the facility at 4:46 PM sitting at the front nurse's station. RN B stated she told the charge nurse to notify the family, doctor, and the DON. RN B stated they called the family to get consent to move her into the locked unit, and then moved her into it. RN B stated Resident #1 had no complaints during her assessment. RN B stated Resident #1 had no changes to her skin, no redness, and no pain. RN B stated Resident #1 had no signs or symptoms of distress. RN B stated she never heard an alarm from any of the doors. RN B stated Resident #1 may have fallen out of her chair or rolled into the parking lot during her elopement from the facility and no one would have been aware. In an interview with CNA C at 1:02 PM on 01/02/25, CNA C stated she was working a 6:00 AM to 6:00 PM shift on the day of the elopement. CNA C stated she saw the alarm was disengaged at around 10:00 AM to 10:30 AM. CNA C stated she was walking by with a breakfast cart when she saw the red button off. CNA C stated she went to the door to latch it and it gave a little click, but the alarm did not reengage. CNA C stated she looked for the manager on duty but got distracted by a call light. CNA C stated she got busy after that and never told her manager the alarm was disengaged. CNA C stated there were in-services and drills after the incident covering elopement procedures. CNA C stated Resident #1 could have fallen out of her chair and hurt herself outside the building and no one would have known about it to help her. An interview was attempted with Resident #1 at 1:31 PM on 01/02/25, but Resident #1 was not interviewable. During an observation at 3:07 PM on 01/02/25, this state surveyor observed the red light on one of the side exit doors. This state surveyor opened the side exit door and then closed it. The screamer alarm sounded for approximately 20 seconds. After that alarm ended, the alarm connected to the keypad continued to ring. The keypad connected alarm continued to ring until the MS entered the code into the keypad to stop it. Several staff were seen approaching the door to investigate the alarm for a possible elopement. Record review of the facility policy titled Elopements and Wandering Residents implemented on 11/21/22 revealed the following: 1. The facility may be equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. d. Adequate supervision will be provided to help prevent accidents and elopements. In interviews beginning at 1:00 PM on 12/31/25 with both day and night shift staff, CNA A, RN B, CNA C, LVN D, AA E, PT F, RN G, LVN H, the DON, the SW, the MS, and the AD were able to identify the elopement process, wandering residents, knowledge on the new door alarms/locks, what to do if the door alarm sounds, locate cause of alarm, do not reset alarm without determining who entered or exited, identify code grey as the elopement code, and the different types of abuse and neglect. Record review and verification of the corrective action implemented by the facility beginning on 08/17/24: Resident #1 was moved to the locked unit in the facility on 08/17/24 verified through record review and interview with the DON. Re-educated and in-serviced staff beginning on 08/17/24 verified through interviews with various staff members and record review of in-services on 01/02/25. - Abuse and Neglect - Wandering/exit seeking, interventions for exit seekers - Do not give out code to non-employees - If anyone notices any doors not functioning properly immediately report - Staff to be mindful, alert, and aware of surrounding residents in the area when entering, exiting or opening doors - If you see any non employee entering the code to door report immediately - Do not use any side doors as exits, do not use override code. All new admissions have had wandering assessment completed. Verified through record review on 12/31/24. All residents were assessed for elopement risk beginning on 8/17/24. Verified through record review and interview with DON on 01/02/25. Daily (Monday-Friday) exit door checks by maintenance, notify administrator immediately if any of the doors appear to malfunction. Verified through interviews with MS and record review of maintenance log on 01/02/25. Side exit doors received new screamer alarm systems beginning on 09/04/24. Verified through record review, observations, and interview with MS 01/02/25. All staff were educated on operation of new door alarms. Verified through staff interviews (as mentioned above) and record reviews beginning on 12/31/24. Fixed keypad alarm system to not disengage at random times on 01/02/25. Verified through observation of alarm and interview with MS 01/02/25. No other incidents of elopement have occurred since Resident #'1's elopement incident on 08/17/24. Verified through record review and interview with the DON on 12/31/24. The noncompliance was identified as PNC. The PNC began on 08/17/24 and ended on 09/04/24. The facility had corrected the noncompliance before the investigation began.