**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure the resident received adequate supervision to prevent accidents for one (Resident #1) resident of three residents reviewed for elopement. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility unsupervised on 01/13/2025. Resident #1 had unspecified dementia, other lack of coordination and wore a wander guard. Resident #1 eloped from the facility without anyone noticing him or hearing the wander guard alarm system go off. Resident #1 was located between the facility's white fence and the home next door approximately 10-15 feet from the facility's nearest exit door. The noncompliance was identified as PNC. The IJ began on 01/13/2025 and ended on 01/13/2025. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for harm and/or serious injury. Findings included: Record review of Resident #1's undated Facesheet reflected Resident #1 was a [AGE] year-old-male who admitted to the facility on [DATE] and discharged on 01/13/2025. Resident #1 had diagnoses which included: dementia (confusion and forgetfulness), other lack of coordination (problem with balance), unspecified cataracts (clouding of the lens in your eye) and viral hepatitis (infection that causes liver inflammation and damage). Record review of Resident #1's Quarterly MDS assessment, dated 12/05/2024 reflected Resident #1 had a BIMs score of 3, which indicated severe cognitive impairment. Under Section E (Behavior) did not reflect any wandering behavior for Resident #1. Under Section GG (Functional Abilities) reflected Resident #1 ambulated independently. Record review of Resident #1's undated care plan, reflected Resident #1 was an elopement risk/wanderer with interventions/tasks that included, staff to monitor wander guard. Record review of Resident #1's clinical record reflected an Elopement Risk Assessment completed on 01/13/2025, indicating a high risk for elopement. Record review of the Provider Investigation Report dated 01/13/2025 revealed on 01/13/2025 [Resident #1] was observed sitting in the dining room eating breakfast at 8:00 am. At 08:15 am, staff were alerted that the resident was outside. [Resident #1] was noted to be found by staff on the facilities sidewalk between the facility and the adjacent home, approximately 15-20 feet from the facility's exterior door. [Resident #1] was promptly and easily re-directed back into the facility and a head-to-toe assessment followed immediately, with no injuries noted. When asked about his intentions, [Resident #1] stated, I was going to pick up some money [Resident #1] was placed on one-on-one supervision, and an elopement assessment was competed. [Resident #1] reported no pain or discomfort. The MD and Family was promptly notified. An Order was received for transfer to a male secure unit at another SNF facility. [Resident #1] remained on one-on-one supervision until time of transfer the same day at 04:00 pm. The facility investigation findings were inconclusive. Record review of Resident #1's Physician Orders reflected Check wander guard every shift effective 11/1/2023. Record review of Resident #1's order summary dated 12/01/2024 to 01/13/2025 revealed a new order starting on 01/13/2025 for 1:1 Monitoring x 24 hours every shift for 2 days. Review of website: timeanddate.com on 01/30/2025 reflected the following temperatures for the area the facility was located: 1/13/24 7:53 AM 31°F 1/13/24 8:53 AM 34°F Record review of Resident #1's progress notes dated 01/13/2025 at 09:33 AM written by the SW revealed, [Resident #1] recently moved to another room due to [Resident #1] and roommate not being compatible. [Resident #1's] prior roommate stated that [Resident #1] was packing up his belongings and putting them on the roommate's bed while he was in the bed. [Resident #1] had confusion and wandered about the facility and appeared to be more lost since the room move. [Resident #1] was pleasantly confused. The nurse reported that [Resident #1] exited the facility this morning. [Resident #1] will need alternate placement in a secured memory care unit. [Resident #1] was currently on one-to-one supervision at this time. Record review of Resident #1's progress notes dated 01/13/2025 at 11:59 AM written by the SW revealed, I called other facilities with secured areas ([Name of other Facilities]) to see if they have any openings in their secured areas. [Name of Facilities] have openings. I have sent [Resident #1] referral paperwork to [Name of Facilities] (marked urgent) and will follow up shortly. I spoke with [Resident #1] [family member]/RP. He understood and is fine with [Resident #1] moving to either of the above facilities. I will notify him once I know which facility [Resident #1] will be going to and what time. [Resident #1] remains on one-to-one supervision at this time. Record review of Resident #1's progress notes dated 01/13/2025 at 01:25 PM written by [LVN] revealed, the resident was found walking outside of facility by another employee. [Resident #1] went out the side door of the facility after he finished breakfast. [Resident #1] stated he was trying to get his money. [Resident #1] was brought back into the facility by staff, he was redirected, and educated on the importance/safety of not exit seeking from the building. [Resident #1] was also placed on 15-minute observation, and an aide was with him at all times. [Family member] was notified of situation and understood that [Resident #1] did leave facility, and the actions the facility has taken to ensure his safety. Record review of Resident #1's progress notes dated 01/13/2025 at 03:54 PM written by LVN C revealed, the representative from [Facility] was at the facility to pick up the resident for admission to facility. All meds, med list with face sheet were provided and the resident was transported. The MD was notified. During an observation and interview on 01/24/2025 at 12:05 pm with the DON, the outside of the facility, the parking lot, both sides of the facility, the house next door, the four-lane street and surrounding area were observed by Surveyor. The facility was located in a business and residential area and was adjacent to a multi-purpose gas station on one side and a private residence on the other side. The DON reported Resident #1 was located standing in the grass area adjacent to the house next door approximately 10-15 feet from the facility's nearest exit door. In an interview on 01/24/2025 at 02:15 pm with the HRM, she stated when she returned to the facility on [DATE] around 08:15 am, as she walked towards the door, something caught her eye and she saw Resident #1 walking outside of the facility. The HRM stated CNA E had already ran outside and yelled that was Resident #1. The HRM stated Resident #1 stopped by the white fence that separated the facility from the home next door. The HRM stated they spoke with Resident #1 and redirected him back into the building. The HRM stated Resident #1 kept saying let me go. The HRM stated nothing they said worked. The HRM stated they eventually got Resident #1 to return to the facility as they convinced him he needed to put on a jacket. The HRM stated she was in-serviced by the DON and the MTD on elopements, wander guard and door alarms and they completed elopement drills on several days. In an interview on 01/24/2025 at 02:40 pm with LVN A, she stated they believed Resident #1 exited the front door when someone left out because it took 15 seconds for the alarm to re-activate. LVN A said the HRM saw Resident #1 outside and CNA E ran outside after him. LVN A stated they brought Resident #1 back inside, assessed him, and placed him on 1:1 monitoring until he transferred to a secure unit. LVN A said Resident #1 wore a wander guard and he had never eloped prior to the incident. LVN A said she took the two residents that wore a wander guard to the front door and ensured the wander guards worked properly. LVN A said she was in-serviced on abuse and neglect, elopements, wander guards, door alarms and they completed elopement drills. LVN A stated the wander guard alarm sound was now different and louder throughout the facility. LVN A said she was in-serviced by the DON and the MTD. LVN A stated she did not learn anything new, and the only thing that was different was the sound of the alarm and its increased volume. In an observation and interview on 01/24/2025 at 03:50 pm with the MTD, revealed the wander guard system had been checked weekly. The MTD provided a copy of the Doors, Locks, & Alarms logbook and it revealed it was updated. The MTD stated they had a wander guard alarm on the 100 and 200 hall exit doors by the nurse's station. The MTD stated the main entrance, the 400 hall and the backdoor all have an alarm that released in 15 seconds. The MTD stated management requested he check the alarms weekly, but he checked the alarms three times a day. The MTD stated they had not had any issues with the alarms. The MTD stated if they had any issues, they called [Service Company]. The MTD stated no resident knew the door code. The MTD stated he checked all the exit doors and they were all operating properly. The MTD stated he still called [Service Company] to come out. The MTD stated the DON and he conducted in-services on door alarms, elopements, fire drills, abuse and neglect and they also conducted elopement drills on 01/14/2025, 01/15/2025, and 01/16/2025. The MTD demonstrated for the Surveyor at each door and both nursing stations that the alarm system worked properly. In an interview on 01/24/2025 at 04:20 pm with the DON, she stated only two residents remained with wander guards. The DON stated they had three nurses on duty and now utilized four nurses. The DON stated at the time of the elopement, the nurses were away from the nurse's station on dining duty and did not hear the alarm. The DON stated [Service Company] came out and adjusted the alarm volume on all doors and ensured everything worked properly. The DON stated [Service Company] increased the volume of the alarm system at the nurse's station and it was now heard throughout the facility. The DON stated they completed elopement drills and in-serviced on abuse and neglect, elopements and missing residents, and fire drills. The DON stated she was in-serviced by the DOR on the Elopement Process on Missing Residents and they toured the building and checked all doors. The DON stated the biggest thing for her was the alarm system and how crucial and important it was it worked properly. The DON stated it exposed her to what she needed to improve on and ensured staff did not become complacent. The DON stated it was bad it happened, but good due to being retrained and refreshed on the emergency codes. In an interview on 01/27/2025 at 10:00 am with LVN B, she stated she was told the HRM saw Resident #1 outside. LVN B stated Resident #1 wore a wander guard. LVN B stated Resident #1 was high functioning. LVN B stated Resident #1 liked to walk up to the doors but had never eloped. LVN B stated she was in-serviced on the alarm systems, how to recognize the sounds, and the protocols if a resident was missing. LVN B stated they completed an in-service on elopements and completed an elopement drill. LVN B stated she was in-serviced by the ADON, DON and the MTD. LVN B stated she learned the new sound system. LVN B stated the wander guard system had a different tone now and the volume was much louder. In an interview on 01/27/2025 at 10:25 am with CNA A, he stated he was informed when he exited a door to make sure the door closed properly. CNA A stated if someone eloped, he searched the inside and outside of the building and if needed, he expanded the search. CNA A stated he was in-serviced on abuse and neglect, doors and door codes, elopements, fire drills and they signed the paperwork. CNA A stated he was in-serviced by the MTD and the DON. CNA A stated the in-services were more of a re-education as he already knew the information. In an interview on 01/27/2025 at 10:50 am with CNA B, she stated she was at work when Resident #1 eloped. CNA B stated Resident #1 had recently moved to another hall. CNA B stated after Resident #1 finished breakfast, he walked back towards his room. CNA B stated she returned to the dining room and assisted with breakfast. CNA B stated she observed Resident #1 re-enter the facility with the HRM and CNA E. CNA B stated the ADON assigned her to 1:1 supervision and she completed a 15-minute checklist. CNA B stated she was in-serviced on abuse and neglect, elopement policy, wander guard system, 15-Miniute elopement checklist, and the different emergency color codes. CNA B stated she was in-serviced by the ADON, the DON, and the MTD. CNA B stated she did not learn anything new. CNA B stated she continued to monitor all residents more closely. In an interview on 01/27/2025 at 01:25 pm with CNA C, she stated she was not at work when the incident occurred. CNA C stated she was in-serviced by the DON and the MTD on abuse and neglect, the different alarm systems, door codes, elopement, and what to do and how to react if one of these situations occurred. CNA C stated they completed an elopement drill and had unscheduled fire drills without warning. CNA C stated whenever she saw Resident #1 approach the door, she immediately redirected him. CNA C stated even if Resident #1 stared at the door, she redirected him. CNA C stated the in-services were more of a refresher. CNA C stated she would not do anything different, just remain aware and vigilant. In an interview on 01/27/2025 at 01:50 pm with CNA D, she stated Resident #1 eloped prior to her shift. CNA D stated Resident #1 stayed in his room mostly and did things for himself. CNA D stated she did not know what made Resident #1 leave. CNA D said she was in-serviced by the DON and the MTD on door alarms and if the fire alarm sounded, they called 911. CNA D said they had alarms on the doors in case a resident attempted to leave unsupervised. CNA D stated the alarms were now louder and she noticed the difference. CNA D said they were in-serviced on elopements and they completed an elopement drill. CNA D stated the MTD conducted the drills. CNA D said the DON conducted the training on abuse and neglect. CNA D stated she did not know what could had been done different. CNA D stated based on what she learned, it was a refresher and she would not be doing anything different. In an interview on 01/27/2025 at 02:15 pm with LVN C, he stated this incident occurred prior to his shift, but Resident #1 was transferred out during his shift. LVN C stated he was told Resident #1 exited the building and had to be redirected inside. LVN C said Resident #1 was new to his hall as he had transferred to a new room. LVN C stated he was unaware if Resident #1 ever attempted to leave the facility. LVN C stated he believed everything was handled accordingly. LVN C stated all doors had been tested. LVN C stated Resident #1 would ask him where his room was located. LVN C stated Resident #1 never came across as an exit-seeker. LVN C stated he was in-serviced on elopements, abuse and neglect, and they conducted an elopement drill. LVN C stated he was in-serviced by the ADON and the DON. LVN C stated the MTD was present and he led the actual elopement drill. LVN C stated the wander guard system is now much louder. LVN C stated he did not learn anything new and it was more of a refresher. LVN C stated moving forward, he would be more vigilant and mindful of the residents that like to wander. In an interview on 01/27/2025 at 02:30 pm with the MR/ADC, she stated she was at work but did not see what happened. The MR/ADC stated she sat at the main entrance and Resident #1 had not exited from her area. The MR/ADC stated she did not see Resident #1 walk past her office window. The MR/ADC stated when she heard Resident #1 got out, she searched inside and outside. The MR/ADC stated she completed a fire and elopement drill and was in-serviced on abuse and neglect, door codes, and elopement. The MR/ADC stated Resident #1 was quiet and had never eloped. The MR/ADC stated she learned to pay attention even when she was already paying attention. The MR/ADC stated moving forward, she would go outside and look to make sure no resident was out front. The MR/ADC stated the alarm system was much louder now. In an interview on 01/27/2025 at 02:45 pm with LVN D, she stated she was not working when Resident #1 eloped. LVN D stated Resident #1 recently transferred from her hall. LVN D stated she was in-serviced on abuse and neglect, the elopement policy, monitoring the residents, door safety, and the alarm systems. LVN D said they also conducted an all-staff elopement drill. LVN D stated if they saw a resident leaving, they were supposed to make sure the wander guard is on and working properly. On 01/27/2025, multiple attempts were made to contact the MD. A returned phone call was not received prior to exiting. On 01/27/2025, multiple attempts were made to contact the ADON. A returned phone call was not received prior to exiting. On 01/27/2025, multiple attempts were made to contact CNA E. A returned phone call was not received prior to exiting. In an interview on 01/27/2025 at 04:15 pm with the DON, she stated Resident #1 recently moved to a new room. The DON stated the room change made Resident #1 confused and disoriented due to his new surroundings. The DON stated Resident #1 wore a wander guard due to aimlessly wandering throughout the facility. The DON stated Resident #1 had been in the dining room eating breakfast as usual. The DON stated once Resident #1 finished eating, he normally went back to his room. The DON stated Resident #1 was stopped between the facility and the house next door. The DON stated there had been maybe a 15-minute gap from the time Resident #1 finished breakfast. The DON stated Resident #1 had never tried to elope. The DON stated Resident #1 watched tv, slept, and minded his business. The DON stated Resident #1 was not an exit-seeking resident. The DON stated Resident #1 started wearing a wander guard in July 2023 due to wanting to return home and pushing on the door. The DON stated they kept eyes on Resident #1 and he had done good. The DON stated they explained to the family back then if Resident #1 tried to elope he would be transferred out. The DON stated Resident #1 never tried to leave until the recent incident on 01/13/2025. The DON stated Resident #1 was assessed with no injuries, placed on 1:1 and transferred out the same day. The DON stated the MTD checked the alarms every morning and at the end of the day. The DON stated on 01/13/2025 the MTD said he checked the doors and alarms at 08:00 am and they worked properly. The DON stated she could not say for sure, which door Resident #1 exited from because they found him on the side of the building. The DON stated if Resident #1 had exited the front door, the alarm was loud and the wander guard would had triggered it. The DON stated the side doors had alarms and wander guard systems were at both nursing stations. The DON stated they did not have video cameras. The DON stated staff observed Resident #1 at 08:00 am in the dining room, and they observed him again outside at approximately 8:15 am. The DON stated the alarms were checked at 08:00 am and worked properly. The DON stated the HRM saw Resident #1 outside when she returned from the store. The DON stated either Resident #1 pushed the door, or he followed someone out. The DON stated due to it being breakfast time, no one was at either nurse's station. The DON stated the nurses went to the dining room to assist. The DON stated the CNAs assisted in the dining room after passing trays on the halls. Record review of the Quality Assurance Performance Improvement Meeting revealed it was held on 01/20/2025 with the Medical Director in attendance. Under Nursing Concerns, QM Action Plan or PIP reflected, Elopement Incident regarding Resident #1 with interventions put in place. Elopement - Dated 01/13/2025 A new elopement assessment was conducted on 01/13/2025 to identify any residents who may be at imminent risk of elopement. No residents were found to be at immediate risk. Responsibility: Nurse Management Monitoring: Regional Director of Clinical Services / Director of Nursing Elopement assessments will be completed upon admission, on a quarterly basis, and whenever a resident triggers a potential imminent risk for elopement. In such cases, the elopement response protocol will be activated. Any resident identified as having an elopement risk will be placed under 1:1 monitoring until it is no longer deemed necessary. Monitoring: Regional Director of Clinical Services - Residents at risk of elopement will remain on 1:1 supervision until alternative or safe living arrangements are found. They will be supervised by facility staff. The resident's photo and face sheet will be included in an elopement binder, and care plans will be updated accordingly. The Director of Nursing and/or Nurse Manager will conduct weekly audits to ensure compliance by reviewing elopement assessments and the elopement binders. These audits will be performed weekly for a duration of four weeks, ending on 02/06/2024, and will then be conducted monthly on an ongoing basis. The Regional Director of Clinical Services will also review the documentation weekly for compliance. The Executive Director will monitor daily compliance for the first four weeks, then conduct a review. Record review of an in-service dated 01/13/2025 reflected all staff attended and the subject matter was regarding the facility policy on Missing Resident Drill: Create an incident response protocol that staff can easily activate when a patient is missing. The protocol should specify the sequence of events (e.g., the action plan) that should take place when staff are notified that a patient is missing. The protocol should include the communication plan (e.g., notification of unit supervisor, security, patient's physician, patient's family, administration) and must include up-to-date contact information for all parties who need to be notified. Ensure that all staff are educated about preventing and responding to elopement events e.g., risk factors, communication protocols, action plans). Evaluate elopement events and attempted elopement events to identify gaps in the protocol or in staff education or response. Modify the protocol as needed. Record review of the Elopement Drill Checklists for an all-staff elopement drill revealed drills were conducted on 01/14/2025 at 10:00 am, 01/15/2025 at 10:00 pm, and 01/16/2025 at 01:30 pm. Record review of an in-service dated 01/14/2025 reflected all staff attended and the subject matter was regarding the facility policy on abuse and neglect. Record review of an invoice from [Company] dated 01/13/2025 revealed under notes, Checked all doors and all mag locks are locked and alarming and egressing as they should. Interviews were conducted with facility staff from various shifts on 01/27/2025 from 3:00 pm to 4:00 pm. Staff interviewed were ADON, HRM, CNA A, CNA B, CNA C, CNA D, LVN A, LVN B, LVN C, LVN D. Interviews with staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on responding to all alarms to ensure resident safety, how to check the panel on the halls to determine what door alarm was sounding, conducting a resident head count, full searches inside/outside the facility, and ensuring they searched all sides of the building outside. Record review of the Facility's Policy titled Elopements revised December 2024 reflected: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing .2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the departure in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the Charge Nurse or the Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall; a. examine the resident; b. Notify the attending physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure resident was free from abuse and neglect for 1(Resident # 2) of 10 residents reviewed for abuse and neglect. 1. The facility failed to protect Resident # 2 from physical abuse by CNA F. Resident #2 was aggressively respositioned and hit twice in the face with an opened hand and closed fist by CNA F. Resident #2 grimaced after being hit twice in the face by CNA F. This failure could place residents at risk of abuse, injury, and emotional distress. The noncompliance was identified at PNC. The noncompliance began on 5/15/2024 and ended on 5/15/2024. CNA F was arrested by law enforcement and terminated immediately. The facility had corrected the non-compliance by conducting skin assessments on all nonverbal residents, conducted safe surveys for every verbal resident, educated staff on abuse and neglect and customer service, and the facility implemented monitoring by all departments completing guardian angel daily rounds daily for six weeks. Findings include: Record review of Resident #2 face sheet dated 12/19/2024 reflected an [AGE] year-old female who was admitted to the facility 6/24/2021 with diagnoses which included: combined systolic and diastolic heart failure, dysphasia following other cerebrovascular disease, hyperlipidemia, and Alzheimer's disease. Record review of Resident #2 quarterly MDS assessment dated [DATE] reflected a BIMS score of 99 which indicated the interview was unable to be completed. Record review of Resident #2 care plan dated 10/4/2024 reflected Resident #2 had impaired cognitive function and impaired thoughts and communication problem related to Alzheimer's, ADL self-care performance deficit related to Alzheimer's, confusion, and limited mobility, and swallowing problem related to dysphasia. (Requires total assistance with eating, bed mobility, transfers, dressing, toilet use and personal hygiene) Record review of provider investigation report dated 5/22/2024 reflected video footage of CNA F slapping and hitting Resident #2 and rearranging Resident #2 forcefully. Skin assessments and x-rays were conducted and showed no results of bodily harm or bruising. CNA F was removed by law enforcement and was terminated immediately. Further investigation, documentation, and evidence confirmed the allegation. In an interview on 12/17/2024 at 4:37pm, Resident #2's representative stated Resident #2 room had video surveillance camera installed 5/14/2024. The representative stated on 5/15/24 at approximately 5:00am, she reviewed the video footage and observed a staff member hitting resident twice in the face with an open hand, and aggressively pulling Resident #2 from the top of the head to the other side of the bed. Resident #2's representative stated after viewing the video footage she notified law enforcement. She stated law enforcement visited the facility and arrested CNA F. Observation and interview on 12/18/2024 at 12:28pm. Resident #2 were observed sitting up staring at the ceiling. The state surveyor attempted to interview Resident #2 but Resident #2 could not verbally communicate. In an interview on 12/18/2024 at 1:00pm, the DON stated Resident #2 is nonverbal and require total care and is dependent on staff for ADL's. She stated on 5/14/2024 at approximately 5:00pm or 6:00pm, resident # 2 had video surveillance camera installed in her with approval from the facility. She stated on 5/15/2024 at approximately 6:00am, she was contacted by staff and informed law enforcement showed up to the facility with video footage of CNA F hitting Resident #2 twice in the face. She stated staff told her law enforcement addressed the incident with CNA F and then arrested CNA F. She stated immediately following the arrest, CNA F was terminated. She stated there were no witnesses present during the incident. She stated following the incident, the resident was treated off site, and a skin assessment and X-rays were conducted. She stated no injuries were founded. She stated on 5/15/2024, the facility started their investigation and initiated skin assessments on all non-verbal residents, safe surveys on all verbal residents, in services on abuse and neglect and customer service, and Angel rounds were conducted and completed by all department heads daily for six weeks. Attempted interview on 12/19/2024 at 12:55pm, the state surveyor attempted to contact CNA F via phone. The attempt was unsuccessful, the state surveyor left a message requesting a call back. In an interview on 12/20/2024 at 4:37am, RN D stated on 5/15/2024, she was the nurse on duty during the 10pm-6am shift. She stated at approximately 5:00am, law enforcement showed up to the facility and approached the nurse's station. She stated the officer asked who provided care to Resident # 2. She stated CNA F was standing at the nurse's station and responding to the officer stating she provided care to Resident # 2. She stated the officer asked CNA F if she physically assaulted Resident #2 and CNA F denied physically assaulting Resident # 2. She stated the officer showed CNA F video footage of CNA F physically assaulting Resident # 2. She stated after the officer showed CNA F the video footage, she still denied physically assaulting Resident # 2. She stated the officer handcuffed CNA F and escorted CNA F out of the facility. She stated the officer showed her the video footage. She stated in the video footage she identified CNA F and observed CNA F pulling Resident # 2 roughly and slapping Resident #2 on her forehead. She stated she notified the ADM and the DON immediately. She stated she was in serviced on abuse and neglect. She stated the risks of staff not reporting abuse or neglect to the abuse coordinator could allow the abuse to continue. In an interview on 12/20/2024 at 5:17am, CNA G stated she worked full time during the 10pm-6am at the facility. She stated the night the incident between CNA F and Resident # 2 took place, she was off. She stated she was in serviced on abuse and neglect. She stated the risks of staff failing to report abuse or neglect could put the residents a harm for continued abuse. In an interview on 12/20/2024 at 8:07am, the ADM stated she was not employed at the facility when the incident between CNA F and Resident # 2 occurred. She stated she was hired in September 2024. She stated after reviewing the PIR, she was informed there was video footage of CNA F physically hitting Resident # 2 twice to the face. She stated the PIR indicated law enforcement arrested CNA F at the facility. She stated the PIR revealed CNA F was terminated immediately and the facility-initiated safety and prevention measures. She stated the facility initiated in services on abuse and neglect and customer service. She stated skin assessments were conducted on all non-verbal residents, and safe surveys conducted on all verbal residents. She stated the facility's monitoring plan included angel rounds conducted daily for 6 weeks by all department heads. She stated the risks of staff failing to report abuse or neglect could put the residents at risks of getting hurt and having adverse effects. Observation and interview on 12/20/2024 at 9:00am with the ADM and the DON, the state surveyor revealed she received the video footage of the incident between CNA F and Resident # 2 on 12/20/2024. Surveyors reviewed the video with the ADM and the DON. The video revealed at 5/15/24 at 2:26am, CNA F was observed in Resident #2 room whipping Resident #2 chin with a towel. CNA F was observed slapping Resident # 2 on her forehead with a right open hand causing loud noise. CNA F was then observed aggressively grabbing Resident #2 by the head and pulling Resident #2 to the other side of the bed as she positioned Resident #2. CNA was then observed hitting Resident #2 on the forehead with a right closed fist. Resident #2 was observed with a grimacing face after being hit in the face. After watching the video, the DON was able to identify the CNA as CNA F. The DON stated after she was informed about the incident, the facility terminated the CNA F immediately. She stated she tried to contact CNA F, but the attempt was unsuccessful. Record review revealed a skin assessment performed on 5/15/2024 on Resident # 2 with no adverse physical findings. Record review revealed skin assessments performed on 5/15/2024 on all non-verbal residents. Record review of in-service training record dated 5/15/2024 revealed nurses, CNAs, and CMAs were in serviced by nursing management on abuse and neglect and customer service. Dietary staff was in serviced on customer service. Record review of safe surveys dated 5/15/2024 revealed departments heads conducted safe surveys on verbal residents. Record review of Guardian Angel Daily Rounds revealed department heads conducted angel rounds. The angel rounds were initiated on 5/15/2024 and completed on 7/16/2024. Record review of Police Report dated 5/15/2024, reflected law enforcement dispatched to the facility. The video footage was provided to the responding officer. Due to the video evidence CNA F was taken into custody for the offense of injury to elderly. The disposition of the police report was cleared by arrest. Record review of the facility's policy titled Risk Management: Abuse, neglect, exploitation, mistreatment of resident, or misappropriation of resident property dated December 2023, Policy statement: The facility has designated and implemented processes which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of residents' property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement/involuntary seclusion, or separation of a resident from other residents or from their room or other area against the resident's will or the will of the resident's legal representative. Intimidation with resulting physical harm, or pain, or mental anguish. Punishment with resulting physical harm, or pain, or mental anguish. Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. 1. Residents must bit be subject to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, or other individuals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #1) resident of three residents reviewed for elopement. 1. The facility failed to ensure Resident #1 was adequately supervised to prevent her from leaving the facility unsupervised. Resident #1 had severely cognitive impairment and lacked safety awareness. Resident #1 eloped from the facility rolling in her wheelchair across a four-lane busy residential street arriving at the fire station across the street 50 yards away. It was determined these failures placed Resident #1 in a non-compliance Immediate Jeopardy (IJ) situation from 07/01/24-07/02/24. The facility corrected the noncompliance before the survey began. This failure placed residents at risk for harm and /or serious injury. Findings included: Record review of Resident #1's other MDS assessment, dated 07/11/2024 reflected the Resident was an [AGE] year-old-female who admitted to the facility on [DATE] and readmission on [DATE] and discharged on 07/11/2024. The resident had diagnosis which included: Malignant Neoplasm of colon (cancer of the colon), intestinal obstruction (mass in the intestine), dementia (confusion and forgetfulness), functional decline, generalized weakness, anxiety (restlessness) and lack of coordination (unable to walk). The MDS reflected he had a BIMs score of 4, which indicated severe cognitive impairment and the resident was ambulatory with a wheelchair and required assist of one staff for activities of daily living. The MDS did not reflect any wandering behavior. Record review of Resident #1's care plan, dated with an review date of 07/01/2024, addressed the resident's impaired cognition due to short term memory loss (unable to remember after 5 minutes), and assistance required for activities of daily living. Further review of the clinical record reflected, the resident's moderate risk for elopement was not addressed, until 07/01/2024. Record review of Resident #1's Elopement [NAME] Assessment completed 06/05/2023 scored Resident #1 as no risk for elopement. Further review of Resident #1's elopement risk dated 06/04/2024 reflected Resident #1 as no risk for elopement. Record review of the clinical record reflected an Elopement Risk Assessment completed on 07/01/2024, indicating a high risk for elopement. Record review of Provider Investigation Report dated 07/01/2024 reflected a finding of Unfounded for Neglect. Review of the External/Internal/Systemic Approach Investigation Summary dated 07/01/2024 completed on 07/05/2024 reflected: . An emergency QAPI meeting was held on 07/02/2024 with Medical Director in attendance . all residents had a new elopement assessment to identify any current patients that are imminent risk for elopement (no other residents were found to be at imminent risk of elopement) . (who was responsible: Nurse Management . who will monitor: Regional Director of Clinical Services/Director of Nursing.elopement assessment will be completed upon admission and quarterly by the charge nurse and/or nurse managers and for any resident that triggers an imminent risk for elopement, the elopement response protocol will be initiated Any patient that triggers elopement risk will be placed on 1:1 monitoring until no longer deemed necessary. DON will monitor for compliance for 4 weeks until 08/08/2024 and then monthly on an ongoing basis .Who will monitor: Regional Nurse of Clinical Services Until alternative and or safe living arrangements are made, they will be placed on one-one-supervision with facility staff. The resident's picture and face sheet will be placed in an elopement binder. Resident care plans will also be updated. The Director of Nursing and/or Nurse Manager will monitor weekly for compliance by completing an audit of the elopement assessments and the elopement binders. Audits will be completed weekly for 4 weeks until 08/08/2024 and monthly on an ongoing basis The Regional Director of Clinical Services will review the documentation each week for compliance The Executive Director will monitor daily to ensure compliance for four weeks and will review . Further review of the Providers Investigation Report reflected monitoring and audits by the designated staff (DON Nurse Managers and Regional Nurse consultant) had occurred. Record review of progress notes reflected Resident #1 on 06/01/2024 through 07/01/2024 had previously indicated she had no behaviors of wandering or attempting to exit the facility. Further review of the progress note reflected Resident #1 had a diagnosis of anxiety, that had increased on 06/17/2024, The nursing staff contacted the physician, who came and visited the resident who as not sleeping well at night and stating she did not know what to do with herself anymore. The physician medications changes increased the anxiety medication. Record review of the Medication Administration Records for Resident #1 reflected the Lorazepam 05mg two time a day had been increased to three times a day on 06/17/2024. Record review of progress notes reflected Resident #1 on 07/01/2024 she was observed by LVN A, who was the MDS coordinator at the time, in her wheelchair mobilizing across a busy four lane residential road. Record review of In-service dated 07/01/2024 reflected all staff attended and the subject matter was regarding Facility policy on elopement and reducing the risk for elopement: initiating a frequent monitoring form, communicating any related changes in any resident immediately to the charge nurse, if you notice a residents exhibiting exit seeking behavior to notify the charge nurse immediately and do not leave the resident alone, and to be aware where the elopement binders are located at each nurses station. and updating the care plan. Record review of the In-serviced dated 07/02/2024 reflected an all-staff elopement drill. In an interview on 12/18/2024 at 10:00 am with the ADON revealed she was working on the day that Resident #1 left the facility, she did not know which door she went out of. ADON stated, A code was called and everyone went running, I stayed inside to assist the other nurse to make sure all the other residents were accounted for and were safe. The ADON said she did not know the resident that well, she had not worked here long. Resident #1 was pleasant and she had never been told by staff that she would elope, she did not wear a wander guard. The ADON stated at times the resident was anxious, but not exit seeking. In an interview on 12/18/2024 with LVN A at 10:53 a.m. revealed he was looking at the window and he thought he saw the resident crossing the street in her wheelchair, going towards the old fire station. LVN A said, I could not believe my eyes; I called a code pink and ran out telling he receptionist to tell everyone. By the time I got to her she was already across the street and in the parking lot of the fire station. LVN A stated the traffic had stopped on both sides of the street as she crossed. Resident #1 told me she was coming to see about the fireman, the DON was right behind me and a whole lot of staff. She was brought back to the facility and the DON assessed her; she was not injured. Resident #1 never mentioned about leaving, the LVN stated he saw her every day and she was always out of her room and she was wheeling around in her wheelchair, but not trying to leave. The LVN stated Resident #1 goes to all activities and she will sit at the nurse's station and talk to other residents. An observation on 12/18/2024 at 4:00 p.m. revealed the surrounding outside area, parking lot, and streets adjacent to the facility. The facility was in a residential/business area with multiple car lots, multiple restaurants, a large shopping center, and multiple businesses. The street in front of the facility was very busy with cars. There was a popular highway less than a quarter of a mile away, as well as a very busy main four lane street that leads to residential areas, and large shopping centers, that has heavy traffic on the road all times of the day and night. Where the resident was found (in the parking lot of the old fire station) is approximately 150-200 feet away across busy streets. In an interview on 12/18/2024 with Social Worker at 11:10 a.m. revealed she had worked here since December 2017 there had not been any elopements. The Social Worker stated she had been in-served by the new Administrator. The staff is supposed to report any exit seeking behaviors, that would include a resident talking about leaving. The resident is immediately replaced on 1:1 until they can locate a safe place for them to reside. The Social Worker stated she assisted in locating several secured units for the family to tour and pick from. The Social Worker stated Resident #1 had never had any exit seeking behaviors. The Social Worker stated the facility had an in-service about elopement and conducted an elopement drill. In an interview on 12/18/2024 at 11:15 a.m. with CNA B revealed she was working the day that Resident #1 left the facility. CNA B stated she had been in the dining area around 12:30 p.m. and Resident #1 had been in the dining room, ate her lunch and left the dining area. The CNA stated she did not say anything about leaving and she did not notice any unusual behavior related to Resident #1. The CNA stated the resident came into the dining area ate her lunch and left, came as she has always done. CNA B stated when she came back inside, I got the feeling she was not eloping, she was just going to introduce herself to the fireman, like she was their neighbor. The CNA stated the facility had in-service on elopement and we had an elopement drill also. CNA B stated Resident #1 had a wander guard placed on her and staff was asked to do 1:1 monitoring her 24 hours a day until she left the facility. In an interview on 12/18/2024 with CNA E at 12:00 p.m. revealed she knew where the wander guard binders were at the nurse's station. CNA E stated she had taken care of Resident #1; she was very busy resident and would sit for awhile if you gave her an activity book. CNA E stated Resident #1 attended all the activities. The resident never said anything about leaving the facility. The CNA stated she had been in-serviced on elopement and had attended a drill for elopement and knew what to do. In an interview/observation on 12/18/2024 with the Maintenance Director at 12:10 p.m. revealed the wander guard system was checked once a week. The Maintenance Director and the Surveyor revealed the maintenance logs together the last check had been on 12/16/2024. Further view revealed the wander guard system had been checked the morning of 07/01/2024. The Maintenance Director stated the doors were easy release doors that if you hold them, they will release in 15 seconds and if you wear a wander guard the doors will alarm. The maintenance demonstrated that the wander guard worked with a loose wander guard that had been engaged. The maintenance Director explained if the wander guard bracelet was engaged it was blinking. In an interview on 12/18/2024 with LVN C at 12:45 p.m. revealed LVN C had seen Resident #1 on 07/01/2024 coming out of the dining room. LVN C stated it was after she had eaten lunch. Resident #1 was not her resident, but she knew her because she mobilized all around in her wheelchair. LVN C stated that Resident #1 had never said anything about wanting to leave that day or any other day. LVN C stated she was working that day. She stayed inside and made sure all the other residents were accounted for. The LVN stated the facility had an in-service on elopement and had an elopement drill. In an interview on 12/18/2024 at 3:45 p.m. with primary care physician revealed Resident #1 was his resident. The physician stated the resident could be confused at times due to the cancer that had spread to her brain. He stated Resident #1 did not have history of wandering. Resident #1 anxiety medications had been changed prior to her leaving the facility, when the nurses had called me informing me that her anxiety had increased. I came to see her around June the 17th 2024 and she was more anxious, but she never mentioned to me about leaving or wanting to go home. I was concerned about her pain making her more anxious, but she said she did not hurt, so I made sure her pain medication was scheduled since she did not have to ask for it. The facility informed me when she left the building and then when she was back inside. I told them she needed to be moved to a secured unit, since she was so mobile still in her wheelchair. I spoke to the family about her moving, they did not want her to, since she had lived there for so long, but I assured them this was the right thing to do for her safety, The facility was offered several options, and moved her. The physician stated that Resident #1 had never tried to leave the facility before and he had not had other occurrences of elopement. In an interview on 12/20/204 at 4:45 a.m. with RN D revealed she was surprised when she heard about Resident #1 leaving the facility. RN D stated she would get up at night and roll around the facility, but never tried to leave. She did not sleep that much at nighttime, but she was not disruptive. RN D stated Resident #1 was more restless at times than others and would ask what she should do, but she was easily redirected and she would go back to bed most of the time. The physician had changed the anxiety medicine sometime in June I cannot recall, the increase settled her down some. Resident #1 never went into other resident's rooms and she always recalled where her room was. The RN stated she had an in-serviced on elopement a drill and on abuse/neglect after this happened. Resident #1 had a 1:1 staff member on the night shift until she transferred to another facility with a secured unit. In an interview on 12/20/2024 at 8:45 a.m. with DON revealed Resident #1 did leave the facility on 07/01/2024. The DON stated she was in the medication room when the code was called and went out the side door and ran out to the street. The MDS nurse was already there with Resident #1 in the old fire station parking lot. The DON stated that it really scared me, Resident #1 had no history of exit seeking behavior, and never tried to leave before, we immediately placed a wander guard on here and I called the family and told them she needed to be relocated to a secured unit for her safety. The family did not want her to move, but only agreed that it was best for her. The DON stated Resident #1 was placed on 1:1 monitoring until she transferred. The DON stated Resident #1 tried one time when she was on 1:1 to leave again, that was when I told the Social Worker the family had to decide right away. The Social Worked called the family again and she left the next day. The DON stated that she had an all-staff elopement drill on 07/02/2024 and had an in-service on 07/01/2024. In an interview on 12/20/2024 at 10:15 a.m. with the Administrator revealed she was not the administrator at that time and there had been no elopements since she had been at the facility. The Administrator stated she had been informed of the elopement when she first came to work at the facility. The DON had informed me that in-services had been conducted as well as an elopement drill. There is a wander guard system on the doors and the maintenance director checks it once a week and the nurses are required to check the wander guards each shift to make sure they are working correctly. Attempts were made to contact the previous administrator on 12/18/2024, 12/19/2024 and 12/20/2024 with no return calls. Record review of the Facility's Policy titled Elopements revised December 2023 reflected: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing .2. I an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the departure in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the Charge Nurse or the Director of Nursing Services that a resident has left the premissies.3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall; a. examine, the resident; b. Notify the attending physician; c. Notify the resident's legal representative (sponsor) of the incident; Record review of the facility's policy titled Risk Management: Abuse, neglect, exploitation, mistreatment of resident, or misappropriation of resident property dated December 2023, Policy statement: The facility has designated and implemented processes which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of residents' property Definitions: Abuse means the willful infliction of injury, unreasonable confinement/involuntary seclusion, or separation of a resident from other residents or from their room or other area against the resident's will or the will of the resident's legal representative. Intimidation with resulting physical harm, or pain, or mental anguish. Punishment with resulting physical harm, or pain, or mental anguish. Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. 1. Residents must be subject to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, or other individuals