**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1, who had dementia, was provided with adequate supervision to prevent her from eloping from the facility on 08/08/25. The resident was found half a block away from the facility. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 08/08/25 and ended on 08/08/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents who require supervision at risk of harm, severe injury, and possible death. Findings included:Record review of Resident #1's admission Record, dated 09/04/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included cerebral infarction unspecified (when the blood supply to part of the brain is blocked or reduced which prevents brain tissue from getting oxygen and nutrients and brain tissue begins to die), unspecified dementia (a group of symptoms affecting memory, thinking and social abilities), with unspecified severity and without behavioral disturbance; psychotic disturbance (a severe mental health condition characterized by a disconnection from reality); mood disturbance (mental health conditions that primarily affect a person's emotional state); and anxiety (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs). Record review of Resident #1's Optional State Assessment MDS Assessment, dated 07/13/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS (cognitive screening tool) score of 6. The MDS reflected the resident did not have wandering behaviors. Record review of Resident #1's Elopement Risk Evaluation, dated 07/17/25, which is used to assess the likelihood of a resident leaving a facility without the facility's knowledge and supervision, reflected the resident was at a moderate risk of elopement with a score of 6. Record review of Resident #1's Consent for Secured Unit, dated 08/08/25 reflected Resident #1 gave consent to be placed on the Secured Unit. Record review of Resident #1's Progress Notes from 07/10/25-08/07/25 reflected no documented evidence that she was exit-seeking or had made any elopement attempts. Record review of Resident #1's Progress Notes written by LVN K on 08/08/25 at 6:34 PM reflected: Today around 1500 [3:00 PM] [Resident #1] was found outside down the street by staff members after she escaped our facility by following an unknown someone who was exiting the building after they used the passcode that only staff knows. She was found with her walker outside and was brought back to the facility. We looked through the sign-out binder to see if anyone signed her out today and no one had signed her out. When I asked her roommate if she had any knowledge or warning from [Resident #1] that she was going to try and escape her roommate said ‘Yes. [Resident #1] said she was getting out of here.' When I asked [Resident #1] why and how she escaped outside today she said, ‘I don't want to be here anymore people are mean to me and call me names.' And when describing how she got out she said, ‘Someone got out of a car, went to open the door, as that person was entering, another person exiting, and I followed that person out the door.' I called her Responsible Party to alert her to this elopement, she didn't answer my call, I left a voicemail. Record review of Resident #1's Care Plan, dated 09/05/25, reflected: Focus: [Resident #1] resides in secure unit related to High Risk for Elopement-8/8/25: Actual Elopement.Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the secured unit.Interventions: Admit to secure unit per DR orders. Assist and monitor resident for off unit activities if able.Involve resident in daily activities designed for secured unit. Monitor for s/s of depression, withdrawal from usual activities.Notify MD and family of any changes.Psych services per DR orders. Record review of the facility's Provider Investigation Report, completed by the Administrator on 08/15/25, reflected the following under the Investigation Summary section: On 8/8/2025 at 2:55pm.housekeeper saw what she thought was a resident outside the facility. She came to the administrator's office and wanted to report what looked like a resident outside. Admin started running down towards the exit door. Housekeeper used her car to go down the road. [Housekeeper M] located the resident halfway down the block. [Housekeeper M] placed resident in her car and picked up the admin as well. Admin asked resident, why she left the facility, and she stated she got kicked out. She would not elaborate on anything else. Resident was brought back to the facility around 2:59pm. Resident was placed on the secure unit after being interviewed by the DON. Admin reviewed cameras and resident left from the 300-hall main exit. Video shows the resident walking to the door, an outside transport company was delivering a new resident, opened the door, and let the resident out without asking the resident any questions or stopping the resident. The transport staff did not let anyone know of the resident walking out. Admin called transport company to inform them of the incident. We are still waiting for staff in servicing information. Codes to exit doors were changed. All doors were checked for proper functioning with no issues. Elopement drill was conducted. Elopement assessment on all residents conducted. Verified signage is still placed on exit doors. Sent a message to all employees on change of code to the door. Sent a message to all families about not letting any resident out of the facility and to make sure the door closes behind them. Further record review of the facility's Provider Investigation Report reflected the following: Provider Action Taken Post-Investigation: In service on Elopement response.In service on Elopement prevention.In service on Abuse/Neglect.In service on door alarms. Interview on 09/04/24 at 10:22 AM, with LVN K revealed that Resident #1 had not eloped previously or attempted eloping previously. LVN K stated that she was unaware that Resident #1 had eloped until she was notified by the ADON that she had gone. LVN K stated that she had not previously noticed Resident #1 watching the front door or exit seeking. Interview on 09/04/25 at 11:47 AM, 12:18 PM, and on 09/05/25 at 9:38 AM with Resident #1 was attempted, but the resident did not awaken from her sleep. Interview on 09/04/25 at 10:43 AM with Housekeeper M revealed at about 2:50 PM on 08/08/25 she had clocked out and exited the facility. Housekeeper M stated immediately after she left, she saw an elder with a walker walking in the middle of the street. Housekeeper M said the resident said she had been kicked out of where she lived, and so the Pope told her to leave. Housekeeper M asked the resident her name, but she was not familiar with the individual's name. Housekeeper M returned to the facility and went directly to the Administrator. Housekeeper M stated she told the Administrator the name given, but he did not recognize the name (he later learned that was not her first name). However, the Administrator immediately began walking down the street toward the resident while Housekeeper M drove her car to the resident. Housekeeper M asked the resident to get in the car, and she did. The Administrator arrived to them and recognized the resident and got into the car as well. They brought Resident #1 back to the facility where she was placed on the secured unit and notified the nurse. Housekeeper M stated she received messages on her phone regarding the elopement and was in-serviced on elopement response and elopement prevention. Housekeeper M also said that the facility codes were changed on the doors. Interview on 09/04/25 at 4:03 PM with the Administrator revealed he was in his office when a housekeeper came to him and said it looked like someone who may be a resident is on the corner outside. The Administrator stated he walked to the resident, and Housekeeper M took her car and together they found Resident #1 halfway down the block from the facility. The Administrator explained that a transportation driver did not ask questions, and he let her out the door when he entered the building. The alarm did not sound because the transportation driver used the code when entering the building. The Administrator stated he discovered Resident #1 was gone about five minutes after reviewing facility video footage. The Administrator also stated he did not have a copy of the video footage because the camera footage only saved nine days at any given time. The Administrator revealed when she was brought back to the facility, a nurse completed a skin assessment and pain assessment with no injuries found. The Administrator stated they completed an elopement assessment on Resident #1 and then placed her on the secured unit. The Administrator also said elopement assessments were completed on all residents with no residents triggering for elopement. The Administrator stated when a resident eloped, they could be injured by falling. The Administrator also revealed it was all staff's responsibility to monitor the facility's exit doors. The Administrator revealed that staff were in-serviced on Door Alarms, Elopement Prevention, Elopement Response, and Abuse/Neglect. The Administrator stated the facility sent a cover message to all staff on elopement prevention as well as a change in the code to the door alarms. The Administrator said the Maintenance Director checked all doors to ensure they were working. The Administrator stated all the door alarms were working correctly. The Administrator then revealed he started elopement drills which he continued five times per week for four weeks. The Administrator stated a QAPI was completed which revealed that the facility medical director was notified of the resident elopement. A review of the witness statements for the facility revealed no other staff had knowledge of Resident #1's elopement. Interview on 09/04/25 at 3:01 PM with the ADON revealed she was told by the Administrator that Resident #1 eloped through an exit door. The ADON said she collected the witness statements and gave them to the Administrator. The ADON also revealed the staff were in-serviced on listening for the door alarms, elopement prevention, elopement response, and abuse and neglect as well. The ADON stated everyone was supposed to be listening for the door alarms, and respond, and re-direct residents if needed to prevent residents from eloping from the facility. Then staff should notify the Administrator and the DON immediately, so the resident could be assisted back into the facility. Interview on 09/04/25 at 12:14 PM with CNA L revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 1:05 PM with CNA N revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior)Elopement Response (get the census and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found ), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 1:32 PM with CNA O revealed he had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 1:44 PM with CNA P revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response (call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 2:05 PM with CNA Q revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response (call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 2:28 PM with LVN R revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response (call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 9:49 AM with MA S revealed he had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response (call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 9:59 AM with CNA T revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 10:10 AM with CNA U revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention(observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 10:26 AM with LVN V revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 10:33 AM with CNA W revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention(observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 10:53 AM with Social Services revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention(observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect(physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). The Administrator was notified on 09/05/25 at 12:35 PM, that a past non-compliance IJ had been identified related to the facility's failure to provide adequate supervision to prevent an elopement. It was determined this failure placed Resident #1 in an IJ situation on 08/08/25. Observation on 09/05/25 at 12:40 PM of the facility's exit doors and secured unit doors revealed they were locked and the keypads next to them had their green lights on indicating they were working properly. An attempt to push on the doors to open were unsuccessful. The doors stayed closed and never opened. There were signs posted on the doors which reflected the following: Reminder/Families If Resident is leaving the facility.Did you notify the Nurse? You must sign out in the Sign out book at the nurses' station prior to leaving the facility. Thank you, Management Attention!!! Staff and Visitors When Entering/Leaving Please Ensure the Door Fully Closes Behind You.Do Not Let Residents Out of the Door Without First Checking with the Nurse Thank you, Management . The facility implemented the following interventions: Record review of an Elopement Drill/Actual Event Participation Log reflected a date of 08/08/25. Record review of an Elopement Drill/Actual Event Participation Log reflected a date of 08/13/25. Record review of an Elopement Drill/Actual Event Participation Log reflected a date of 08/21/25. Record review of an Elopement Drill/Actual Event Participation Log reflected a date of 08/25/25. Record review of the facility's Elopement Prevention QA Check List reflected a date of 08/08/25 and the following items reviewed/monitored:1. Doors 1-10 maglocks were secured and armed2. Doors with keypads codes have codes that are changed monthly3. All exit doors have alarms that are loud enough to be heard when opened4. All Door lock/alarm functions validated weekly in maintenance care5. Elopement policy in place6. Elopement policy reviewed in facility general orientation7. Elopement policy in-service at least annually8. Elopement risk assessments are completed upon admission/significant change/new behavior or elopement attempt9. Care plans with elopement risk interventions in place10. Secure Unit Windows have a device that allow them to open only six inches11. Secure unit present, exit doors must not have a delayed egress function. Instead do they release when any of the following occur:a. The fire alarm or sprinkler system activatesb. The facility loses powerc. A switch or button at the main nurses' station and at the monitoring station is activated. 12. Secure unit, courtyard doors have alarm/lock for going outside and NO alarm for coming inside13. Secure unit present, is there a manual fire alarm pull station located within five feet of each exit door with a sign indicating Pull to release door in emergency. Record review of the facility's Post Elopement Drill or Actual Elopement QAPI Evaluation Checklist reflected a date of 08/08/25. The QAPI evaluation checklist reflected that the facility followed its elopement response protocol, notified the family, notified the physician, notified the Administrator, and followed the procedure correctly. Record review of the facility's Elopement Risk Assessment Completed reflected a date of 08/11/25 and that Resident #1 had attempted to elope one or more times in the last week, was restless, ambulated independently, and lived on the secured unit Record review of facility's Monitoring Tool reflected staff were signing off that they had monitored all doors functioning, including the dining room door and alarms 5 times per week beginning 08/11/25 through 09/05/25. Record review of an in-service titled Elopement Response dated 08/08/25 reflected staff had been trained on the facility's policy and procedures by being provided the policy and procedure as well as being explained the policy and procedure. The policy stated that the nurses were to use the census and divide the staff on the halls into assignments. The facility will call a code orange. The facility will look for the resident both inside and outside until the resident is found. Administration is to be notified immediately. Record review of an in-service titled Elopement Prevention dated 08/08/25 reflected staff had been trained on the facility's policy and procedures by being provided the policy and procedure as well as being explained the policy and procedure. Staff are to monitor for anxiousness or exit seeking behaviors and alert their nurse to the behavior. The resident is to be re-directed until the behaviors change. Notify administration. Record review of an in-service titled Abuse and neglect dated 08/08/25 reflected staff had been trained on the facility's policy and procedures by being provided the policy and procedure as well as being explained the policy and procedure. Staff is to monitor for the types of abuse/neglect and notify the abuse coordinator immediately if signs or symptoms are observed. Record review of an in-service titled Door exits/alarms ringing dated 08/08/25 reflected staff had been trained on the facility's policy and procedures by being provided the policy and procedure as well as being explained the policy and procedure. If a door alarm sounds, staff are to check the exits for residents that may have eloped. Staff are not to ignore the alarms. The door codes are not to be given out to visitors or family members. Record review of the facility's Elopement Response policy, revised January 2023, reflected: .1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. 2. Determination of missing resident either by routine nursing rounds or door alarms: A. Note: A resident is determined to be missing when he/she leaves the facility without the staff's knowledge.3. Should an employee observe a resident leaving the premises, he/she should A. Attempt to prevent the departure: B. Obtain assistance from other staff members in the immediate vicinity, but do not leave the resident alone, if necessary: C. Instruct another staff member to inform the charge nurse or Director of Nursing that a resident has left the premises; and D. Be courteous in preventing the departure and in returning the resident to the facility. 4. Should an employee discover the resident is missing from the facility (Code Orange) he/she should: A. Report to the charge nurse B. Determine if the resident is out on an authorized leave or pass. If not; C. Make a thorough search of the building(s) and premises. If not located; D. Notify the Administrator and the Director of Nursing; E. Notify the resident's responsible party. J. Make an extensive search of the surrounding area.Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission. The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, upon new exit seeking behavior, and upon change of condition. 2. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. 6. Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented in the nurses' notes. Director of Nursing Services should be notified of elopement. 7. If a resident is discovered to be missing, a search shall begin immediately. Record review of the facility's Abuse/Neglect policy, revised 03/29/18, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 3 of 10 residents (Residents #2, #3, and #4) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #2, #3, and #4 were free of abuse from Resident #1. Resident #1 hit Resident #2 and #3 with her doll in the face and head when she was upset and punched Resident #4 in the stomach after she approached her boyfriend. An Immediate Jeopardy (IJ) was identified on 02/11/25 at 3:47 PM. The IJ template was provided to the facility on 2/11/25 at 4:00 PM. While the IJ was removed on 02/13/25, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of physical abuse from other residents. Findings included: Record review of Resident #1's Quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), stroke, seizure disorder, and profound intellectual disabilities. Resident #1 was not able to complete a BIMS due to her impaired cognition and she was rarely understood by others and rarely/never understood others. The MDS further reflected Resident #1 was independent with walking and did not have any impairment to upper and lower extremities. Record review of Resident #1's care plan initiated on 06/16/23 reflected she had the potential to demonstrate physical behaviors related to poor impulse control. Resident #1 had poor impulse control and would utilize her baby doll to make contact with other residents in an aggressive way and would also get upset and physical when felt that others were talking to her boyfriend. Intervention included to analyze key times, places, circumstances, triggers, and what de-escalates the behaviors and document. Other interventions included to intervene before agitation escalated and guide away from source of distress and immediately intervene to protect the residents involved and call for assistance. Record review of Resident #2's Annual MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), stroke, hemiplegia (medical condition that causes paralysis or weakness on one side of the body), reduced mobility, and difficulty in walking. Resident #2 had a BIMS of 13 which indicated his cognition was intact. The MDS also reflected the resident had impairment on one side to his upper extremity and impairment on both sides to his lower extremity and used a wheelchair for mobility. Record review of Resident #3's Quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included coronary artery disease (condition in which the arteries that supply blood to the heart muscle become narrowed or blocked), stroke, difficulty in walking, and muscle weakness. Resident #3 had a BIMS of 8 which indicated his cognition was moderately impaired. The MDS further reflected the resident had impairment on one side to upper and lower extremities. Record review of Resident #4's annual MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included heart failure, stroke, difficulty in walking, weakness and history of falling. Resident #4 had a BIMS of 7 indicating her cognition was severely impaired. The MDS further reflected the resident was independent with walking and most all ADL's. Record review of the facility's Provider Investigation Reports reflected the following: 12/05/24 On 11/25/24, [Resident #2] was sitting one table down from [Resident #1] in the main dining room. According to [Resident #2], [Resident #1] threw her doll at him. He in turn grabbed the doll and threw it on the floor. [Resident #1] got up and picked her doll up and started crying. [Housekeeper D] saw the altercation and intervened. According to her statement, [Resident #1] hit [Resident #2] several times but after interviewing [Resident #2], he was only struck by the doll when it was thrown at him ] 01/23/25 [Resident #3] was sitting one table down to [Resident #1] in the dining room during breakfast. After breakfast was complete, [Resident #1] was tapping her foot on the floor and [Resident #3] asked her to stop tapping so loud because he could not hear the TV. [Resident #3] turned back around to look at the TV and [Resident #1] took her doll and hit [Resident #3] in the forehead. Another resident saw the altercation and went to tell the nurse 01/26/25 [Resident #1] was sitting in her usual spot in the dining room. [Resident #4] went up to [Resident #1] to ask her a question. [Resident #1] responded by saying that is my boyfriend don't talk to my man and punched her with a closed hand. [Resident #4] retaliated by hitting [Resident #1]. Residents were pulling hair. Staff intervened and separated both residents Skin assessments were conducted with [Resident #4] showing a quarter size bruise to inner upper left arm. No injuries to [Resident #1] Record review of Resident #1's progress notes on the following dates reflected: 10/21/24 - documented by the Social Worker Visit with [Resident #1] regarding the incident where she threw her baby doll at another resident. She did not act like she knew what this SW was talking about. SW discussed with her that her baby is little and can get hurt. She needs to be a good Mom and not throw her baby. She said she knew not to hurt baby 11/15/24 - documented by LVN CC Resident continues with loud laughing, taunting other residents in dining room, yelling and crying @ random intervals. Was recently started on Klonopin in afternoon by psych 11/16/24 - documented by LVN E Res in dining room yelling and laughing at other residents, CNA approached and told her to go to her room, res then ran up to cna and grabbed her by her hair, and started hitting her in the face. Another staff member intervene and separates Res from staff 11/25/24 - documented by LVN CC Noted resident sitting in dining room, sticking her tongue out at several male residents and yelling at them get out of here, I don't like you and flipping them off with the middle finger of her left hand. Resident's chair was moved so that her back was turned toward the male residents and toward the TV so she can continue watching the program that was on. She was instructed that this behaviour is not acceptable and she can't remain in the dining room if she continues to act out toward other residents in this way. Resident stated I won't do it and was holding her baby doll and smiling as writer left at table Observation and interview on 02/11/25 at 9:58 AM of Resident #1 revealed she was sitting at a dining room table next to another male resident. The resident had 7 stuffed animals and two dolls in a chair next to her. The two dolls had a soft, cloth stuffing and the hands, feet, and head were a firm plastic/rubber material. Attempted to interview Resident #1 but she was only able to give simple 2 to 3 word sentences and did not recall any incident or altercations with other residents. Observation and interview on 02/11/25 at 10:05 AM with Resident #2 revealed he was in his room. He was slowly self-transferring from his wheelchair to the bed and appeared to have paralysis to the left side of body. Resident #2 was asked about the incident with Resident #1 and he said he was in his room and Resident #1 approached his door and took a few steps inside and threw her doll at him. Resident #2 said the doll hit his face so he then threw the doll back at Resident #1 and she then began to yell and curse. Resident #2 also said there was an incident where Resident #1 pushed his wheelchair with him in it against the wall but he was not hurt and there was no one around at that time nor did he tell anyone. Resident #2 further stated he was not afraid of Resident #1 just rather he was irritated at the things she did. He described Resident #1 as a rude person who cursed and yelled at others so he now preferred to keep his distance and did not go out to the dining room much to avoid Resident #1. Observation and interview on 02/11/25 at 10:52 AM with Resident #4 revealed she was in her room sitting on the side of her bed. She was asked about the incident with Resident #1 and she said she had approached Resident #1's male friend that was sitting with her at the dining room table and asked him for a quarter. At that time Resident #1 told Resident #4 to get away from her man and then stood up and punched her in the stomach so she then in return pulled Resident #1's hair and hit her back. Resident #4 stated she was not afraid but if Resident #1 was going to hit her, she was going to hit her back. Observation and interview on 02/11/25 at 10:22 AM with Resident #3 revealed he was sitting in the dining room listening to bible study and eating a snack. The resident was observed using a wheelchair and getting up to walk short distances. Resident #3 said Resident #1 has history of acting out in the mornings and said the day of the incident, 01/23/25, Resident #1 was hitting the bottom of the dining room table and he asked her to stop and that is when Resident #1 came around and hit him in the head with her doll. Resident #3 said the doll hurt his head when it made contact with his forehead because the doll contained some hard parts. Resident #3 further stated Resident #1 would get upset with different people when they would talk to her boyfriend who sat at her table and Resident #1 always started the fights. Resident #3 said he was not afraid of Resident #1 but the residents were annoyed with her behaviors. Interview on 02/11/25 at 12:08 PM with Housekeeper D revealed during the incident with Resident #2 she was across the hall and heard yelling but could not make out what was being said. As she turned she saw Resident #1 hitting Resident #2 on the head with her baby doll. This incident occurred outside of the rooms, as they used to be neighbors. Housekeeper D said she separated the residents and went to report the incident to the Administrator. The Housekeeper said had heard Resident #1 yell at other residents but that was the first time she had seen her become physical with them. Interview on 02/11/25 at 12:13 PM with LVN D revealed she was told by CNA F that Resident #1 was in the dining room, on 11/16/24, and she believed Resident #1 might have been trying to hit someone with her baby doll when CNA F tried to intervene. CNA F told her Resident #1 then grabbed CNA F's hair and began to hit her in the face with her other hand. LVN D further stated Resident #1 had a history of becoming verbal with others especially when other residents tried to talk to her male friend that sat with her at the dining room table. Interview on 02/11/25 at 12:29 PM with CNA F revealed she approached Resident #1 and told her to go to her room so she could change her. Resident #1's male friend told Resident #1 she needed to go with CNA F and CNA F touched her male friend on his shoulder and Resident #1 jumped up out of her chair and grabbed CNA F by the hair and began to punch her. CNA F said that had been the first time Resident #1 had hit her and it all happened because Resident #1 would become defensive if anyone was around her male friend. CNA F further stated Resident #1 had a history of hitting others with her baby dolls and cursing at staff and residents all day long. CNA F said it was difficult to prevent Resident #1 from hitting and yelling at others because she would not stay in her room and stayed in the dining room all day long. If and when they tried to redirect Resident #1 she would begin to yell and curse. CNA F also said Resident #2 now preferred to stay in his room to avoid Resident #1 and others resident would also get frustrated and leave the dining room so they did not have to hear Resident #1 yell out. Interview on 02/11/25 at 12:39 PM with the Weekend Supervisor revealed during the incident between Resident #1 and Resident #4, she was in the wound care office next to the dining room when she heard Resident #1 screaming. When they heard Resident #1, they usually knew something was going on because the resident had a history of swinging at people. When the Weekend Supervisor entered the dining room Resident #4 had Resident #1 by her hair and they were immediately separated and Resident #1 was put on 1:1 safety checks. The Weekend Supervisor said she had not worked at the facility long but had been told Resident #1 had a history of hitting but she had never witnessed it prior to that incident. Resident #1 would sit in the dining room all day and yell and scream random things at others and they would try to redirect the resident to her room but she always refused to go. The Weekend Supervisor further stated everyone just had to work around Resident #1. Interview on 02/11/25 at 12:50 PM with the Social Worker revealed they were seeing some regression with Resident #1's developmental disability and the resident had begun to throw her baby dolls at others and there were not patterns to her behaviors. The Social Worker described Resident to be very territorial of her space and of her male friend that sat with her and they tried to redirect her behavior if they saw it coming. She said Resident #1 has previously been treated for a UTI and they had discussed her behaviors with the PASSR representative. The Social Worker further stated she had spoken to Resident #1 after her physical incidents but due to her cognition the resident did not really seem to recall the incidents and forgot as soon as they occurred. Interview on 02/11/25 at 1:32 PM with the DON revealed he had only been working at the facility for less than 2 months and he had been made aware of the incidents between Resident #1 and Residents #3 and #4. The DON said they had inserviced staff in the past about techniques to deescalate physical altercations between the residents. Staff were also to frequently monitor Resident #1 and they had just adjusted the resident's medications. The DON said they had not tried to take Resident #1's dolls because that would infringe on her rights but they had encouraged her to not have so many baby dolls in the dining room. Interview on 02/11/25 at 1:42 PM with the Administrator revealed they had met and discussed to limit how many dolls Resident #1 kept and to make sure staff frequently monitored to prevent altercations with other residents. The Administrator said there had not been any injuries as a result of the incidents and also said Resident #1 would not let go of her baby dolls because she was really attached to them. Record review of the facility's policy titled Abuse/Neglect revised 03/2018 reflected the following: The resident has the right to be free of abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Resident should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals An Immediate Jeopardy/Immediate Threat was identified on 02/11/25. The Administrator, DON and the Regional Nurse Consultant were notified of the Immediate Jeopardy on 02/11/25 at 3:43 PM. The IJ template was provided to the facility on [DATE] at 4:00 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 02/12/25 at 9:44 AM and reflected the following: Plan for Removal: F600 Failure to Prevent Abuse and Neglect Interventions: Resident #1 was immediately placed on 1:1 supervision on 2.11.25 with facility staff. Resident #1 discharged to alternate facility with guardians' approval 2.11.25. Resident #1's baby doll with the plastic heads were immediately removed from Resident #1's possession and from resident #1's room on 2.11.25 by regional compliance nurse. Resident's #1's care plan was reviewed by Regional Compliance Nurse for appropriate interventions to prevent resident and staff altercations on 2.11.25. Resident #1's care plan was updated by the Regional Compliance Nurse to reflect additional interventions of 1:1 supervision and removal of baby dolls with hard plastic pieces on 2.11.25. IDT team will schedule a care plan meeting with Responsible Party, Physician, and Resident to review and evaluate interventions to prevent repeated altercations with staff and residents starting 2.11.25. The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics. Completed 2.11.25 o Abuse and Neglect- Prevention of abuse/neglect and ensuring interventions listed on the care plan are implemented to prevent abuse. o Behavior Management Policy- Managing behaviors and intervening appropriately. The Medical Director was notified on 2.11.25 of the immediate jeopardy. An ADHOC QAPI was held with the IDT Team on 2.11.25 to discuss the immediate jeopardy and plan of removal. In-services All staff will be in-serviced on the following topics below by the Administrator, Regional Compliance Nurse, DON, and ADON to prevent resident to resident abuse and ensure appropriate response to aggressive behaviors. In-servicing initiated on 2.11.25 and will be completed by 2.12.25. All staff who are not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to starting their shift. o Abuse and Neglect- Prevention of abuse/neglect and ensuring interventions listed on the care plan are implemented. o Behavior Management Policy- Managing behaviors and intervening appropriately. Monitoring of the facility's Plan of Removal included the following: Observation on 02/12/25 at 10:04 AM revealed Resident #1 was no longer at the facility and had been discharged to another nursing facility. Record review of Resident #1's progress notes dated 02/11/25 documented by LVN C reflected the following Resident transferred to sister [facility] due to behaviors. Vitals within normal limits, medication and belongings sent with her. Guardian notified of transfer Record review of the facility's inservices titled Abuse/Neglect dated 02/11/25 reflected all facility staff were educated on the different types of abuse, abuse prevention and ensuring interventions were implemented to prevent abuse, and managing behaviors and intervening appropriately. If staff are to witness resident to resident abuse, they are to immediately intervene, ensure the residents are safe and report the incident to the Administrator. To prevent abuse, staff are to redirect residents away from aggressive or agitated behaviors and watch for signs of aggression. Interviews on 02/12/25 at 1:02 PM to 02/13/25 at 2:35 PM from staff from various shifts were the Administrator, DON ADON P, Weekend Supervisor, Social Worker, Transportation, BOM , Medical Records, Dietary Manager, PTA, OT, LVN A, LVN C, Housekeeper D, LVN E, CNA F, LVN G, MA I, MDS Nurse K, MDS Nurse L, CNA N, CNA O, MA Q, CNA R, Housekeeper T, Housekeeper U, CNA V, [NAME] W, [NAME] X, MA, Z, CNA AA, and CNA BB. All staff were able to identify the following: - The different types of abuse. - What to do if they witness resident to resident abuse. - What signs to watch for in residents to prevent resident to resident abuse/behaviors - Who to report any incidents of abuse - All staff stated there were no other residents they were aware of that were having consistent physical altercations in the facility. The Administrator was notified on 02/13/25 at 3:30 PM, the Immediate Jeopardy was removed. While the IJ was removed on 02/13/25, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to ensure Resident #1 was provided with adequate supervision and free of potential harm when he eloped from the facility on 07/30/2024 without staff knowledge. The facility was informed of the elopement by a family member who reported the resident was found 8 miles from the facility. The facility failed to ensure staff rounded often to ensure all Resident #1 was in the facility prior to leaving at the end of their shift or upon starting their shift on 07/30/2024. A past non-compliance Immediate Jeopardy (IJ) situation was identified on 08/02/2024 at 1:40 PM. The Immediate Jeopardy began on 07/30/2024 and ended on 07/31/2024. The facility had corrected the non-compliance before the surveyor began. These failures placed residents at risk of harm and, serious injury, or death. Findings included: Record review of Resident #1's Face Sheet dated 08/02/2024 reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included alcohol abuse with alcohol-induced psychotic disorder (psychosis after the intake of alcohol), cognitive communication deficit (trouble reasoning and making decisions), cerebral infarction (disrupted blood flow to the brain), dysphasia (the ability to produce and understand language), vascular dementia, moderate (fourth stage of dementia - symptoms are more prominent), anxiety disorder (sudden feelings of anxiety or panic), major depressive disorder (persistent feelings of sadness and lack of interest), and gastrostomy status (surgical opening in the stomach for nutritional support). Record review of Resident #1's MDS assessment dated [DATE] reflected he had no BIMS score, which indicated severe cognitive delay. Staff assessment for mental status indicated short-term memory problems and difficulty in new situations for daily decision-making skills. Resident #1 had a feeding tube and was totally dependent for feeding. He was independent for transfers, walking, and dressing. Wandering behaviors were not exhibited. Record review of Resident #1's Care Plan dated 04/30/2023 and updated 07/30/2024, reflected, Focus: [Resident #1] has impaired cognitive function/dementia or impaired thought processes r/t cognitive deficit, cluster of septic arterial embolisms, substance abuse. [resident #1] does not typically verbally respond to BIMS and PHQ-9 questions. [Resident #1] has a communication problem r/t cognitive deficit, cluster of septic arterial embolisms, substance abuse. [Resident #1] speaks minimally and only to certain individuals. Interventions: Alternative interventions: promote use of non-verbal communication, ask yes or no questions when inquiring about wants/needs, provide sense of security, reduction of noise, approach with calming voice, validate non-verbal expressions of emotion, provide sensitivity to personal space. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. [Resident #1] needs assistance with all decision making. Refuses to use communication board. Focus: At risk for elopement as evidenced by: History of attempts to leave facility unattended, 4/30/24-went outside through front door, 7/30/24-went out through his window. Interventions: 15-minute checks. May need to go to a private room on secured unit temporarily until family is able to visit and calm [Resident #1's] frustration. Moved to secured unit. SW to try to move resident to another facility that has secured doors. UA collected, Assess/record/report to MD risk factors for potential elopement such as: Wandering, Repeated requests to leave facility, statements such as I'm leaving I'm going home, attempts to leave facility, elopement attempts from previous facility, home, or hospital. Supervise closely and make regular compliance rounds whenever resident is in room. Determine the reason the resident is attempting to elope. Is the resident looking for something or someone? Does it indicate the need for more exercise? Intervene as appropriate. Distract resident from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, books. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Record review of the Elopement Risk assessment dated [DATE] and signed by LVN H, reflected, a score of 18, Elopement risk. Record review of the facility's incident report, dated 07/30/2024 at 7:15 AM and signed by the DON, reflected, The Director of Nurses received a call from resident's [family member] at 7:15am, [family member] stated that an employee at [a restaurant 8 miles away] had called her and told her [Resident #1] was there. DON immediately got van driver to go to [restaurant] to pick up resident When DON went to resident's room to talk with roommate, DON found [Resident #1's] window open and screen not in place. It appears resident went out his window. [Resident #1's] roommate stated [Resident #1] was in the room when he went to sleep, and he just found out resident was gone. Charge nurse stated the last time he seen [Resident #1] was between 4 and 4:30am. Van driver and [Resident #1] returned to the facility at approximately 8:15am. [Resident #1] returned Resident was immediately taken to the secured unit. [Resident #1] was able to ambulate into the facility into his new room. [Resident #1] appeared tired but otherwise appeared to be in good health. Intervention: Resident moved to secured unit into a room where the window opens up into a secured patio. In an interview on 08/02/2024 at 8:55 AM with the Administrator and DON, the DON stated Resident #1 eloped from the facility on 07/30/2024. She stated Resident #1 did not speak and did not have a BIMS because of his limited ability to communicate. She said and was discovered at a restaurant 8 miles from the facility by a worker who called Resident's family. She said Resident #1 carried a paper with family phone numbers on it. The DON said she received a call from Resident #1's family member at about 7:15 AM and immediately sent the van driver to pick up Resident #1. She stated RN E did not check on Resident #1 after an ordered treatment was provided at 4:15 AM. CNA C did not do walking rounds to check on residents at the end of his shift at 6:00 AM. She said LVN G and CNA A and CNA B came on shift at 6:00 AM and did not check on Resident #1 either. She stated she notified the MD who wanted a follow up when Resident #1 returned. She stated Resident #1 did have a decrease in Depakote recently due to recent labs that reflected abnormal liver function. She said that may have cause a change in Resident #1's behavior. She said Resident #1 had a follow up appointment with Psychiatry to reevaluate medications on 08/05/2024. The DON said staff were not aware Resident #1 was gone from the facility until she informed them after 7:15 AM. She said when she went into Resident #1's room, the curtains were in front of the window, but the window was open, and the screen pulled back. She said Resident #1's roommate said he did not hear anything as he was sleeping. The DON said Resident #1 first came to the facility in 2020 and was in the secured unit. She said during Covid-19, he was placed off the unit in a Hot Zone, for isolation. She said Resident #1 eloped through a window at that time as well. She said Resident #1 went to another facility then a group home, but the family wanted him to return to the facility outside the secured unit. The DON said when Resident #1 returned to the facility he was an elopement risk but did not show any elopement behaviors. She said the elopement assessment completed on 07/30/2024 was 20 which indicated elopement risk. She said the family has agreed to leave Resident #1 in the secured unit while they secure alternate placement and arrangements for him. The Administrator said staff did not complete rounds to ensure residents were in the facility and did not know Resident #1 had eloped. The DON stated RN E administered a water bolus at 4:00 AM on 07/30/2024 and did not see the resident after that. She said when she found out of the elopement at 7:15 AM, she called a Code Orange which meant elopement. The Administrator said he was informed at about 7:15 AM and directed a discussion with family to have Resident #1 placed in the secured unit, start in-services on walking rounds, abuse and neglect, and elopement procedures, and completed elopement assessments on all residents. An observation and interview on 08/02/2024 at 10:25 AM reveled Resident #1 in his room, in the secured unit, sat on his bed. Resident #1 only responded by nods to yes/no questions. There was a communication board in the corner of the room, Resident #1 nodded no when asked if he used it. The window in the room was open and screen was bent back on the left corner. Resident #1 laughed and nodded yes when asked if he did that. He nodded yes when asked if he opened the window and screen in his last room when he eloped. He nodded yes when asked if he walked 8 miles and a restaurant worker called his [family member]. He nodded yes when asked if he was tired, if it was dark, if he had shoes on. He nodded yes when asked if he liked the facility and no when asked if he wanted to leave again. He did not answer when asked if he knew where he was going or why he eloped. In an interview on 08/02/2024 at 10:37 AM, the Corporate Compliance Nurse stated the facility did fail to ensure Resident #1 was safe from the hazards of elopement, but the Administrator and DON have implemented all actions needed to correct the failure on 07/30/2024 and 07/31/2024. In an interview on 08/02/2024 at 10:55 AM, the SW stated she was unable to get a BIMS for Resident #1. She said she used pictures but his limited ability to communicate contributes to his sever cognitive ability. She said she was looking for a group home that met Resident #1's tube-feed needs. She said the DON already implemented in-services for all staff to address elopement and abuse and neglect on 07/30/2024. She said there was an elopement drill and all residents' elopement assessments were updated also on 07/30/2024. In an interview on 08/02/2024 at 11:03 AM, CNA A stated she came on shift on 07/30/2024 at 6:00 AM and did not do rounds to check on residents. She said she should have because she would have seen that Resident #1 was gone. She said she did not know Resident #1 was gone until the DON called an elopement drill. She stated she received in-servicing on elopement protocol and walking rounds throughout the shift and at the end of shifts to ensure all residents were okay. In an interview on 08/02/2024 at 11:10 AM, CNA B said she came on shift at 6:45 AM on 07/30/2024. She said she was called in to cover so she had been a little late. She said she did not check on the residents when she arrived and then the DON called an elopement drill. She said we all started checking rooms and were told that Resident #1 had eloped. She said Resident #1 would get frustrated and want to leave the facility sometimes. She said that would occur when people did not understand him. She said he had a communication board and computer but rarely used them for communication. She said she should check on residents regularly and when she came on shift to ensure residents were safe. She said she was in-serviced on doing rounds and elopement procedures. She said the DON completed the in-services on 07/30/2024. A telephone interview on 08/02/2024 at 11:33 AM with Resident #1's family member revealed a community member called her to say Resident #1 was in a restaurant near the city center. She said called the facility and informed the DON the Resident #1 was 8 miles from the facility at a restaurant. She said the DON sent staff to get Resident #1. The family member said Resident #1 returned to the facility outside the secured unit at her request. She said she wanted him to have the best quality of life possible. She said she knew he could get frustrated and want to leave the facility at times, but the staff were good at redirecting him. She said she did not know where else Resident #1 could live but did agree to place him in the facility's secured unit while the facility worked with her to find an alternate placement. She said the DON told her that staff had not checked Resident #1's room after about 4:00 AM and then they found the window open, and screen pulled back. In an interview on 08/02/2024 at 1:21 PM, the Maintenance Director stated he checked the door alarms weekly and checked them again on 07/30/2024. He said he repaired the screen in the room where Resident #1 eloped on 07/31/2024. He said the DON in-serviced all the staff on elopement procedures and checking on residents regularly. He said Resident #1 could have been hurt when he eloped and walked 8 miles before being found. He said all staff were responsible to ensure residents were safe. In an interview on 08/02/2024 at 2:45 PM, LVN I stated she worked on the secured unit. She said Resident #1 was on 15-minute checks until further notice from the DON. She stated the DON in-serviced all the staff on elopement protocol, walking rounds, and abuse and neglect. She said Resident #1's care plan had been updated on 07/30/2024 and all residents had an updated elopement risk assessment completed. She said she expected CNAs to tell her where they are at all times and ensure residents were supervised. She said it was all staff's responsibility to ensure residents were safe from accidents or hazards. In an interview on 08/02/2024 at 3:05 PM, Resident #1's roommate stated he had been sleeping when Resident #1 eloped. He stated he did not hear or see anything until the morning when the DON came to ask him about it. In an interview on 08/022024 at 3:10 PM, LVN G said she came on shift on 07/30/2024 at 6:00 AM. She said she had not rounded and did not check on all her residents that morning. She said she did not know Resident #1 was missing when she came to work but would have noticed had she checked on her residents that morning. She said the DON called an elopement drill at about 7:30 AM and that was when she found out Resident #1 had eloped. She said she expected the CNAs to check on residents too, but it was all staff's responsibility to ensure residents were safe and accounted for when they come on shift. She said the DON provided in-services to all staff on elopement procedures, abuse, and neglect, and rounding frequently. A telephone call on 08/02/2024 at 3:18 PM to LVN L revealed no response. In an interview on 08/02/2024 at 3:24 PM, the DON stated she did not give LVN G or RN I counseling because rounding had not been an issue in the past. She stated she planned on monitoring by taking turns with the ADONs and unit managers to do walking rounds. She said she will continue this until rounding becomes a habit for all staff. In an interview on 08/02/2024 at 3:45 PM, the Corporate Nursing Consultant stated she will conduct random checks in the halls and by reviewing documentation to ensure staff are following the facility's rounding expectations. She stated she will monitor resident's elopement risk assessment when there are change in condition or new admission / readmissions. She said monitoring will also be addressed in the facility's QAPI meetings. In a telephone interview on 08/02/2024 at 3:53 PM, CNA C stated Resident #1 was standing by the bed, watching television on 07/30/2024 at about 12:15 AM. He said when he looked into the room again at 3:15 AM, the lights were off, and he assumed Resident #1 was sleeping. He said she did not physically touch or see Resident #1. He said he should go into the room and check on all residents. He said he did not because he did not want to wake them up. CNA C said he completed his shift at 6:00 AM and did not know Resident #1 had eloped. He said he was in-serviced on elopement protocol, rounding and ensuring residents are safe, and abuse and neglect policy, on 07/31/2024. He said he understood that not checking on Resident #1 placed him at risk of harm because he was able to elope and walk 8 miles before being found. In a telephone interview on 08/03/2024 at 8:15 AM, RN E stated he last saw Resident #1 about 4:00 AM on 07/30/2024 when he gave the water bolus. He said he did not check on Resident #1 after that and left the facility at 6:00 AM when his shift ended. He said he did not know Resident #1 eloped and realized there was no excuse to ensure all residents were safe and accounted for at the end of his shift. He said he was in-serviced on rounding, elopement policy, and abuse and neglect. Record review of Resident #1's MAR dated 07/30/2024 and signed by RN E at 4:00 AM, reflected, Enteral Feed Order every 4 hours related to GASTROSTOMY STATUS Bolus with 200ml of water every 4 hours for hydration and tube patency. Record review of the facility's Provider Investigation Report, dated 07/30/2024, reflected the following: On 7/30/2024 at 7:15am, the [DON] answered the phone and [Family Member] let her know that she received a call from [restaurant employee] that [Resident #1] was lost. The DON immediately sent the van driver to pick [Resident #1] up. Once van driver arrived, he saw [Resident #1] sitting with police, van driver loaded [Resident #1] and brought him back to the facility. DON placed [Resident #1] in the secure unit; pain and skin assessment performed. No injuries and no distress when he returned. The last staff to see [Resident #1] was a nurse that documented a treatment at 4:30am. As soon as the DON was informed, she went to the [Resident #1's] room and noticed the window open and the screen push away from the room. The roommate was interviewed, and he did not see or hear anything since he was asleep. Elopement risk assessment completed for all other residents completed. Doctor was notified and in servicing initiated. The investigation was confirmed, and the following provider actions taken: In service on Elopement, Elopement Prevention QA checklist, Check the locking mechanisms or alarm is functioning properly, [Resident #1] was placed in our secure unit in a room that face an inner courtyard. On 08/02/24 at 12:30 PM, a search via AccuWeather, https://www.accuweather.com revealed the temperature on 07/30/2024 at 8:00 AM in [county], was 84 degrees F. Record review of the facility's policy titled, Elopement prevention, revised January 2023, reflected, Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1.The Elopement Risk Assessment will be completed upon admission. The assessment should be completed by reviewing the resident's medical history and social history. Information may be obtained by reviewing current medical records, if available, interview with resident/family, or conference with the interdisciplinary team member. The assessment tool should be completed, and interventions implemented as indicated. The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, upon new exit seeking behavior, and upon change of condition. 2. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. 3. The resident's current chart and assessments will be reviewed to determine what changes have occurred that would trigger elopement episodes. 4. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. 5.Interventions into elopement episodes will be entered onto the resident's care plan and medical record. 6. Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented in the nurses' notes. Director of Risk Management and\or Director of Nursing Services should be notified of elopement. 7. If a resident is discovered to be missing, a search shall begin immediately. (See policy entitled Elopement Response). Record review of the facility's policy titled, Elopement response, revised 10/27/2010, reflected, Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented . 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. 2. Determination of missing resident either by routine nursing rounds or door alarms .7. Post return resident evaluation and care: C. The facility will evaluate its elopement prevention program and all residents will be reassessed for elopement risk. 8. Documentation: An event note is to be made out on all residents who, without knowledge of the staff, leave the facility. Including the following: Date, Time resident was first determined missing, Responsible party notified and time, attending physician notified and time, Emergency Personnel, Condition of resident when located, where located and time located. Record review of the facility's policy titled, Abuse/neglect, revised, 03/29/2018, reflected, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart .The facility will provide and ensure the promotion and protection of resident rights . Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. A past non-compliance Immediate Jeopardy (IJ) situation was identified on 08/02/2024 at 1:40 PM. The Immediate Jeopardy began on 07/30/2024 and ended on 07/31/2024. The facility had corrected the non-compliance before the surveyor began. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of the Elopement Risk assessment dated [DATE] and signed by the DON, reflected, a score of 20, Elopement risk. Record review of the facility's completed door alarms checks, dated 07/30/2024 and signed by the Maintenance Director, reflected all alarmed doors were checked and in working order. Record review of the facility's elopement risk assessment list dated 07/30/2024 and 07/31/2024, reflected updated elopement risk assessment were completed for each resident. Record review of the facility's, Elopement drill record, dated 07/30/2024, reflected, start: 7:15 AM and end: 7:30 AM. Notifications made and evaluated by the DON. Post Event Documentation Review: E1opement Risk Management Event Nurse's Note, Elopement Risk Assessment, Follow-up elopement nurse's notes. Care plan updated with actual elopement and at risk for elopement care plans. Record review of the facility's, Resident 15 min visual check sheet, dated 07/30/2024 at 8:00 AM - through 08/02/2024 at 2:15 PM, reflected Resident #1 was monitored for location and activity every 15 minutes for the time period and continues. Record review of the facility's in-service record, titled, Elopement, Abuse/Neglect, dated 07/30/2024 and administered by the DON to all staff, covered the elopement and Abuse/Neglect policies and, Walking rounds are to be conducted. At the beginning of your shift, At the end of your shift, as frequently as you can (but at least every 2 hours), Every resident must be a counted for every time you do a walking round, you must know where your residents are to keep them safe, you must have relief before you leave your shift. Interviews on 08/02/2024 from 10:00 AM to 4:00 PM with the Social Worker, Maintenance Director, HR Director, Dietary Manager, Housekeeping and Laundry Supervisor, Physical Therapist, CNAs A, B, C and D; RNs E and F; LVNs G, H, and I; and COTAs J and K, revealed they had received in-service training between 07/30/2024 and 07/31/2024. They stated the training had included how to properly secure the exit doors and reset the alarms. They were able to convey knowledge of the facility's policy on abuse/neglect and elopement policy and procedures.