**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 6 residents (Resident #24) reviewed for supervision. The facility failed to ensure Resident #24, who had a history of exit seeking behaviors and was a high risk for elopement, eloped from the facility on 08/08/25. The resident was found near an apartment complex on a busy street next to the facility by a passerby, who brought her back to the facility. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 08/08/25 and ended on 08/12/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of harm and/or serious injury.Findings included: Record review of Resident #24's annual MDS assessment, dated 07/10/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's Disease (brain disorder caused by damage to nerve cells in the brain), anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), unsteadiness on feet and unspecified lack of coordination. The MDS reflected Resident #24 had moderate cognitive impairment with a BIMS score of 11. The MDS further reflected Resident #24 did not exhibit wandering behaviors. Record review of Resident #24's care plan, dated 06/19/25, reflected care plan did not address Resident #24 exit seeking behaviors. Care Plan was updated on 08/08/25, reflected Problem: Resident is at risk of elopement as evidenced by. Goals: Resident will not leave the facility. Approach(s): Notify physician and family of any further concerns. Discuss secure unit placement. Monitor and record behavior with it occurs. 1:1 monitoring within eyesight. Divert residents attention and refocus attention elsewhere, staff to orient and redirect resident as needed if she talks of leaving. Record review of Resident #24's Elopement/Wandering Observation quarterly, dated 06/18/25, reflected Resident #24 was high risk for elopement. The evaluation indicated resident had a medical diagnosis associated with confusion, which may indicate future likelihood of high-risk behavior(s). Mobility: Resident is physically able to exit on foot or by wheelchair. Record review of Resident #24's Elopement Risk Evaluation, dated 08/08/25, reflected Resident #24 was at risk for elopement. The evaluation indicated Resident #24 had a history of attempting to leave the facility one or more times in last week. Statement and/or treats to leave facility. Record review of Resident #24's progress notes dated 08/08/25 at 10:55 AM reflected: This nurse was notified by [NAME] Hall nurse that resident was found next door by a resident of the apartment complex. Vitals and skin assessment normal to resident baseline. MD/DON/RP notified. New orders given via telephone from MD: CBS/CMP/UA/Chest Xray. DON will enter the orders. Resident reports she was going back home attempted to redirect resident and successful. Record review of facility Twenty-Four Hour Report dated 08/08/25 reflected: Resident Name: Resident #24; 6AM-2PM: Eloped @ 1055 [10:55AM]; 1:1 ratio at all times. 2PM-10PM: Elope cont. 1:1, stable, in bed. Record review of facility Event Report for Resident dated 08/08/25, time of event 1055 [10:55AM] reflected: Type of Event: Elopement, Note how long missing: 3-5 mins. Heat to toe assessment: no new injuries noted. Skin warm to touch. MD & RP notified of event. Nurse on St.2 told Administrator resident went out front door behind another resident's family [Initial Name] daughter. 3-5 min later she as with a lady. Statement of resident obtained: Not able to recall. No injury. List new interventions: Resident on 1:1 supervision. Interview on 09/03/25 at 12:06 PM, LVN A revealed she was the nurse assigned to Resident #24 when she eloped from the facility. She stated she could not recall the exact time, but it was between the times of 10AM - 11AM when Resident #24 eloped. She stated she was getting ready to do blood sugar checks when RN B brought Resident #24 to her and told her someone from the apartment complex saw the resident outside and brought her back to the facility, rang the doorbell and asked if this resident lived here. LVN A stated the Activity Director opened the door and verified Resident #24 was a resident from the facility and brought Resident #24 back to her hall. She stated the last time she observed Resident #24 she was in the dining area. She stated it was about a 5 - 10-minute window from when she last observed Resident #24 to when she was brought back to the facility. She stated she does not know exactly how Resident #24 exited the facility, she stated no alarm doors were heard. LVN A stated after Resident #24 was brought back they checked all the doors to ensure they were all closed and alarms working properly. LVN A stated that morning a visitor had come to visit another resident, and she believes when the visitor left the facility the visitor did not checked behind her and Resident #24 followed her out. LVN A stated Resident #24 saw the opportunity and went for it. She stated Resident #24 had history of exit seeking, she stated she would always say I want the code for the door, if someone was leaving the building resident would say I am going with them, she stated she would try to push the door, and the alarms would go off. LVN A stated Resident #24 would be easily redirected and they would keep her busy with activities. She stated resident would propel in her wheelchair and she was fast moving around. LVN A stated she completed a head-to-toe assessment on Resident #24, and no injuries were noted skin was intact. She stated she notified the doctor, Resident #24 family member/POA, the DON and the Administrator. She stated Resident #24 was placed on 1:1 supervision until she discharged to another facility on 08/11/25. LVN A stated staff were in serviced on elopement, what to do when a resident goes missing, elopement binder was updated, the front pages of the elopement binder were the residents who were high risk. She stated elopement risk assessment were completed on all residents, care plans were updated, she stated she completes a head count of resident upon the start of her shift. LVN A stated when a visitor visits, they must open the door for them and when they leave the staff puts in the code for them to exit, she stated staff were not allowed to give out codes. Interview on 09/03/25 at 12:19 PM, RN B revealed she was working on 08/08/25 on [NAME] Hall. She stated she was not the nurse assigned to Resident #24; however, she was behind the Activity Director when she opened the door, saw a woman returning Resident #24 and asked if the resident lived here. She stated Resident #24 was in her wheelchair and the woman said she had seen the resident next door in the apartment complex in the middle of the street. RN B stated she asked Resident #24 what she was doing, and Resident #24 told her she was going to go get her car. RN B stated she took Resident #24 back to her hall and told LVN A resident was outside in the street, and someone found her next door and brought her back. RN B stated she could not recall the exact time she had last seen Resident #24, she stated it was after breakfast, before lunch when she was brought back to the facility. She stated when Resident #24 exhibits those behaviors of wanting to leave, they monitor her more frequent and redirect her. RN B stated Resident #24 had a history of exit seeking and trying to open doors. She stated Resident #24 was placed on 1:1 supervision. She stated staff were inserviced on elopement, what to do when a resident goes missing, elopement risk assessment was completed on all residents, care plans were updated, all doors were checked and ensure alarms door worked properly and ensure when a visitor visit staff must open the door and when they leave staff are the ones put the code in. RN B stated staff should not provide door codes to visitors. Interview on 09/03/25 at 12:31 PM, the Activity Director revealed she was working on 08/08/25 when Resident #24 eloped from the facility. She stated the last time she observed Resident #24 she was eating breakfast in the dining room around 8-8:30AM. She stated she could not recall the time, but someone ranged the doorbell, and she opened the door. She stated a women asked if the resident lived here, and she told her yes. She stated she notified the nurse and to take her to her hall. She stated the women stated resident was around the apartment complex next door to the facility. Activity Director stated no alarms were heard that morning. She stated Resident #24 was an elopement risk but she had not seen her open doors. She stated she was inserviced on elopement, elopement binder, where to locate it, and what to do when a resident goes missing. She stated staff are not allowed to give out codes to visitors and staff must always open the door for them when entering and leaving. Interview on 09/03/25 at 12:38 PM, the DON revealed she was informed by LVN A Resident #24 was found by a lady coming out of the apartment complex. The lady saw resident, stopped her car and brought the resident back to the facility and asked if the resident lived here. She stated the Activity Director was the one who opened the door and informed the lady that Resident #24 was a resident at the facility. She stated per LVN A last time she observed Resident #24 she was in the dining area and resident was out for about 3-5 minutes. She stated Resident #24 would ambulate in her wheelchair and was known to peddle fast in it. The DON stated Resident #24 was an elopement risk, she stated an elopement assessment was completed on 08/08/25, and resident scored high risk. The DON stated she could not locate any prior elopement assessment completed on Resident #24, then stated she did not look to ensure if any were completed prior to the elopement but she knew resident was a high risk. She stated Resident #24 had history of attempting to leave the facility, she stated one time unknown of date of when it happened, Resident #24 was attempting to leave but was within eyesight of hers and she immediately stopped her and redirected her. The DON stated Resident #24 was placed on 1:1 supervision until she discharged to another facility. She stated LVN A notified the doctor and family member. She stated elopement risk assessment were completed on all residents, the elopement binder was updated and can be located at the nurse's station. Staff were inserviced on elopement, elopement book, complete head count prior to start of shift, what to do if a resident goes missing, making sure when visitor visit only staff can use the code to open the door. The DON stated they put signs on all the doors to ensure visitors to check behind them when leaving and ensure doors are closed. Interview on 09/03/25 at 1:03 PM, the Administrator revealed Resident #24 had exited the facility on 08/08/25. She stated till this day they still do not know how resident exited the facility. She stated someone from next door apartment complex found Resident #24 and brought her back to the facility and asked if she lived here. The Administrator stated Resident #24 was only gone for a couple of minutes. She stated she was in her office and could not recall when the last time Resident #24 was last seen. She stated Resident #24 eats her breakfast in her room, once done she was out and about. The Administrator stated Resident #24 was an exit seeker, has tried in the past to exit but was not successful. She stated Resident #24 would always say her car was outside. She stated they would try to redirect resident, keep her busy with activities and watch her within eyesight. She stated after the elopement Resident #24 was placed on 1:1 supervision until they could find an appropriate placement for her. She stated a QAPI meeting was completed with the DON and MD regarding the elopement and suggested Resident #24 required a secure unit. She stated the DON reached out to the family twice on 08/08/25 and LVN B was able to notify the family regarding the incident. The DON stated Resident #24 discharged from the facility on 08/11/25. She stated all staff were inserviced on elopement, what to do if a resident elopes from the facility, where to find elopement binder, signs of elopement, and not to provide door codes to visitors, complete head counts at the beginning of every shift. Elopement risk assessments were completed on all residents, care plans were updated on residents identified as being at high risk of elopement, and she completes door audits weekly to ensure doors alarms were working properly. Interview on 09/03/25 at 3:03 PM, CNA E revealed she was the CNA assigned to Resident #24 when she eloped. She stated the last time she observed Resident #24 she was in the dining area around 10:30AM. She stated she could not recall if any visitors visited the morning of 08/08/25. She stated she did not observe Resident #24 exit the facility. She stated Resident #24 was found on the road next to the apartment complex and was brought back to the facility. She stated no injuries were noted on the resident. She stated Resident #24 was known to exit seek, she stated Resident #24 was easily to redirect when she would get close by the doors. She stated Resident #24 would have the tendency of saying she needed to go find her car outside. CNA E stated Resident #24 was placed on 1:1 supervision until she discharged . Record review of facility Elopements policy, dated 12/2017, reflected the following: It is the policy of this home to provide a systematic approach to searching for a resident who may have left the home and/or home grounds. PROCEDUREThe following steps are to be followed when a resident is noted absent and is not found on initial search of the home. This also includes when a resident leaves the home grounds without staff notification. Home Staff will:-Search the home and grounds-Send staff member(s) out to locate the resident-Notify Administrator or on-call person immediately-If resident is not located within 30 minutes, call the local police. Administrative / Supervisory Staff will:-Determine if elopement is reportable to state regulatory agency-Interview staff and obtain written statements. If resident was returned by outside personnel, obtain name, phone number and details with any information of where resident was found and under what circumstances the resident was found.-Establish a monitoring system for resident until flight risk is resolved-Determine what measures can be taken to prevent it from happening again-If elopement is reported, contact appropriate corporate personnel. This was determined to be a Past Non-Compliance Immediate Jeopardy on 09/03/25 at 4:15 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 09/03/25 at 4:40 PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of facility QAPI revealed a meeting was completed on 08/08/25. Record review of Elopement Risk Assessment reflected they were reviewed and completed on Resident #8, Resident #9, Resident #14, Resident #24, Resident #30 and Resident #35 on 08/08/25. Record review of Resident #8, Resident #9, Resident #14, Resident #24, Resident #30 and Resident #35's Care Plans reflected care plans were reviewed and updated from 08/08/25 through 08/12/25 to reflect them as being high risk for elopements and to monitor for exit seeking behaviors. Record review of facility Elopement binders located on main nurse's station reflected facesheets of residents who were high risk of elopement with pictures and elopement risk assessment on all residents. Record review of facility Audit to Ensure the Doors are Secure and Alarm Working forms for all exit doors from 08/08/25 through 09/02/25 reflected door checks were being completed weekly. Observation on 09/03/25 from 2:06 PM through 2:12 PM revealed all facility door alarms were checked with the Maintenance Director and doors were functioning properly. Alarms were loud enough to be heard throughout the facility. A code was needed to turn off the alarms. Observed signs on all the doors indicating: Caution Make sure this door locks. Do not let any resident out behind you, and main entrance door: Attention Visitors Do Not let residents out without speaking to nursing staff. Record review of in-services with a start date of 08/08/25 reflected all facility staff were in-serviced on Elopement Risk Report, Elopement & Binder, what to do for Elopement, Elopement Risk Assessments. Summary of Meeting: Elopement risk assessments assist staff in knowing what residents are at risk to elope/try to leave facility. High risk residents' pace, wander, pack their items, talk about going home, watches the doors that are exits. Residents who are bed bound, can't push or move their w/cs on their own and can't transfer out of bed are less likely to be high risk. We care completing Elopement Risk assessments, updating care plans, updating elopement binder if any residents are exit seeking nurse, DON, Administrator be told immediately. Elopement Risk Binder will be set up with ALL resident's elopement risk assessment, face sheet, resident at high risk for elopement - (want to be able to walk or use own w/c to push, packs items)- will be at front of binder. Low risk will be next, no risk - (bed bound can't transfer or move w/c independently) -no risk back of binder. Do not provide codes to visitors, during an elopement check inside and outside, complete a head count, make sure visitor check in. In-services were completed by 08/12/25. Interviews on 09/03/25 from 12:25 PM through 3:30PM with LVN A, RN B, [NAME] D, Activity Director, Dietary Manager, CNA E, Dietary Aide G, CNA H, Laundry Aide, CNA I, LVN J, LVN K, Rehab L, Rehab Director, Maintenance Director who worked the shifts of 6:00 AM-2:00 PM, 6AM - 6PM, and 2:00 PM-10:00 PM revealed the facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize the in-service on elopement, signs of elopement, elopement binder, and what to do in case of an elopement/missing person. Nursing staff stated they must complete head counts at the beginning of every shift, elopement risk assessment was reviewed/competed (an evaluation to determine any resident at risk of elopement), where to locate elopement binders, care plans were updated on resident who were identified as high risk of elopement. Staff stated when a resident goes missing/elopes they must stop what they are doing, report to all staff a resident was missing, ensure all residents were counted for, ensure all doors are closed, check inside and outside the facility perimeter. Staff stated door codes were not to be provide to visitors, when a visitor visits, they must open the door for them when entering and exiting the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 resident (Resident #24) of 6 residents reviewed for care plans. The facility failed to develop a person-centered comprehensive care plan for Resident #24, who was at high risk for elopement and who had exit-seeking behaviors. Resident #24 eloped from the facility on 08/08/25, she was found near an apartment complex on a busy street next to the facility by a passerby and brought her back to the facility. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 08/08/25 and ended on 08/12/25. The facility had corrected the noncompliance before the survey began. The failure placed the resident at risk for serious adverse outcomes including serious harm.Findings included: Record review of Resident #24's annual MDS assessment, dated 07/10/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's Disease (brain disorder caused by damage to nerve cells in the brain), anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), unsteadiness on feet and unspecified lack of coordination. The MDS reflected Resident #24 had moderate cognitive impairment with a BIMS score of 11. The MDS further reflected Resident #24 did not exhibit wandering behaviors. Record review of Resident #24's care plan, dated 06/19/25, reflected care plan did not address Resident #24 exit seeking behaviors. Record review of Resident #24's Elopement/Wandering Observation quarterly, dated 06/18/25, reflected Resident #24 was high risk for elopement. The evaluation indicated resident had a medical diagnosis associated with confusion, which may indicate future likelihood of high-risk behavior(s). Mobility: Resident is physically able to exit on foot or by wheelchair. Record review of Resident #24's Elopement Risk Evaluation, dated 08/08/25, reflected Resident #24 was at risk for elopement. The evaluation indicated Resident #24 had a history of attempting to leave the facility one or more times in last week. Statement and/or treats to leave facility. Record review of Resident #24's progress notes dated 08/08/25 at 10:55 AM reflected: This nurse was notified by [NAME] Hall nurse that resident was found next door by a resident of the apartment complex. Vitals and skin assessment normal to resident baseline. MD/DON/RP notified. New orders given via telephone from MD: CBS/CMP/UA/Chest Xray. DON will enter the orders. Resident reports she was going back home attempted to redirect resident and successful. Record review of facility Twenty-Four Hour Report dated 08/08/25 reflected: Resident Name: Resident #24; 6AM-2PM: Eloped @ 1055 [10:55AM]; 1:1 ratio at all times. 2PM-10PM: Elope cont. 1:1, stable, in bed. Record review of facility Event Report for Resident dated 08/08/25, time of event 1055 [10:55AM] reflected: Type of Event: Elopement, Note how long missing: 3-5 mins. Heat to toe assessment: no new injuries noted. Skin warm to touch. MD & RP notified of event. Nurse on St.2 told Administrator resident went out front door behind another resident's family [Initial Name] daughter. 3-5 min later [NAME] as with a lady. Statement of resident obtained: Not able to recall. No injury. List new interventions: Resident on 1:1 supervision. Interview on 09/03/25 at 12:06 PM, LVN A revealed she was the nurse assigned to Resident #24 when she eloped from the facility. She stated she could not recall the exact time, but it was between the times of 10AM - 11AM when Resident #24 eloped. She stated she was getting ready to do blood sugar checks when RN B brought Resident #24 to her and told her someone from the apartment complex saw the resident outside and brought her back to the facility, rang the doorbell and asked if this resident lived here. LVN A stated the Activity Director opened the door and verified Resident #24 was a resident from the facility and brought Resident #24 back to her hall. She stated the last time she observed Resident #24 she was in the dining area. She stated it was about a 5 - 10-minute window from when she last observed Resident #24 to when she was brought back to the facility. She stated she does not know exactly how Resident #24 exited the facility, she stated no alarm doors were heard. LVN A stated after Resident #24 was brought back they checked all the doors to ensure they were all closed and alarms working properly. LVN A stated that morning a visitor had come to visit another resident, and she believes when the visitor left the facility the visitor did not checked behind her and Resident #24 followed her out. LVN A stated Resident #24 saw the opportunity and went for it. She stated Resident #24 had history of exit seeking, she stated she would always say I want the code for the door, if someone was leaving the building resident would say I am going with them, she stated she would try to push the door, and the alarms would go off. LVN A stated Resident #24 would be easily redirected and they would keep her busy with activities. She stated resident would propel in her wheelchair and she was fast moving around. LVN A stated she completed a head-to-toe assessment on Resident #24, and no injuries were noted skin was intact. She stated she notified the doctor and Resident #24 family member. She stated Resident #24 was placed on 1:1 supervision until she discharged to another facility on 08/11/25. LVN A stated she could not recall if Resident #24's was care planned for being at risk of elopement. She stated the DON was responsible for updating care plans. She stated if Resident #24 was exhibiting exit seeking behaviors it should had been care planned. She stated care plans were needed to keep up with resident's care, safety and have interventions in place. Interview on 09/03/25 at 12:38 PM, the DON revealed she was informed by LVN A Resident #24 was found by a lady coming out of the apartment complex. The lady saw resident, stopped her car and brought the resident back to the facility and asked if the resident lived here. She stated the Activity Director was the one who opened the door and informed the lady that Resident #24 was a resident at the facility. She stated per LVN A last time she observed Resident #24 she was in the dining area and resident was out for about 3-5 minutes. She stated Resident #24 would ambulate in her wheelchair and was known to peddle fast on it. The DON stated Resident #24 was an elopement risk, she stated an elopement assessment was completed on 08/08/25, and resident scored high risk. The DON stated she could not locate any prior elopement assessment completed on Resident #24, then stated she did not look to ensure if any were completed prior to the elopement but she knew resident was a high risk. She stated Resident #24 had history of attempting to leave the facility, she stated one time unknown of date of when it happened, Resident #24 was attempting to leave but was within eyesight of hers and she immediately stopped her and redirected her. The DON stated Resident #24 was placed on 1:1 supervision until she discharged to another facility. She stated she was not sure if Resident #24 was care planned for her exit seeking behaviors prior to being updated on 08/08/25. The DON reviewed Resident #24 and stated resident had not been care planned for her behaviors. She stated the ADON C was responsible for reviewing and updating care plans but since the ADON C left, she was not responsible for care plans. She stated Resident #24 care plan was updated after her elopement and being on 1:1 supervisor. She stated the potential risk of not care planning elopement behaviors would be staff not knowing the interventions in place for high-risk residents for elopements. Interview on 09/03/25 at 1:03 PM, the Administrator revealed Resident #24 had exited the facility on 08/08/25. She stated till this day they still do not know how resident exited the facility. She stated someone from next door apartment complex found Resident #24 and brought her back to the facility and asked if she lived here. The Administrator stated Resident #24 was only gone for a couple of minutes. She stated she was in her office and could not recall when the last time Resident #24 was last seen. She stated Resident #24 eats her breakfast in her room, once done she is out and about. The Administrator stated Resident #24 was an exit seeker, has tried in the past to exit but was not successful. She stated Resident #24 would always say her car was outside. She stated they would try to redirect resident, keep her busy with activities and watch her within eyesight. She stated after the elopement Resident #24 was placed on 1:1 supervision until they could find an appropriate placement for her. She stated a QAPI meeting was completed with the DON and MD regarding the elopement and suggested Resident #24 required a secure unit. She stated the DON reached out to the family twice on 08/08/24 and LVN B was able to notify the family regarding the incident. The Administrator stated Resident #24 discharged from the facility on 08/11/25. She stated she was not aware Resident #24 exit seeking behaviors were not care planned. The Administrator stated at that time the ADON C and Social Worker were responsible for reviewing and updating care plans, but they left after transitioning to the new company. She stated care plans were important so that staff can keep up with the resident's care. She stated the potential risk would be staff not knowing the interventions in place for resident who are high risk of elopement. The Administrator stated all staff were inserviced elopement risk assessments were completed on all residents, care plans were updated on residents identified as being at high risk of elopement. Record review of the facility's policy Care Plan-Resident, dated December 2018, reflected:It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident. 5. Resident Goalsa. List a measurable, reasonable goal for each problem identified.This was determined to be a Past Non-Compliance Immediate Jeopardy on 09/03/25 at 4:15 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 09/03/25 at 4:40 PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of facility QAPI revealed a meeting was completed on 08/08/25. Record review of Resident #24's care plan, updated on 08/08/25, reflected Problem: Resident is at risk of elopement as evidenced by. Goals: Resident will not leave the facility. Approach(s): Notify physician and family of any further concerns. Discuss secure unit placement. Monitor and record behavior with it occurs. 1:1 monitoring within eyesight. Divert residents attention and refocus attention elsewhere, staff to orient and redirect resident as needed if she talks of leaving. Record review of Resident #8, Resident #9, Resident #14, Resident #30 and Resident #35's Care Plans reflected care plans were reviewed and updated from 08/08/25 through 08/12/25 to reflect them as being high risk for elopements and to monitor for exit seeking behaviors. Record review of in-services with a start date of 08/08/25 reflected all facility staff were in-serviced on Elopement Risk Report, Elopement & Binder, what to do for Elopement, Elopement Risk Assessments. Summary of Meeting: Elopement risk assessments assist staff in knowing what residents are at risk to elope/try to leave facility. High risk residents' pace, wander, pack their items, talk about going home, watches the doors that are exits. Residents who are bed bound, can't push or move their w/cs on their own and can't transfer out of bed are less likely to be high risk. We care completing Elopement Risk assessments, updating care plans, updating elopement binder if any residents are exit seeking nurse, DON, Administrator be told immediately. Elopement Risk Binder will be set up with ALL resident's elopement risk assessment, face sheet, resident at high risk for elopement - (want to be able to walk or use own w/c to push, packs items)- will be at front of binder. Low risk will be next, no risk - (bed bound can't transfer or move w/c independently) -no risk back of binder. Do not provide codes to visitors, during an elopement check inside and outside, complete a head count, make sure visitor check in. Inservices were completed by 08/12/25. Interviews on 09/03/25 from 12:25 PM through 3:30PM with LVN A, RN B, LVN J, LVN K, who worked the shifts of 6:00 AM-2:00 PM and 2:00 PM-10:00 PM revealed the facility staff were able to verify education was provided to them. Nursing staff stated elopement risk assessments were reviewed/competed (an evaluation to determine any resident at risk of elopement), and care plans were updated on residents who were identified as high risk of elopement. Nursing staff stated if any resident exhibits any behaviors, they will report to the DON for care plans to be updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Residents #1, #2, #3, and #4) of six residents and two (CNA B and CNA C) out of five staff in the facility reviewed for infection control practices and transmission-based precautions. 1. The facility failed to ensure Residents #1 and #2 were separated after Resident #2 tested positive for COVID on 10/19/23, and Resident #1 did not. 2. The facility failed to ensure Residents #3 and #4 were separated after Resident #4 tested positive for COVID on 10/19/23, and Resident #3 did not. 3. The facility failed to ensure staff utilized PPE appropriately to prevent cross contamination between residents positive with COVID-19 and residents who were not positive for the virus. An Immediate Jeopardy (IJ) was identified on 10/23/23 at 3:45 PM. While the IJ was removed on 10/24/23, the facility remained out of compliance at no actual harm with the potential for more than minimal harm with a scope identified as pattern because the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life. The findings included: Review of Resident #1's face sheet, dated 10/24/23, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior), chronic obstructive pulmonary disease with acute exacerbation (a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Review of Resident #1's physician's orders for October 2023 did not reveal an order for isolation related to COVID-19. Review of Resident #1's quarterly MDS Assessment, dated 10/11/23, reflected she had a BIMS score of 09 indicating moderate cognitive impairment. Review of Resident #1's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested negative for COVID-19 on 10/16/23, 10/19/23, 10/23/23, and 10/24/23. Review of Resident #3's face sheet, dated 10/24/23, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute respiratory failure (a condition where the lungs cannot provide enough oxygen), dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), and Alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior). Review of Resident #3's physician's orders for October 2023 did not reveal an order for isolation related to COVID-19. Review of Resident #3's quarterly MDS Assessment, dated 07/26/23, reflected she had a BIMS score of 11, indicating moderate cognitive impairment. Review of Resident #3's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested negative for COVID-19 on 10/16/23, 10/19/23, 10/23/23, and 10/24/23. Review of Resident #2's face sheet, dated 10/24/23, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included 2019-nCov acute respiratory disease (COVID-19), alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior), and cerebral infarction (a stroke). Review of Resident #2's physician's orders for October 2023 reflected the following: isolation precaution [dx: 2019-nCov acute respiratory disease] which began on 10/19/23. Review of Resident #2's quarterly MDS Assessment, dated 08/31/23, reflected she had a BIMS score of 02 indicating severe cognitive impairment. Review of Resident #2's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested positive for COVID-19 on 10/19/23. Review of Resident #2's care plan, dated 08/31/23, reflected the following: Problem: Problem Start Date: 10/20/23, [Resident #2] requires isolation r/t: COVID POSITIVE .Approach: Approach Start Date: 1) Follow facility isolation policy Review of Resident #4's face sheet, dated 10/24/23, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included transient cerebral ischemic attack (a stroke), 2019-nCov acute respiratory disease (COVID-19), and dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally). Review of Resident #4's physician's orders for October 2023 reflected the following: isolation precaution [dx: 2019-nCov acute respiratory disease] which began on 10/19/23. Review of Resident #4's significant change in status MDS Assessment, dated 08/30/23, reflected she had a BIMS score of 13, indicating no cognitive impairment. Review of Resident #4's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested positive for COVID-19 on 10/19/23. Review of Resident #4's care plan, dated 07/13/23, reflected the following: Problem: Problem Start Date: 10/20/23, [Resident #2] requires isolation r/t: COVID POSITIVE .Approach: Approach Start Date: 1) Follow facility isolation policy . Observation on 10/23/23 at 8:15 AM revealed Residents #1 and #2 were in their rooms together. Resident #1 was not wearing a mask and was sitting in her wheelchair next to her bed a few feet from Resident #2 who was in her bed asleep and not wearing a mask. Observation on 10/23/23 at 8:16 AM revealed Residents #3 and #4 were in their rooms together. Resident #3 was not wearing a mask and was sitting in her wheelchair with her bedside table in front of her eating breakfast. Resident #4 was not wearing a mask and was sitting on her bed and was a few feet from Resident #3. Observation on 10/23/23 at 8:17 AM outside Residents #1, #2, #3, and #4's room revealed two three-drawer bins with PPE in them including gowns, gloves, and face shields. There was also a sign posted that read to see nurse before entering room. Observation on 10/23/23 at 8:18 AM revealed CNA B walked into Residents #3 and #4's room wearing only an N95 mask and gloves. CNA B walked into the room and went to Resident #3 to retrieve her breakfast tray, took the tray to the cart on the hall, walked back into the room and went to Resident #4. CNA B tried taking Resident #4's tray and Resident #4 told her she was not finished with her breakfast and did not want her to take it yet. CNA B took her gloves off and walked out of the room without performing hand hygiene. Observation on 10/23/23 at 4:10 PM of Resident #1 revealed she was sitting in her wheelchair and had rolled to Resident #2's side of the room. Resident #1 was observed so close to Resident #2 that Resident #1's knees were touching the railing on Resident #2's bed. Neither resident has a mask on. Observation on 10/23/23 at 4:20 PM of Resident #4 revealed she was sitting in her wheelchair in the doorframe of her room, making her perpendicular to Resident #3's bed where she was currently lying down. LVN D walked down the hall towards Resident #4 and asked/encouraged her to go back to her side of the room. Neither resident was wearing a mask. Observation on 10/23/23 at 4:25 PM of Resident #1 revealed she was sitting in her wheelchair and had rolled to Resident #2's side of the room. Resident #1 was observed so close to Resident #2 that Resident #1's knees were touching the railing on Resident #2's bed. Neither resident has a mask on and Resident #2 was currently yelling for staff to help her and the residents were having a conversation with each other about waiting for the staff to come and help Resident #2. In an interview on 10/23/23 at 8:20 AM with CNA B revealed both residents in the room she just left were positive for COVID-19 or had been exposed to it. CNA B said she only went into Residents #3 and #4's room to get their breakfast trays and wore her N95 mask and gloves. CNA B said what she wore in the room was fine so long as she was not changing the residents. CNA B said she did not feel like putting on all the PPE like the gown just to retrieve a breakfast tray from the residents. CNA B said no one told her she should or should not make this choice, she did what she felt like she should do and that was what she did. CNA B said she did not want to continue talking about this and ended the interview. In an interview on 10/23/23 at 8:25 AM with the Activity Director revealed she provided a census and indicated a plus sign next to Residents #2 and #4. The Activity Director said that meant those two residents were positive for COVID-19. The Activity Director said since the roommates of those residents did not have a plus sign next to them it meant they were negative for COVID-19. The Activity Director confirmed that Residents #1 and #3 were negative for COVID-19 and each in a room with a positive for COVID-19 resident (Residents #2 and #4). In an interview on 10/23/23 at 8:30 AM with LVN D revealed she cared for Residents #1, #2, #3, and #4. LVN D said Residents #2 and #4 were positive for COVID-19 and their roommates Residents #1 and #3 were negative for COVID-19. LVN D said the residents were in the same room because there was no where else to move them without contaminating the new room if they did become positive for COVID-19 later on. LVN D said that was why the choice was made to keep them all in the same room. In an interview on 10/23/23 at 8:45 AM with the Administrator revealed the facility hired a new DON last week who was out of the building for a few days so she was acting as the facility's Infection Preventionist for now. The Administrator/IP said Residents #2 and #4 were positive for COVID-19. In an interview on 10/23/23 at 10:35 AM with LVN D revealed since she knew Residents #1 and #3 were negative for COVID-19 and were in the same room as Residents #2 and #4 who were positive for COVID-19 she always wore PPE when entering their rooms. LVN D said she already had an N95 mask on so she put on a gown, gloves, and a face shield when caring for the residents. LVN D said she tried to care for the COVID-19 negative residents first, performed hand hygiene, changed her PPE, and then cared for the COVID-19 positive residents next. In an interview on 10/23/23 at 10:52 AM with CNA B revealed she knew to wear her N95 mask while in the facility because there were positive residents. CNA B said she knew that when caring for Residents #1, #2, #3, and #4 that she was supposed to wear a gown, gloves, and a face shield. CNA B said she was supposed to care for the COVID-19 negative residents, which were #1 and #3, first and perform hand hygiene and change her PPE before caring for the COVID-19 positive residents, which were #2 and #4. In an interview on 10/23/23 at 11:01 AM with CNA C revealed she knew to wear her N95 mask while in the facility because there were positive residents. CNA C said while she was not assigned to Residents #1, #2, #3, and #4 she knew that Residents #2 and #4 were COVID-19 positive and Residents #1 and #3 were COVID-19 negative. CNA C said if she had to care for these residents she would treat them the same and wear full PPE including a gown and gloves. Observation on 10/23/23 at 11:25 AM of Residents #3 and #4 revealed there was a family member in their room and they were telling Resident #3 to stay on their side of the room so they did not also catch COVID-19. Resident #3 was observed standing in the middle of the room with her walker and Resident #4 was sitting in her wheelchair a few feet away. Resident #3 began to walk backwards and sat down on her bed. Neither resident was wearing a mask. Continuous observation on 10/23/23 at 11:56 AM of CNA B, CNA C, and LVN D passing trays to Residents #1, #2, #3, and #4's rooms revealed the following: - CNA B was wearing an N95 mask, put on a gown but did not put on gloves or a face shield and walked into Residents #1 and #2's room to take Resident #1 her lunch tray. CNA B asked LVN D if she needed to change her gown before taking Resident #2's tray to her and LVN D told her yes. CNA B took off her gown and washed her hands inside the room. CNA B put on a new gown, face shield, and gloves. CNA B walked into the room and sat down next to Resident #2 to assist her with her lunch meal. - CNA C was wearing an N95 mask, put on a gown but did not put on gloves or a face shield and walked into Residents #2 and #4's room to take Resident #4 her tray. CNA C took off her gown and gloves, did not wash her hands, and walked out of the room. CNA C put on new gloves, a gown, and a face shield. CNA C walked to Resident #3's bed and sat her lunch tray down. CNA C took off her gown, gloves, and face shield and washed her hands before leaving the room. - LVN D was attempting to correct CNA B and CNA C in live time ensuring they were wearing the correct PPE and washing their hands but they were not listening. LVN D was visibly frustrated and ended up leaving the area saying she could no longer be a part of the situation. In an interview on 10/23/23 at 12:10 PM with CNA C revealed she could not remember what she did or did not do because there was too much going on all at once. CNA C said she thought she did everything right. In an interview on 10/23/23 at 1:15 PM with CNA B revealed she knew what she did wrong but did not want to specify. In an interview on 10/23/23 at 4:30 PM with LVN D revealed she had a conversation before the lunch meal service with CNA B and CNA C and went through what they needed to do and what PPE they needed to have on. LVN D said there were also signs posted on the outside of the doors to the residents' rooms both inside and outside. LVN D said she was not sure why CNA B and CNA C failed to put on the correct PPE and failed to perform hand hygiene properly. In an interview on the phone on 10/23/23 at 5:41 PM with Physician A revealed he was one of the doctor's treating residents at the facility. Physician A said he was aware the facility had experienced a COVID-19 outbreak and had positive residents. Physician A said he was last at the facility on 10/19/23 to check on residents and provide support to the facility. Physician A said he did not know there were both COVID-19 positive and negative residents together in the same room. Physician A said he would not advise the facility to cohort residents unless they were both positive for COVID-19. Physician A said he did not think it would be wise or allowed by CMS or the state of Texas to cohort residents if one was COVID-19 positive and the other COVID-19 negative. In an interview on 10/23/23 at 12:18 PM with the Administrator/IP revealed the facility had recently experienced an outbreak of COVID-19 beginning on 10/11/23 when LVN E tested positive. The Administrator/IP said she immediately began testing all residents and staff and found five positive residents on 10/11/23, one positive resident on 10/12/23, and then four positive residents on 10/19/23. The Administrator/IP said Residents #2 and #4 were two of the four residents who tested positive on 10/19/23. The Administrator/IP said both residents #2 and #4 had roommates which were Residents #1 and #3. The Administrator/IP said based on a lot of times previously the roommates of positive residents test positive for COVID-19 the next day after being exposed so she did cohort the positive and negative residents (referring to Residents #1, #2, #3, and #4). The Administrator/IP said she felt it would be upsetting and detrimental to move the residents around especially the specific groups of roommates (referring to Residents #1 and #2, and #3 and #4). The Administrator/IP said she and the staff were trying to keep the residents apart in the rooms and use separate PPE when caring for them. The Administrator/IP said it would also have triggered a lot of other residents to have had to move rooms if they did separate the positive and negative COVID-19 residents since the facility did not currently have any empty rooms. The Administrator/IP said she looked at the CDC's recommendations to see what their isolation guidelines were and informed the local health department the facility had COVID-19 positive residents and staff. The Administrator/IP said she could not find any information from the CDC about cohorting residents and only saw information regarding isolation and quarantine periods. The Administrator/IP said she usually wanted to try and move residents and not cohort them together in the same room if one was COVID-19 positive and the other was COVID-19 negative but was not sure what the facility's policy was and would have to look at it first. The Administrator/IP said the purpose of cohorting residents correctly based on their COVID-19 status was to stop the spread of the infection. The Administrator/IP said the risk of residents not cohorted based on their COVID-19 status put them at risk of getting infected by COVID-19. The Administrator/IP said when caring for these residents staff should be putting on full PPE meaning a gown, gloves, and a face shield. The Administrator/IP said PPE was available outside the residents' rooms and there were signs posted for staff to follow that showed the order to put the PPE on. The Administrator/IP said the purpose of putting on the PPE was to prevent others from getting COVID-19 germs on them and spreading that to other residents. The Administrator/IP said the risk of staff not putting on the correct PPE while caring for COVID-19 positive residents was that they could spread the infection to other residents. The Administrator/IP said she expected staff to also perform hand hygiene when entering/exiting a resident's room or putting on/taking off their PPE. The Administrator/IP said the purpose of performing hand hygiene was to get the germs off their hands to not spread infection. The Administrator/IP said staff had been in-serviced on what PPE to wear when going into rooms and when to wash their hands or use hand sanitizer. The Administrator/IP said the nursing staff and management were monitoring staff to ensure they were following infection control practices and procedures correctly. Review of the facility's policy, titled COVID-19 Plan, revised 03/24/21, reflected the following: Suspected case(s) of COVID-19 in the Facility .only patients with the same respiratory pathogen may be housed in the same room. For example, a patient with COVID-19 should not be housed in the same room as a patient with an undiagnosed respiratory infection .For a resident with known or suspected COVID-19: staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available Review of the facility's Infection Control- Precautions- Categories and Notices policy, dated August 2020, reflected the following: .3. Standard Precautions will be used in the care of all residents regardless of their diagnosis, or suspected or confirmed infection status .5. In addition to Standard Precautions, Droplet Precautions must be implemented for a resident documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by the resident coughing, sneezing, talking, or the performance of procedures.) .b. Resident placement .place the resident in a private room, when a private room is not available, residents with the same infection with the same microorganism, but with no other infection may be co-horted Review of the facility's Hand Washing policy, dated August 2020, reflected: .It is the policy of this home that hand hygiene is the primary means to prevent the spread of infection .1. The use of gloves does not replace proper hand washing .Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .before and after direct resident contact .before and after entering isolation precaution settings .after removing gloves Review of the CDC's website on 10/23/23 (accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) Reflected the following Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated 05/08/23 .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection . The IPC recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing . Patient Placement .Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room .Personal Protective Equipment .HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The Administrator was notified on 10/23/23 at 3:45 PM that an IJ situation was identified due to the above failures. The Administrator was provided the IJ template on 10/23/23 at 3:49 PM. The facility's plan of removal was accepted on 10/24/23 at 9:52 AM and included the following: 10/23/2023 Plan of Removal - F 880 Immediate Action Taken Resident Specific All residents tested for Covid 19 by rapid antigen card on 10/23/23 at 4:02 pm. All residents negative. All staff in facility tested on 10/23 and were all negative. All nursing staff currently on Staff inserviced regarding PPE usage at 12:00 pm by Administrator. Resident #[1] and # [3] (negative residents) moved to room [#] at 10/23/23 at 4:55 pm. MD notified of the IJ on 10/23/2023 at 3:53 pm by Administrator, no new orders received. Resident #[2] and Resident #[4] (positive residents) moved to room [#] on 10/23/23 at 5: All other staff in facility(including housekeeping, laundry, dietary) inserviced on PPE usage by Administrator. System Changes Facility will ensure that positive and negative residents are not cohorted together in the same room. Education Administrator providing education to all staff regarding correct PPE usage for Covid Positive staff and and educated on not cohorting positive and negative residents together, and hand washing. All staff present in the facility were educated on 10/23/2023. Return demonstration will be performed on all staff in facility on 10/23. All Staff (including housekeeping, laundry, dietary) not present for the education will receive the education prior to their next shift with return demonstration on proper PPE usage and hand washing. Nurse consultant to educate Administrator on proper PPE usage and hand washing. Monitoring Residents are monitored daily for signs/symptoms of Covid while in outbreak. Staff will be monitored for correct PPE usage by Administrator/designee each day and logged on a monitoring tool. Staff will be monitored for correct hand washing/hand sanitizer usage by Administrator/designee each day and logged on a monitoring tool. On 10/24/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Monitoring observations on 10/24/23 at 12:15 PM revealed Residents #1 and #3 were in a room together and Residents #2 and #4 were in a room together. Positive and negative residents were no longer cohorted together in the same room. Monitoring observations on 10/24/23 from 12:20 PM to 1:11 PM revealed staff performing hand hygiene before/after entering/exiting a residents' room and before/after donning/doffing PPE. Staff were observed donning gowns, gloves, and a face shield before entering Residents #1, #2, #3, and #4's rooms to care for them. Staff were observed performing hand hygiene, doffing their PPE, and donning new PPE before interacting with another resident. Monitoring interviews were conducted on 10/24/23 starting at 1:11 PM and continued through 2:44 PM with the following staff from various shifts: CNA B, CNA C, CNA F, CNA G, CNA H, LVN D, LVN E, LVN I, LVN J, the Dietary Manager, the Activity Director, the Housekeeping Director, and the Administrator/IP. Staff knew that residents who were positive and negative for COVID-19 could not be in the same room together. Staff knew what PPE to wear when caring for a positive COVID-19 resident, in what order the PPE was to be put on and taken off, and when to perform hand hygiene. On 10/24/23, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with the potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.