**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and to ensure resident receives adequate supervision to prevent accidents for 2 of 4 residents (Residents #1 and #2) reviewed for accidents and hazards. 1. The facility failed to ensure the environment was free of hazards to Resident #1 after the resident was hospitalized for suicidal ideation on 05/14/2025 and then on 08/14/2025 the resident attempted to self-infict an injury to her wrist with a razor. Resident #1 was discovered with a bleeding right wrist and a shaving razor on her bed on 08/14/2025 at 5:00 PM. 2. The facility failed to ensure Resident #1 was provide supervision the resident after being hospitalized for a suicidal ideation on 05/14/2025, resulting in the resident's attempt at self-injury on 08/14/2025.3. The facility failed to put effective measures in place to prevent Resident #2 from eloping from the memory care unit on 07/04/2025. An IJ was identified on 8/21/2025. The IJ template was provided to the facility on 8/21/2025 at 12:44 PM. While the IJ was removed on 8/23/2025 at 2:27 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because the facility needed to evaluate the effectiveness of the POR and complete required staff training. These failures could place residents at risk of inadequate supervision and monitoring leading to an environment that is not free of accidents/hazards. Findings included: 1. Record review of Resident #1’s admission record (Face sheet) dated 08/19/2025 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (a condition where brain tissue dies due to a blockage in a blood vessel), anxiety disorder (excessive and persistent worry that interferes with daily life), hemiplegia affecting right dominant side (a condition where paralysis or weakness affects the right side of the body), and depression (a serious mood disorder that affects how one thinks, feels, and acts, often making daily activities difficult). Record review of Resident #1’s quarterly MDS dated [DATE] revealed a BIMS score of 15/15 indicating the resident’s cognitive skills for daily decision making were not impaired, she felt down/depressed/hopeless several days, and she sometimes felt socially isolated. The resident was able to ambulate with the use of a walker and eat, dress, toilet, and perform personal hygiene independently. Record review of Resident #1’s comprehensive care plan, updated 08/06/2025 and reviewed on 08/19/2025, revealed a focus area indicating the resident was at risk for changes in mood related to migraines, depression, insomnia, seizures, anxiety and pain; an initial mood evaluation where she reported little interest or pleasure in doing things; feeling down, depressed or hopeless; impaired sleep pattern; little energy; feeling bad about self; and having a hard time concentrating on things (initiated 05/02/2025). The goal was for the resident to have improved mood state through the review date (initiated 05/02/2025, revised on 07/24/2025). Interventions/tasks included: Administering medications as ordered and monitoring for side effects and effectiveness; assisting the resident to identify strengths and positive coping skills; behavioral health consults as needed; monitoring/recording mood to determine if problems seem to be related to external causes; and monitoring/recording/reporting to MD prn risk for harming others; increased anger, labile mood or agitation; feeling threatened by others or thoughts of harming someone; possession of weapons or objects that could be used as weapons (all initiated 05/02/2025). The care plan also revealed focus areas for the resident's use of antidepressant medication, with the intervention/task of monitor/document/report PRN social isolation, suicidal thoughts and withdrawal (initiated 04/22/2025); and the resident's anxiety diagnosis and use of antianxiety medication, with the interventions/task of monitoring/documenting/reporting PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions, intentionally harming or trying to harm self, refusing to eat, drink, take medications or therapies or sense of hopelessness, impaired judgment or safety awareness (initiated 04/22/2025). There was no focus area in Resident #1's comprehensive care plan indicating the resident had a history of and hospitalization for a suicidal ideation on 05/14/2025 and had also attempted to injure herself on 08/14/2025. Record review of Resident #1's electronic Physician's Orders revealed orders for: -Duloxetine HCL oral capsule delayed release sprinkle 30 mg, give one capsule by mouth one time a day for depression with an order date of 08/06/2025 and a start date of 08/07/2025 -Duloxetine HCL oral capsule delayed release sprinkle 60 mg, give one capsule by mouth one time a day for depression with an order date of 04/22/2025 and a start date of 04/23/2025 -Hydroxyzine HCL oral tablet 25 mg, give one tablet by mouth every 8 hours as needed for anxiety with an order and start date of 08/05/2025 Record review of Resident #1's Medication Administration Record from 08/01/2025 - 08/20/2025 revealed she was monitored daily for side effects to antianxiety medication but only monitored on 08/20/2025 for side effects to antidepressant medications. Record review of a progress note dated 05/14/2025 at 7:27 AM in Resident #1’s EHR revealed the resident was found crying in her bedroom by a CNA. Resident #1 stated she did not want to live and “did not want to be here anymore.” The resident’s RP and MD were contacted and the resident was transferred to the hospital. The resident returned to the facility on [DATE] to the general population. Record review of Resident #1’s psychiatric evaluation dated 05/14/2025 during her hospital admission noted the resident was physically able to harm herself, was not supervised at her current facility, and would potentially be able to do so. The psychiatrist recommended a memory care facility with closer observation. Record review of Resident #1's EHR revealed the resident received routine psychiatric care, with the most recent psychiatric assessment on 08/13/2025. The note revealed staff reported the resident seemed paranoid and delusional at times, thinking people were talking about her and she did not want to take medications from the staff. The provider spoke with the resident's sister, who confirmed the resident had a history of non-compliance with medications. The note revealed the resident was anxious but not suicidal and there was no risk of aggression. Record review of a progress note by LVN B dated 08/14/2025 at 5:00 PM in Resident #1's EHR dated 08/14/2025 at 5:00 PM revealed the resident was bleeding from her right wrist with a women's shaving razor on the bed beside her. The resident informed the nurse she wanted to die and to go to the hospital. Pressure was applied to the site, the wound was cleaned, treated with antibiotic cream, and dressed with a dry dressing. The wound was superficial and approximately 2 cm long. The resident's vital signs were taken and within normal ranges. The DON was informed, the resident's physician and RP were notified, the resident was on 1:1 watch until transport arrived, and the resident was transported to the ER. The resident returned to the facility on [DATE] to her previous room, which was not on the memory care unit. Record review of a self-reported incident filed by the administrator of the facility on 08/16/2025 revealed: “Brief narrative summary of the reportable incident: Resident sent out to hospital on [DATE] due to suicidal ideation. Returned to facility today 08/16/2025 with hospital records that resident with acute fracture to right ulnar and a healing fracture of distal radius.” During an interview on 08/19/2025 at 2:30 PM, LVN A stated Resident #1 was agitated the morning she cut her right wrist, but later relaxed and asked to speak with the ADON. She had contacted the resident’s psychiatric NP but she didn’t get back to her that day. She spoke to the resident’s family member. LVN A stated she was aware of Resident #1's suicidal ideation and hospitalization in May 2025 and informed management she believed it would be better for Resident #1 to be placed in memory care because it was safer, residents could not have glass or scissors, and staff would go through items brought by family members. During an interview on 08/19/2025 at 2:40 PM, CNA G stated she had never seen Resident #1 sad but the other CNA who cares for her reported she was occasionally depressed after coming back from an outing with her family. Her family brought her things, such as food and personal care items. She never saw the resident try to hurt herself. Residents were not allowed to have razors; if she saw one, she would report it to a nurse. Resident #1 got along well with her roommate. An observation on 08/19/2025 at 3:56 PM revealed the clean utility room was unlocked and contained ladies’ and men’s shaving razors, nail clippers and aerosol cans of deodorant. During an interview on 08/20/2025 at 8:04 AM, LVN C stated he was told in May 2025 that Resident #1 had thoughts of killing herself and did not want to live but had no plan. He contacted her physician and they sent her to the hospital for evaluation. He spoke with her family, and they reported she tended to have hallucinations. He did not know how she obtained a razor. He recalled the resident had groceries delivered that day, so it was possible it was in one of the bags. The clean utility room did not have a lock, but the staff supervised it. During an interview on 08/20/2025 at 10:05 AM, the ADON stated she had gone into Resident #1’s room sometime between 10:00 – 10:30 AM on 08/14/2025 and Resident #1 told her she was crying because she believed everyone was talking about her. At 5:00 PM, the ADON and DON received a call from LVN B that Resident #1 was having an emergency situation. They both went to Resident #1’s room and observed the resident laying on her bed and holding her right wrist with a towel. LVN B stated it looked like the resident attempted to use a razor to cut herself. The ADON remained with the resident while LVN B called psychiatric services, the resident’s doctor and the resident’s family. The resident was calm at this time. The resident was transferred to the hospital. During an interview on 08/22/2025 at 4:20 PM, the Administrator stated she had assumed the position of administrator earlier that month. She was out of town the day Resident #1 attempted to injure herself. She received a call from the DON, who described the situation as the resident having a suicidal ideation and she did not believe the resident's attempt to injure herself with the razor was a suicide attempt, and she did not believe the resident's attempt to injure herself with the razor was a suicide attempt and required reporting to the state agency. During an interview on 08/22/2025 at 4:30 PM, the DON stated he called the Administrator on 08/14/2025 and told her Resident #1 was sent to the hospital. He recalled describing the resident cutting herself but did not recall if he used the term suicide attempt, as it was an ongoing situation. He remembered Resident #1 being hospitalized in May 2025 for a suicidal ideation but was unaware of the recommendation by the hospital psychiatrist to have the resident admitted to a secure unit. The DON did not believe the resident needed a secure unit and could be managed with increased supervision. Record review of the facility policy Incidents and Accidents, revised 04/11/2025, revealed, Policy explanation: The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. 5. The following incidents/accidents require an incident/accident report but are not limited to: self inflicted injuries; suicide or attempted suicide. Record review of the facility policy Resident Rights, updated 20252, revealed, Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Record review of the facility’s policy, “Abuse, Neglect and Exploitation,” updated 2025, revealed, “It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. VII. Reporting/Response. A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.” An Immediate Jeopardy was identified on 08/21/2025. The Administrator and DON were notified of the Immediate Jeopardy on 08/21/2025 at 12:44 PM and were given a copy of the Immediate Jeopardy template and a Plan of Removal (POR) was requested. The facility's POR for the Immediate Jeopardy was accepted on 08/22/2025 at 10:16 AM and reflected the following: The Medical Director was notified of the Immediate Jeopardy on 08/22/2025 at 12:34 PM. 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #1 assessed, first aid administered, Primary Physician notified orders given to send to ER for evaluation and treatment. Person(s) Responsible: Charge Nurse Date: 8/14/2025 Action: Resident #1 has been receiving psychiatric services since 6/23/2025. Prior to the 8/14/2025 incident, the resident seen on 8/13/2025. Most recent visit 8/20/2025. Person(s) Responsible: The facility's contract psychology and psychiatry services. Date: 8/13/2025, 8/20/2025, on-going Action: Resident #1 placed in secure unit per resident’s request. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/20/2025 Action: Resident #1s room cleared of all items that the resident could use to harm self. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/14/2025 Completed on the same day Action: Resident #1 care plan updated to reflect risk for suicidal behavior and need for increased supervision. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/21/2025 2. How the Facility Identified Other Possibly Affected Residents: Action: Conduct safe surveys with residents/family for signs of suicidal ideation. No other residents identified. If a resident expresses or exhibits signs/symptoms of suicidal ideation during a safe survey assessment: The staff member immediately notifies the Charge Nurse, DON/ADON, and Administrator. The physician and psychiatric provider are contacted immediately for further evaluation and treatment orders. The resident is placed on one-to-one monitoring until cleared by a licensed practitioner. The resident’s responsible party is notified. The care plan is updated with individualized interventions within 24 hours. Documentation is completed in PCC, including a behavior note and entry on the 24-hour report. If the DON/Administrator is unavailable, the ADON or RN Supervisor assumes responsibility to ensure no delay in intervention. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing, Charge Nurse, Administrator Date: 8/22/2025 by 5 pm and ongoing Action: For Suicidal Ideation: Reviewed current resident population for diagnosis associated with suicidal Ideation and updated care plans with individualized interventions (e.g. Assess for underlying causes, consult mental health and/or psychiatric provider, individualized behavior intervention, Implement a behavior monitoring). Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/21/2025 Action: Suicidal Ideation: Conduct staff interviews to ask staff if any residents who: Have exhibited or voiced suicidal ideation: Has a plan, withdrawing from activities and family/friends, extreme mood swings, eating or sleeping pattern change, making statements like “I want to hurt myself” Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Social Services Date: 8/21/2025 Action: Reviewed Incident Reports and Nursing Notes for the past 6 months to identify residents with suicidal ideation. No other residents identified. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing, Social Services Date: 8/21/2025 Action: Upon admission and/or identification of suicidal ideation, the resident will be provided education regarding the importance of reporting suicidal thoughts to staff and the interventions available for support. The responsible party and family members will also receive education on recognizing signs of suicidal ideation and the importance of communicating concerns to facility staff. Education will be documented in the resident’s medical record and reflected in the individualized care plan. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing, Social Services, Date: Ongoing Action: All suicidal or self-harm behaviors will be documented in PointClickCare (PCC) through: Behavior Monitoring Flowsheets, 24-Hour Report, and/or Progress notes. Staff are trained to immediately escalate any report of suicidal ideation or self-harm. If the DON/Administrator is unavailable or on leave, the ADON or designated RN Supervisor assumes responsibility for receiving notifications and ensuring interventions are implemented without delay. All incidents will be reviewed by the interdisciplinary team and integrated into the residents’ individualized care plan within 24 hours. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing, RN Supervisor, Charge Nurses Action: Elopement: Conduct staff interviews: ask staff if any residents who: Have exhibited signs of attempting to exit the facility (testing door alarms, approaching doors when other staff or visitors are entering/exiting). No other residents identified. Person(s) Responsible: DON/ADON Date: 8/22/2025 by noon Action: Suicidal Ideation: Education provided to all staff on suicidal ideation and measures to take if identified (notify DON/Administrator immediately). All staff will be educated prior to working their next shift and new staff will be educated prior to working their first shift. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/22/2025 by 5 pm Action: Review all hospital documentation on residents that admitted or re-admitted over the past 3 months for documentation related to suicidal ideation. Continue to monitor all admissions/re-admissions documentation for suicidal ideation. Updated Care plans as needed. No new residents identified. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Administrator Date: 8/22/2025 by 5 pm and ongoing Action: Ensure current staff and new hires receive Incident, accident, and management of resident behavior training during orientation before working independently and annually thereafter. All staff will be educated prior to working their next shift and new staff will be educated prior to working their first shift. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/22/2025 by 5 pm 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Suicidal Ideation: Education provided to all staff on suicidal ideation and measures to take if identified (notify DON/Administrator immediately). All staff will be educated prior to working their next shift and new staff will be educated prior to working their first shift. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/22/2025 by 5 pm Action: Review all hospital documentation on residents that admitted or re-admitted over the past 3 months for documentation related to suicidal ideation. Continue to monitor all admissions/re-admissions documentation for suicidal ideation. Updated Care plans as needed. No new residents identified. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Administrator Date: 8/22/2025 by 5 pm and ongoing Action: Ensure current staff and new hires receive Incident, accident, and management of resident behavior training during orientation before working independently and annually thereafter. All staff will be educated prior to working their next shift and new staff will be educated prior to working their first shift. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/22/2025 by 5 pm 4. How the Corrective Actions Will be Monitored/Ensure Comprehension, by whom and for how long: Action: The Interdisciplinary team will conduct daily room rounds Monday through Friday on all residents observing any items that could be used for self-harm (e.g. razors, sharp objects, cords, glass). The Manager on Duty will conduct rounds on Saturday and Sunday observing any items that could be used for self-harm (e.g. razors, sharp objects, cords, glass) and immediately remove those items. All rounds will be discussed in the morning meeting. Person(s) Responsible: Interdisciplinary Team and Manager on Duty Date: 8/22/2025 by 5 pm and ongoing Action: Families will be educated on prohibited items during admission and re-educated as needed to ensure unsafe items are not brought into the facility. CNAs and nurses are trained to observe and report unsafe items daily while providing routine care. DON/ADON will review audit results weekly and document compliance in QAPI. Responsible: Director of Nursing and Assistant Director of Nursing, Charge Nurse Date: Ongoing Action: Interview 5 staff weekly x 4 weeks then monthly x 3 months to ensure no residents have voiced suicidal thoughts or attempted self-harm. With verbal comprehension of what to do in the event of resident self-harm or report of suicidal ideation. Responsible: Director of Nursing and Assistant Director of Nursing, Charge Nurse Action: Interview 5 staff weekly x 4 weeks then monthly x 3 months to ensure no residents have exhibited signs or attempts of elopement. With verbal comprehension of what to do in the event of elopement. Responsible: Director of Nursing and Assistant Director of Nursing, , Charge Nurse Date: Ongoing QAPI— Action: Medical Director informed of the deficient practice/IJ and the facility’s plan to remove the immediacy. Person(s) Responsible: Director of Nursing, Administrator, and/or Designee Date: 8/21/2025 The facility's verification of the POR was as follows: 1. Record review of progress note dated 08/14/2025 at 5:00 PM by LVN B revealed, “Pressure applied to site, cleansed with normal saline sol. patted dry, TAO, dry dressing applied, wound superficial 2cm long. T-98.8, P-105, R-20, BP-133/85. DON, NP notified. Record review of progress note dated 08/14/2025 at 8:46 PM by NP revealed, “Chief Complaint: Suicidal ideations, took shaving disposable razor and cut wrist sent to ER.” 2. Record review of Resident #1’s electronic health record revealed psychiatric notes dated 06/23/25, 06/25/25, 07/09/25, 07/30/25, 08/06/25, 08/13/25 and 08/20/25. 3. a. Record review of Resident #1’s electronic health record revealed psychiatric notes dated 08/20/2025 with the following entry: “Spoke with administrator and ADON to move patient to locked memory unit, private room, remove all sharp objects, use of plasticware for meals. Also discussed patient's desire to move to another facility which family has declined at this time. Will continue to monitor closely. Hospitalization is not necessary at this time. b. Observation on 08/21/2025 at 8:30 AM revealed Resident #1 was residing on the secure unit. 4. Observation on 08/21/2025 at 11:00 AM of Resident #1’s room and bathroom revealed there were no sharp objects or anything the resident could use to harm herself. 5. Record review of Resident #1’s care plan, updated 08/21/2025, revealed: “The resident is at risk for changes in mood r/t migraines, depression, insomnia, seizures, anxiety, pain, initial phq9 of 12 where she reported, little interest or pleasure in doing things, feeling down, depressed or hopeless, impaired sleep pattern, little energy, feeling bad about self, hard time concentrating on things. Res has hx of suicidal ideation on 5/14/2025. 8/14/2025 had a suicide attempt using a women's shaving razor. Interventions: o Move to the secured unit for decreased stimulation o Psychiatric evaluation o Staff to speak with family and educate regarding what items can be ordered for resident. Record review of Resident #1’s care plan, initiated 08/21/2025, & revised on 8/22/25 revealed: “Resident exhibits self-injurious behavior (e.g., hitting self, biting, scratching, head banging), which poses a risk to safety and physical well-being. She has a history of scraping her skin with at sharp item. Interventions: o Assess for underlying causes such as psychiatric illness, cognitive impairment, sensory processing disorder, pain, frustration, or past trauma. o Conduct regular skin assessments and medical reviews to monitor for injury and address complications promptly. o Educate staff on warning signs of escalation, de-escalation techniques, and emergency procedures for managing self-injury. o Engage family or responsible party in care plaining and to gather relevant history that may inform effective intervention strategies. o Monitor resident room to ensure no sharp objects are present. o Provide a safe environment, removing or padding items that could be used for self-harm and ensuring close supervision during high-risk periods. 6. Record review of documentation from facility revealed interviewed 48 residents on signs of suicidal ideation. After the POR was accepted, record review of Resident #10's EHR revealed the resident stated to social worker on 08/22/20225 at 11:59 AM he wanted to hurt himself with a plan (he wanted to walk out into freeway; however, resident is bed-bound and not ambulatory). Resident #10 was evaluated by the psych NP the same day and sent to the hospital. Care plan was updated in a timely manner. 7. Staff interviews were conducted on 08/21 - 08/22/2025. RN/LVN = 11; CNA = 18; Dietary = 8; Housekeeping/Laundry/Maintenance = 5; PT/OT = 7; Admin = 8. Staff not interviewed will be interviewed prior to beginning work from 08/22 - 08/25/2025. Staff was asked: o Has any resident ever expressed to you that they may want to self-harm: o Do you know of any residents that you feel would potentially be at risk of self-harm? o If you suspect any resident of self-harm, what would you do? o Who would you report this to? All staff indicated no resident expressed to them a desire for self harm, they were unaware of any residents at potential risk for self-harm, and if they suspected such a risk they would report this immediately to the charge nurse/DON. 8. Record review revealed one resident was identified with a suicidal ideation on 08/08/2025. The resident was sent to the hospital immediately and returned to the facility on [DATE]. This resident verbalized another SI on 08/21/2025 and was again sent to the hospital. 9. Record review of Resident #1’s electronic health record revealed in psych note dated 08/20/2025 the resident received education regarding the importance of reporting suicidal thoughts to staff and the interventions available for support. The resident’s RP also received education on recognizing signs of suicidal ideation and the importance of communicating concerns to facility staff. 10. Record review of resident electronic health records revealed documentation in PointClickCare of resident suicidal and self-harm behaviors for Residents #1 and Resident #10. 11. Record review 8/22/2025 at 3:50 PM of staff roster provided by Admin on 8/22 indicating staff that received in-service training/were asked about elopement behaviors. RN/LVN = 11; CNA = 18; Dietary = 8; Housekeeping/Laundry/Maintenance = 5; PT/OT = 7; Admin = 8. Staff not interviewed will be interviewed prior to beginning work from 08/22 - 08/25/2025. 12. Record review revealed facility included in Resident Welcome Packet section on Restricted Items which included unsafe items. 13. Called the facility's medical director on 08/22/2025 at 12:35 PM; left voice message requesting return call. Record review of QAPI sign-in roster revealed Psych NP was present and the medical director participated by phone. 2. Record review of Resident #2's face sheet, dated 8/19/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged home on 7/8/2025. Relevant diagnoses included senile degeneration of the brain (progressive memory and cognitive decline), schizophrenia (a mental health illness that causes difficulty distinguishing reality from their own thoughts and delusions), and dementia (a progressive disorder affecting cognition and behavior). Record review of Resident #2's physician orders revealed an order dated 7/3/2025 indicating the resident was admitted to the facility for a planned, five-day hospice-respite stay. Record review of Resident #2's discharge MDS, dated [DATE] revealed a BIMS score of 00, indicating severe cognitive decline. Record review of Resident #2's baseline care plan, date printed 8/19/2025, revealed the following: Resident demonstrates wandering and/or exit-seeking behavior placing self at risk for elopement or injury, had elopement on 7/4/2025. Record review of Resident #2's progress notes revealed the following documentation, dated 7/4/2025 at 1:12 PM by LVN D: Resident was seen 5 Minutes before this nurse went into nurses station restroom, after this nurse

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment, to include maintenance services necessary to maintain comfortable and safe temperature levels, for 1 of 1 facility reviewed for a safe, clean, comfortable, and homelike environment, in that: The facility presented with 2 Heating Ventilation and Air Conditioning systems [HVAC], of which 1 HVAC was not functioning causing cold interiors during the winter season. An IJ was identified on [DATE]. The IJ template was provided on [DATE] at 07:04 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. This deficient practice placed residents at risk for harm by a diminished quality of life. The Finding were: The HVAC systems did not use 2 of 4 corridors (A Hall and B Hall) for a portion of the return air supply, inspected for return air supply. Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment. Record review revealed the facility had received a Waiver Approval letter dated [DATE] for Corridor Return Air, which had expired on [DATE] and that renewal documents had been submitted during the [DATE] survey period. Observations between on [DATE] between 10:00 a.m. to 11:00 a.m. revealed rooms on A Hall and B Hall were provided with ducted supply air but not with return air intakes. The return air intakes for the HVAC system were located in the corridors outside the rooms, causing the corridors to serve as a part of the return air system for the adjoining areas. During an exit interview on [DATE] at 5:00 p.m., when questioned as to the use of the A and B Halls being used as return air for the HVAC System, the Administrator said that she knew of the return air use in the aforementioned areas and that the facility had a waiver, as issued on [DATE] by the CMS for a three-year period (expired [DATE]). When asked if he knew the waiver had expired, the Administrator said he did and asked that it be renewed. Record review of the past air temperatures for San [NAME], Texas. In [DATE] the average high air temperature was 91-92 degrees Fahrenheit [F]. In [DATE], [DATE]-21, 2023, was 105 degrees F. The air temperature for [DATE] was 94-97 degrees F. In [DATE] the average high air temperature was 97 degrees F and with humidity was over 100 degrees F. This summer the county had 74 days of 100 degrees F, and over, ambient air temperatures. Observations on [DATE] at 9:50 AM with Maintenance Director X conducted environmental rounds of the facility and stated the temperatures should be between 71-81 degrees F. Observations were made of Residents gathered in the main dining room for the activity of Bingo. The Maintenance Director X stated the #1 HVAC unit was not working for a while, the HVAC unit serviced the A and B halls, which included the main dining room. The Maintenance Director X stated he had set the #1 HVAC unit to heat when he learned residents were going to have bingo in the main dining room. The Maintenance Director X stated he was not sure why the #1 HVAC was not at a good temperature and will notify the Administrator. Further observations and temperature records revealed the main dining room was 62.6 degrees F. At 10:20 AM the main dining the air temperature room was 54.9 degrees F. At 10:22 AM in the C end section of hall, the air temperature was 58.0 degrees F. At 10:23 AM in the C start of hall, the air temperature was 67.3 degrees F. At 10:26 AM in the D Hall, at start of hall (memory care unit), the air temperature was 69.3 degrees F. At 10:37 AM in the D Hall, at end of hall, the air temperature was 67.8 degrees F. Interview on [DATE] at 11:25 AM with the Administrator stated he was notified of the air temperature in the A and B Halls by the Life Safety Code surveyor (LSC) and was not aware that the C and D Halls were not heating for residents. No other reply. Interview on [DATE] at 10:06 AM with the ADON stated the HVAC system was having issues since earlier this year, 2023, either May or [DATE]. The ADON stated the resident families first noticed and reported the staff, that was when the facility was testing air temperatures. The facility brought in mobile Air Conditioning units. The ADON stated they discovered the A Hall (previous secure unit) was not cooling and was hot, so they moved those residents to the B Hall . Then the ADON stated the facility noticed the B Hall was not cooling, so the residents were moved to another part of the facility in May or June of 2023. They had a low census at the time. The facility moved the residents who resided on the A Hall secured unit to the first half of the D Hall and the rest of the residents moved to the second half of D Hall and other residents to the C Hall . A record review of the facility's Homelike Environment policy dated February 2021, revealed, policy statement; residents are provided with a safe, clean, comfortable and home like environment and encouraged to use their personal belongings to the extent possible. policy interpretation and implementation; the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, home like setting. these characteristics include; . comfortable and safe temperatures (71-81 degrees F) . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 07:04 PM. The Administrator was notified. The Administrator was provided with the IJ template on [DATE]. The following Plan of Removal was accepted on [DATE] at 03:10 PM. Immediate Jeopardy PLAN OF REMOVAL [DATE] Immediate Action: - Bids to repair the HVAC system currently out of order are being obtained from [HVAC Contractors]. The ceiling will be secured and repaired as part of the HVAC project. - Is a goal as far as a date to accept a bid by? All bids to be submitted by [DATE]. - Anticipated date of repair? Contractor will be approved to begin work on or before [DATE]. - What is being done in the meantime to ensure residents have a comfortable living environment? No residents currently reside in the area affected by the A/C outage. For the occupied areas of the building, random temperature checks will be taken twice daily (in the morning and in the afternoon/evening) to ensure temperatures are within acceptable range. If temperature is outside limits, thermostats will be adjusted (switched from cooling to heated and vice-versa) as needed. Temperature checks will be completed on regular weekdays by the maintenance director or designee, and on weekends/holidays by the receptionist. The administrator or designee will review the daily temperature logs for completeness and compliance. Plan of Removal Verification [DATE] Record review of several contract bids for HVAC repair. Record review of daily temperature logs, dated [DATE], revealed the morning temperatures were within range for all areas of the facility that were utilized and occupied, apart from the main dining room, which was 64.4 degrees F. The action documented by the facility to remedy the low temperature in the main dining room was switching the HVAC system from A/C to Heat. Further record review of the afternoon/evening temperature logs revealed all temperatures in appropriate ranges for all utilized and occupied areas of the facility. Record review of daily temperature logs, dated [DATE], revealed temperatures to be within appropriate range as required by Appendix PP. Observation on [DATE] at 11:30 AM with Administrator rounded halls for air temperatures revealed Hall D, Hall C and main dining room as required. Observation on [DATE] at 3:45 PM revealed temperatures in all utilized and occupied areas of the building to be as required by the Appendix PP. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 6:49 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that the residents' environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 facility and 18 of 18 residents (Resident #1, #4 , #12, #14, #17, #23, #25, #38, #40, #41, #47, #48, #52, #56, #60, #64, #66, and #67) reviewed for accident hazards and supervision, in that: 1. Residents (Resident # 1, #4, #12, #14, #17, #23, #25, #38, #40, #41, #47, #48, #52, #56, #60, #64, #66, and #67) were residents who resided on the facility's memory care unit and needed supervision and safety monitoring due to their diagnoses of dementia and wander / elopement risks and were without staff care and or supervision, without secured entry exit doors, and without secured windows on 11/17/2023. 2. The facility developed an entrapment hazard when the facility did not effectually disable the electronic locking doors at the previous memory care unit. 3. The facility did not have a functioning call light system for the whole facility - Halls A, B, C, and D. 4. The facility did not have a secured door at the loading dock entry and exit door near Hall D. An IJ was identified on 11/17/2023. The IJ template was provided on 11/17/2023 at 07:04 PM. While the IJ was removed on 11/19/2023, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions These failures could place residents at risk for harm by elopement, entrapment, and neglect. The findings included: 1. Resident #1 A record review of Resident #1's admission record dated 11/18/2023 revealed an admission date of 09/19/2017 with diagnoses which included dementia with behavioral disturbance [not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities]. A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #1's care plan dated 11/18/2023 revealed, Resident resides on the memory care unit date Initiated: 07/24/2022, Revision on: 05/16/2023 .Resident's safety will be maintained through next review date .Monitor Resident per protocol to ensure safety . A record review of Resident #1's elopement risk assessment dated [DATE] revealed Resident #01 was assessed as a High Risk for elopement. A record review of Resident #1's physicians' order, dated 01/18/2023, revealed, Admit to secured unit. A record review of Resident #1's Clinical Census report dated 11/18/2023 revealed Resident #1 resided in the facility's D Hall, in the memory care unit. Resident #4 A record review of Resident #4's admission record dated 11/18/2023 revealed an admission date of 10/19/2021 with diagnoses which included dementia and schizophrenia [serious mental illness that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality]. A record review of Resident #4's quarterly MDS assessment dated [DATE] revealed Resident #0 was an [AGE] year-old male admitted for long term care and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #4's care plan dated 11/18/2023 revealed, Resident resides on the memory care unit date Initiated: 07/17/2022, Revision on: 05/16/2023 .Resident's safety will be maintained through next review date .Monitor Resident per protocol to ensure safety . A record review of Resident #4's elopement risk assessment dated [DATE] revealed Resident #4 was assessed as a High Risk for elopement. A record review of Resident #4's physicians' order, dated 01/18/2023, revealed, Admit to secured unit. A record review of Resident #04's Clinical Census report dated 11/18/2023 revealed Resident #04 resided in the facility's D Hall, in the memory care unit. Resident #12 A record review of Resident #12's admission record dated 11/18/2023 revealed an admission date of 05/03/2021 with diagnoses which included Alzheimer's disease [a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment]. A record review of Resident #12's quarterly MDS assessment dated [DATE] revealed Resident #04 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 05 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #12's care plan dated 11/18/2023 revealed, Resident resides on the memory care unit date Initiated: 07/17/2022, Revision on: 05/16/2023 .Resident's safety will be maintained through next review date .Monitor Resident per protocol to ensure safety . A record review of Resident #12's elopement risk assessment dated [DATE] revealed Resident #12 was assessed as a High Risk for elopement. A record review of Resident #12's physicians' order, dated 01/18/2023, revealed, Admit to secured unit. A record review of Resident #12's Clinical Census report dated 11/18/2023 revealed Resident #12 resided in the facility's D Hall, in the memory care unit. Resident #14 A record review of Resident #14's admission record dated 11/18/2023 revealed an admission date of 12/15/2021 with diagnoses which included dementia. A record review of Resident #14's quarterly MDS assessment dated [DATE] revealed Resident #14 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 04 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #14's care plan dated 11/18/2023 revealed, Resident resides on the memory care unit date Initiated: 07/24/2022, Revision on: 05/16/2023 .Resident's safety will be maintained through next review date .Monitor Resident per protocol to ensure safety . A record review of Resident #14's elopement risk assessment dated [DATE] revealed Resident #14 was assessed as a Moderate Risk for elopement. A record review of Resident #14's Clinical Census report dated 11/18/2023 revealed Resident #14 resided in the facility's D Hall, in the memory care unit. Resident #17 A record review of Resident #17's admission record dated 11/18/2023 revealed an admission date of 01/05/2023 with diagnoses which included dementia and Alzheimer's disease. A record review of Resident #17's quarterly MDS assessment dated [DATE] revealed Resident #17 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #17's care plan dated 11/18/2023 revealed, Resident resides on the memory care unit date Initiated: 02/07/2023, Revision on: 05/16/2023 .Resident's safety will be maintained through next review date .Monitor Resident per protocol to ensure safety . A record review of Resident #17's elopement risk assessment dated [DATE] revealed Resident #17 was assessed as a Moderate Risk for elopement. A record review of Resident #17's Clinical Census report dated 11/18/2023 revealed Resident #17 resided in the facility's D Hall, in the memory care unit. Resident #23 A record review of Resident #23's admission record dated 11/16/2023 revealed an admission date of 08/11/2023 with diagnoses which included dementia and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]. A record review of Resident #23's quarterly MDS assessment dated [DATE] revealed Resident #23 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #23's care plan dated 11/18/2023 revealed, Resident resides on the memory care unit date Initiated: 10/03/2023, .Resident's safety will be maintained through next review date .Monitor Resident per protocol to ensure safety . A record review of Resident #23's elopement risk assessment dated [DATE] revealed Resident #23 was assessed as a Moderate Risk for elopement. A record review of Resident #23's Clinical Census report dated 11/18/2023 revealed Resident #23 resided in the facility's D Hall, in the memory care unit. Resident #25 A record review of Resident #25's admission record dated 11/16/2023 revealed an admission date of 01/21/2015 with diagnoses which included dementia [not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities] and [serious mental illness that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality]. A record review of Resident #25's quarterly MDS assessment dated [DATE] revealed Resident #25 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 07 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #25's care plan dated 11/18/2023 revealed, Resident resides on the memory care unit date Initiated: 07/24/2022, .Resident's safety will be maintained through next review date .Monitor Resident per protocol to ensure safety . A record review of Resident #25's elopement risk assessment dated [DATE] revealed Resident #25 was assessed as a High Risk for elopement. A record review of Resident #25's Clinical Census report dated 11/18/2023 revealed Resident #25 resided in the facility's D Hall, in the memory care unit. Resident #38 A record review of Resident #38's admission record dated 11/15/2023 revealed an admission date of 04/13/2021 with diagnoses which included dementia. A record review of Resident #38's quarterly MDS assessment dated [DATE] revealed Resident #38 was an [AGE] year-old male admitted for long term care and assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #38's care plan dated 11/18/2023 revealed, The Resident [#38] has impaired cognitive function/dementia or impaired thought processes Dementia Date Initiated: 08/23/2022 .Cue, reorient and supervise as needed. A record review of Resident #38's elopement risk assessment dated [DATE] revealed Resident #38 was assessed as a Moderate Risk for elopement. A record review of Resident #38's Clinical Census report dated 11/18/2023 revealed Resident #38 resided in the facility's D Hall, in the memory care unit. Resident #40 A record review of Resident #40's admission record dated 11/16/2023 revealed an admission date of 05/07/2021 with diagnoses which included dementia. A record review of Resident #40's quarterly MDS assessment dated [DATE] revealed Resident #40 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #40's care plan dated 11/18/2023 revealed, Resident [#40] resides on the memory care unit Date Initiated: 06/27/2022 .Resident's safety will be maintained through next review date . Monitor Resident per protocol to ensure safety. A record review of Resident #40's elopement risk assessment dated [DATE] revealed Resident #40 was assessed as a High Risk for elopement. A record review of Resident #40's Clinical Census report dated 11/18/2023 revealed Resident #40 resided in the facility's D Hall, in the memory care unit. Resident #41 A record review of Resident #41's admission record dated 11/16/2023 revealed an admission date of 10/03/2023 with diagnoses which included Alzheimer's disease. A record review of Resident #41's quarterly MDS assessment dated [DATE] revealed Resident #41 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #41's care plan dated 11/18/2023 revealed, Resident [#41] resides on the memory care unit Date Initiated: 07/24/2022 .Resident's safety will be maintained through next review date . Monitor Resident per protocol to ensure safety. A record review of Resident #41's physicians' order, dated 10/04/2023, revealed, May reside on a secured unit. A record review of Resident #41's elopement risk assessment dated [DATE] revealed Resident #41 was assessed as a High Risk for elopement. A record review of Resident #41's Clinical Census report dated 11/18/2023 revealed Resident #41 resided in the facility's D Hall, in the memory care unit. Resident #47 A record review of Resident #47's admission record dated 11/17/2023 revealed an admission date of 06/03/2021 with diagnoses which included Alzheimer's disease and dementia with behavioral disturbance. A record review of Resident #47's quarterly MDS assessment dated [DATE] revealed Resident #47 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 02 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #47's care plan dated 11/18/2023 revealed, Resident [#47] resides on the memory care unit Date Initiated: 07/24/2022 .Resident's safety will be maintained through next review date . Monitor Resident per protocol to ensure safety. A record review of Resident #47's physicians' order, dated 01/18/2023, revealed, Admit to secured unit. A record review of Resident #47's elopement risk assessment dated [DATE] revealed Resident #47 was assessed as a Moderate Risk for elopement. A record review of Resident #47's Clinical Census report dated 11/18/2023 revealed Resident #47 resided in the facility's D Hall, in the memory care unit. Resident #48 A record review of Resident #48's admission record dated 11/17/2023 revealed an admission date of 06/06/2021 with diagnoses which included dementia with behavioral disturbance. A record review of Resident #48's quarterly MDS assessment dated [DATE] revealed Resident #48 was a [AGE] year-old male admitted for long term care and could not complete a BIMS assessment and was assessed with disorganized thinking - ( .the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). A record review of Resident #48's care plan dated 11/18/2023 revealed, Resident [#48] resides on the memory care unit Date Initiated: 05/16/2023 .Resident's safety will be maintained through next review date . Monitor Resident per protocol to ensure safety. A record review of Resident #48's elopement risk assessment dated [DATE] revealed Resident #48 was assessed as a High Risk for elopement. A record review of Resident #48's Clinical Census report dated 11/18/2023 revealed Resident #48 resided in the facility's D Hall, in the memory care unit. Resident #52 A record review of Resident #52's admission record dated 11/17/2023 revealed an admission date of 11/01/2021 with diagnoses which included Alzheimer's disease. A record review of Resident #52's quarterly MDS assessment dated [DATE] revealed Resident #52 was a [AGE] year-old female admitted for long term care and could not complete a BIMS assessment and was assessed with disorganized thinking - .the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). A record review of Resident #52's care plan dated 11/18/2023 revealed, Resident [#52] resides on the memory care unit for wandering and being at risk for placing self in unsafe place Date Initiated: 07/21/2022 .Resident's safety will be maintained through next review date .Initiated: 05/16/2023 .Monitor Resident per protocol to ensure safety . A record review of Resident #52's elopement risk assessment dated [DATE] revealed Resident #52 was assessed as a Moderate Risk for elopement. A record review of Resident #52's Clinical Census report dated 11/18/2023 revealed Resident #52 resided in the facility's D Hall, in the memory care unit. Resident #56 A record review of Resident #56's admission record dated 11/15/2023 revealed an admission date of 08/12/2022 with diagnoses which included dementia with behavioral disturbance [not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities]. A record review of Resident #56's quarterly MDS assessment dated [DATE] revealed Resident #56 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 01 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #56's care plan dated 11/18/2023 revealed, Resident [#56] resides on the memory care unit for elopement risk. He has a history of wandering into other residents' rooms and going outside unattended. Date Initiated: 07/26/2022 .Resident's safety will be maintained through next review date. Date Initiated: 05/16/2023 .Monitor Resident per protocol to ensure safety A record review of Resident #56's elopement risk assessment dated [DATE] revealed Resident #56 was assessed as a High Risk for elopement. A record review of Resident #56's Clinical Census report dated 11/18/2023 revealed Resident #56 resided in the facility's D Hall, in the memory care unit. Resident #60 A record review of Resident #60's admission record dated 11/17/2023 revealed an admission date of 12/02/2022 with diagnoses which included dementia [not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities]. A record review of Resident #60's quarterly MDS assessment dated [DATE] revealed Resident #60 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 05 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #60's care plan dated 11/18/2023 revealed, Resident [#60] resides on the memory care unit for elopement risk. He has a history of wandering. Date Initiated: 12/08/2022 .Resident's safety will be maintained through next review date. Date Initiated: 05/16/2023 .Monitor Resident per protocol to ensure safety A record review of Resident #60's elopement risk assessment dated [DATE] revealed Resident #60 was assessed as a Moderate Risk for elopement. A record review of Resident #60's Clinical Census report dated 11/18/2023 revealed Resident #60 resided in the facility's D Hall, in the memory care unit. Resident #64 A record review of Resident #64's admission record dated 11/17/2023 revealed an admission date of 11/28/2022 with diagnoses which included violent behavior, cognitive social or emotional deficit following cerebral infarction [stroke]. A record review of Resident #64's quarterly MDS assessment dated [DATE] revealed Resident #64 was a [AGE] year-old male admitted for long term care and could not complete a BIMS assessment and was assessed with disorganized thinking - .the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). A record review of Resident #64's care plan dated 11/18/2023 revealed, Resident [#64] resides on the memory care unit for elopement risk. He has a history of wandering. Date Initiated: 12/12/2022 .Resident's safety will be maintained through next review date. Date Initiated: 05/16/2023 .Monitor Resident per protocol to ensure safety A record review of Resident #64's elopement risk assessment dated [DATE] revealed Resident #64 was assessed as a Moderate Risk for elopement. A record review of Resident #64's Clinical Census report dated 11/18/2023 revealed Resident #64 resided in the facility's D Hall, in the memory care unit. Resident #66 A record review of Resident #66's admission record dated 11/17/2023 revealed an admission date of 01/05/2023 with diagnoses which included dementia with behavioral disturbance [not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities] and delusional disorders. A record review of Resident #66's quarterly MDS assessment dated [DATE] revealed Resident #66 was a [AGE] year-old female admitted for long term care and could not complete a BIMS assessment and was assessed with disorganized thinking - .the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). A record review of Resident #66's care plan dated 11/18/2023 revealed, Resident [#66] resides on the memory care unit for elopement risk. He has a history of wandering. Date Initiated: 02/03/2023 .Resident's safety will be maintained through next review date. Date Initiated: 05/16/2023 .Monitor Resident per protocol to ensure safety A record review of Resident #66's elopement risk assessment dated [DATE] revealed Resident #66 was assessed as a Moderate Risk for elopement. A record review of Resident #66's Clinical Census report dated 11/18/2023 revealed Resident #66 resided in the facility's D Hall, in the memory care unit. Resident #67 A record review of Resident #67's admission record dated 11/17/2023 revealed an admission date of 04/21/2023 with diagnoses which included dementia [not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities]. A record review of Resident #67's quarterly MDS assessment dated [DATE] revealed Resident #67 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 07 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #67's care plan dated 11/18/2023 revealed, Resident [#67] resides on the memory care unit for elopement risk. He has a history of wandering. Date Initiated: 05/16/2023 .Resident's safety will be maintained through next review date. Date Initiated: 10/03/2023 .Monitor Resident per protocol to ensure safety A record review of Resident #67's elopement risk assessment dated [DATE] revealed Resident #67 was assessed as a Moderate Risk for elopement. A record review of Resident #67's Clinical Census report dated 11/18/2023 revealed Resident #67 resided in the facility's D Hall, in the memory care unit. During an observation on 11/14/2023 at 10:10 AM revealed the memory care unit housed in the first half of the D Hall presented with 18 residents (Residents #1, #4, #12, #14, #17, #23, #25, #38, #40, #41, #47, #48, #52, #56, #60, #64, #66, and #67). The memory care unit had 2 sets of double doors which were closed without the ability to lock and no alarm. All the windows in the memory care unit were 4 ½ inches off the floor and were able to fully open. Further observations revealed the memory care unit had a malfunctioning call light system which would sometimes illuminate a call light without sounds and sometimes would sound and not illuminate. During an interview on 11/14/2023 at 10:20 AM, LVN H and CNA U stated they were the LVN and CNA for the memory care unit which occupied the beginning of the D Hall. LVN H and CNA U stated the call light system had been malfunctioning for weeks. LVN H stated the staff paid attention to the lights and would round on residents frequently. CNA U and LVN H stated the entry exit doors were kept shut but had no locks on the doors which allowed residents and staff to freely pass through. LVN H stated when residents go out of the memory care unit staff redirect the residents back into the unit. LVN H and CNA U stated the memory care unit was set up sometime in the summer of 2023, due to the previous memory care unit, housed in A-Hall, was uninhabitable due to a faulty air-conditioner unit. LVN H and CNA U stated the previous unit had secured doors and windows and a functioning call light system. LVN H and CNA U stated the facility DON had knowledge of the unsecured doors and malfunctioning call light system. During and observation and interview on 11/14/2023 at 10:38 AM, LVN H and surveyor rounded on residents' rooms and revealed no windows were secured and could fully open. LVN H stated she was unaware the windows could fully open and could pose an elopement risk for residents. During an interview on 11/16/2023 at 1:30 PM, Resident #60's representative with power of attorney stated, Resident #60 is confused, young enough, and strong enough to open a window and get out .I expected the memory care unit to be safe and secure for my [Resident #60]. During an observation on 11/17/2023 at 6:28 AM revealed the memory care unit presented without any secured doors for entry and or exit of the memory care unit. Observation revealed a malfunctioning call light system where the call light panel at the nurse station continuously alarmed. Observation revealed 18 residents, [Resident #19 had been discharged ]; Residents #1, #4, #12, #14, #17, #23, #25, #38, #40, #41, #47, #48, #52, #56, #60, #64, #66, and #67, without staff care and or supervision. Further observation revealed no staff in the memory care unit after a room-to-room search which included a census of each Resident. Continued observation revealed residents ambulating throughout the unit with some residents asleep in their bedrooms. During an observation and interview on 11/17/2023 at 6:40 AM revealed Restorative Aide S entered the memory care unit and stated she was not assigned to care for residents in the memory care unit but was just dropping by to check on residents. RA S stated there were no staff in the memory care unit and she would stay until someone would arrive. During an interview on 11/17/2023 at 6:41 AM LVN B and CNA AA stated they were scheduled to work the D Hall from 11:00 PM to 7:00 AM. LVN B stated CNA F was scheduled to work the memory care unit from 11:00 PM to 6:00 AM and CNA AA was scheduled to care for the rest of the residents on the D Hall who were not residents of the memory care unit. LVN B stated the residents on the memory care unit should have supervision by CNA U who was assigned to relieve CNA F. LVN B stated he was unaware CNA U was not working in the memory care unit. LVN B stated sometimes LVN U was late. LVN B stated no one had reported to him there was no staff in the memory care unit. LVN B stated residents could have eloped and or been injured without staff supervision. LVN B stated he could not be in 2 places and had nursing duties at the end of the non-memory care unit, D Hall. CNA AA stated she was unaware the memory care unit had no staff and was responsible for providing resident care in the non-memory care d-hall. During an observation and interview on 11/17/2023 at 7:00 AM revealed LVN H and CNA U at the facility's time clock. CNA U did not identify herself as CNA U and LVN H stated CNA U should have relieved CNA F at 6:00 AM and stated CNA U had a history of being absent for care in the memory care unit. During an interview on 11/17/2023 at 10:06 AM with the ADON stated the HVAC system was having issues since earlier this year, 2023, either May or June 2023. The ADON stated the resident families first noticed and reported the staff, that was when the facility was testing air temperatures. The facility brought in mobile Air Conditioning units. The ADON stated they discovered the A Hall (previous secure unit) was not cooling and was hot, so they moved those residents to the B Hall . Then the ADON stated the facility noticed the B Hall was not cooling, so the residents were moved to another part of the facility in May or June of 2023. They had a low census at the time. The facility moved the residents who resided on the A Hall secured unit to the first half of the D Hall and the rest of the residents moved to the second half of D Hall and other residents to the C Hall. During an interview on 11/17/2023 at 11:10 AM Staffing Coordinator G stated CNA U had not called in late and his expectation was for CNA U to relieve CNA F. During an interview on 11/17/2023 at 5:02 PM the ADON stated he was unaware the memory care unit was without staff on the morning of 11/17/2023 at 6:00 AM. The ADON stated the expectation was for a staff member to be supervising, caring, and monitoring the residents in the memory care unit and should not leave the unit until the staff member has been relieved by the next staff member. During an interview on 11/18/2023 at 2:22 PM CNA F stated she was scheduled to work 11:00 PM to 6:00 AM in the memory care unit and was usually relieved by CNA U. CNA F stated sometimes she just leaves because CNA U was not there to relieve her at 6:00 AM. CNA F stated LVN B Knows. During an interview on 11/18/2023 at 3:02 PM CNA U stated she did not call anyone to alert them of her tardiness. CNA U stated she had not seen CNA F or LVN B when she arrived on 11/17/2023 at 6:00 AM and stated she had left the memory care unit to use the bathroom. 2. During an observation on 11/16/2023 at 5:35 PM revealed the A Hall previous location of the memory care unit. The path to the unit was clear and unencumbered to any pedestrian or person who used a wheelchair and or walker. The doors to the A Hall presented closed with an electronic keypad adjacent. The doors freely opened without the use of the keypad and locked behind after entry into the unit. Further observation did not reveal any way of exit. The surveyor became entrapped and used the emergency fire exit to exit the A Hall. During an observation and interview on 11/16/2023 at 5:50 PM the Administrator and the Maintenance Director received a report from the surveyor of the entrapment incident. The Administrator and the Maintenance Director demonstrated the secured locked double doors to the A Hall and utilized the keypad to release the locked doors. The Administrator requested the Maintenance Director to enter the secured A Hall and re-set the alarming fire exit door. The Maintenance Director entered the A Hall, the secured doors locked after his entry, he reset the fire alarm door and returned to the locked doors to the A Hall, entered in the code at the keypad to release the doors and exited the A Hall. Upon the Maintenance Directors exit and after the doors shut, the Administrator, to demonstrate the function of the locked door, pushed upon the door and revealed the door op[TRUNCATED]