**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 remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 1 residents (Resident #1) reviewed for accidents and supervision in that: The facility failed to supervise Resident #1 who eloped from the facility on 08/16/25 and was gone from the facility for more than nine hours and found in a closed car and had sustained a heat stroke. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 08/16/2025 and ended on 08/16/2025. The facility had corrected the non-compliance before the survey began on 08/17/2025. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings included: Review of Resident's #1 face sheet, dated 8/17/25, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: multiple sclerosis (a condition in which nerve damage affects the communication between the brain and body), type 2 diabetes mellitus (a condition in which the body's blood sugar was not controlled), and unspecified dementia (a condition in which there is a decline in cognition). Record review of Resident #1's quarterly MDS assessment, dated 7/29/25, revealed a blank BIMS score, indicating the resident could not complete the interview. The MDS revealed that Resident #1 was ambulatory and had wandering behavior. Record review of Resident #1's elopement assessment, dated 1/16/25, revealed Resident #1 had the potential for wandering behavior and was at risk for elopement. Record review of Resident #1's care plan, initiated on 1/16/25, revealed Resident #1 had an identified risk for elopement behavior. The interventions for elopement behavior included close supervision, reporting of risk factor such as wandering behavior and requests to leave the facility to the MD, and increased monitoring. The care plan for Resident #1 was updated on 8/16/25 to include the elopement incident. Record review of Physician Order Summary, dated 8/16/25, revealed Resident #1 was taking Depakote Sprinkles 125 mg for (General Anxiety Disorder), Humalog SQ 100 unit/ML for (Diabetes Mellitus), Metformin HCI 500 MG for (Diabetes Mellitus) and Lantus SQ 300 unit for (Diabetes Mellitus). Record review of the facility incident report, dated 8/16/25, revealed Resident #1 eloped from the facility at 5:10 am and that staff first learned of the incident at 7:30 am and a search on the secure unit was initiated with a Code Orange being called at 9:00 am. Record review of the National Weather Service weather data (https://www.weather.gov/wrh/Climate?wfo=ewx) for 8/16/2025 revealed a high temperature that day of 98 degrees Fahrenheit. Record review of the employee statement from CNA P, dated 8/16/25, revealed she said she took out the trash on the secure unit side door shortly after 11:10 pm on 8/15/25 and made sure the door was locked. Record review of the employee statement from LVN B, dated 8/16/25, revealed he said he took out the trash on the morning of 8/16/25 thru the gate in the courtyard and made sure the courtyard gate was closed. The actual time in the morning was not specified on the statement. Observation of the facility's camera footage revealed Resident #1 exiting the secure unit thru the side door on 8/16/25 at 5:04 am and thru the courtyard gate at 5:10 am. Record review of the facility's actual elopement exercise for Resident #1 revealed the drill was initiated on 8/16/25 at 7:30 am and cleared at 2:55 pm. During an interview with Family Member A on 8/17/25 at 8:00 am, Family Member A stated Resident #1 had gotten out of the facility's secure unit door shortly after 5:00 am on 8/16/25 and was not located until 2:30 pm on 8/16/25. Family Member A stated Resident #1 was found by family members inside of a closed car on a private residence that was one block from the facility. Family Member A stated Resident #1 was then transported to the hospital from this location. Family Member A stated Resident #1 would be returned to the same nursing home facility. During an interview with hospital RN B on 8/17/25 at 9:00 am, hospital RN B stated Resident #1 was admitted to the hospital with a diagnosis of heat stroke. Hospital RN B stated Resident #1 would be given IV fluids along with Magnesium, Potassium, and Electrolytes. During an interview with Resident #1 on 8/17/25 at 9:10 am at her hospital room she stated she did not know where she was currently at or what had happened to her on 8/16/25. During an interview with Family Member C on 8/17/25 at 9:15 am, Family Member C stated she was told by the facility administrator that the side door on the secure unit apparently had a malfunction in its locking mechanism which allowed for Resident #1 to be able to leave the facility. Family Member C stated she was told by the Administrator the cameras on the secure unit were not fully operational at the time of Resident #1's elopement on 08/16/25. Family Member C stated Resident #1 would be returning to the same nursing facility upon hospital discharge. Record review of the facility's staff checklist in-service log dated 8/16/25 revealed that 100 percent of the staff had received the in-service on abuse/neglect, elopement protocol, and ensuring exit doors and gates were locked. Record review of the facility's secure unit resident head count form dated 8/17/25 revealed the protocol for the charge nurse on the secure unit conducting the resident head count. Record review of the facility's secure unit resident rounding form completed by Nurses and CNA staff revealed that the form is completed at the end of the shift. Record review of the facility's care plan listing report revealed that all of the residents on the secure unit had their care plan updated on 8/16/25 for elopement status. Record review of the facility's elopement policy in the Nursing Policy and Procedure Manual WA-03-2.0 revealed the intervention steps for staff to take in conducting an internal and external search for a missing resident as well as the need for staff to manually check all exit doors and outside gates for closure and alarm viability. Record review of the facility's Code Orange Drill Elopement Guide that was undated revealed the steps and notifications that staff are to follow when searching for a missing resident. Record review of the facility's process change form dated 8/16/25 revealed the following updates:a. The side door on the secure unit used by Resident #1 to exit the facility is now permanently secured and closed.b. All secure unit door codes were changed.c. Nurse will conduct hourly resident head counts on the unit.d. CNA and Nursing staff will complete resident head counts at the end of their respective 8 hour and 12-hour shifts.e. The Maintenance Director or designated person (Manager on Duty for the weekends) will check all exit doors and outside gates for alarm viability twice a day).f. Nursing staff completed elopement assessments on all residents.g. Care plans were updated for all residents on elopement risks.h. A spring was added on the outside court- yard gate to increase the automatic closure ability of the gate.i. The elopement policy, abuse/neglect policy, and door/gate closure protocol were reviewed with 100 percent of the staff. Record review of the facility's maintenance log exit door check completed on 8/18/25 at 8:30 am revealed all facility exit doors were alarmed. During an interview with the DON on 8/17/25 at 10:15 am, the DON stated that she believed Resident #1 was able to exit the secure unit thru a side door that had a malfunction on the locking mechanism. The DON stated Resident #1 was last seen on the secure unit at 4:00 am and the resident had a habit of wandering into other resident rooms. The DON stated the facility staff began an internal search of the facility for Resident #1 on 08/16/25 at 7:30 am and the official Code Orange was called at 9:00 am. The DON stated 100 percent of the facility's staff had been in-serviced on 8/16/25 on the elopement protocol which included the steps to undertake to complete an internal and external search for missing resident. The DON stated that the in-service also included the need to staff to manually check all facility exit doors and outside gate to ensure that they were closed and alarmed. During an interview with the Administrator on 8/17/25 at 8/17/25 at 11:20 am, the Administrator stated he felt the locking mechanism on the side door on the secure unit malfunctioned which allowed Resident #1 to exit the building. The Administrator stated that courtyard gate was not properly secured which allowed Resident #1 to go thru that gate to the outside. The Administrator stated that he believed a nurse working on a different unit had left the courtyard gate open and that nurse was suspended. The Administrator stated that Resident #1 was last seen on the secure unit at 4:00am and had a habit of wandering into other resident rooms. The Administrator stated that the facility staff began an internal search for Resident #1 on 8/16/25 at 7:30 am and the official Code Orange was called at 9:00 am. The Administrator stated the facility had new cameras installed and the cameras on the secure unit were recording but the playback from the cameras was not fully operational until 8/17/25. The Administrator stated 100 percent of the facility's staff had been in-serviced on 8/16/25 on the elopement protocol which included the steps to undertake to complete an internal and external search for missing resident. The Administrator stated that the in-service also included the need to staff to manually check all facility exit doors and outside gate to ensure that they were closed and alarmed. During an interview with the Maintenance Director on 8/17/25 at 12:20 pm, the Maintenance Director stated he was not sure how Resident #1 had exited the building thru the side door on the secure unit. He stated that he had checked that exit door on 8/15/25 and the alarm was functioning properly. The Maintenance Director stated during the elopement search on 8/16/25 he checked both the side door of the secure unit in which Resident #1 had exited the building as well as the courtyard gate and both were closed and alarmed. During an interview with CNA D on 8/17/25 at 1:15 pm, CNA D stated she had assisted in the elopement search for Resident #1. CNA D stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with LVN E on 8/17/25 at 1:20 pm, LVN E stated she had assisted in the elopement search for Resident #1. LVN E stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with ADON F on 8/17/25 at 1:35 pm, ADON F stated she had assisted in the elopement search for Resident #1. ADON F stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. ADON F stated during the elopement search she had gone to the side door on the secure unit, and it was properly locked. During an interview with CNA G on 8/17/25 at 1:40 pm, CNA G stated she had assisted in the elopement search for Resident #1. CNA G stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with Housekeeper H on 8/17/25 at 1:50 pm, Housekeeper H stated she had assisted in the elopement search for Resident #1. Housekeeper H stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with LVN I on 8/17/25 at 2:00 pm, LVN I stated she had worked as the Charge Nurse during the night shift on 8/16/25 and did not observe Resident #1 leave the unit. LVN I stated she had not participated in the elopement search but had been re-in-serviced on abuse/neglect, elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with RN J on 8/17/25 at 2:20 pm, RN J stated she had assisted in the elopement search for Resident #1. RN J stated that she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with CNA K on 8/17/25 at 2:25 pm, CNA K stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with RN L on 8/17/25 at 2:30 pm, RN L stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with CNA M on 8/17/25 at 2:35 pm, CNA M stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with CNA N on 8/17/25 at 2:40 pm, CNA N stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with CNA O on 8/17/25 at 2:45 pm, CNA O stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. CNA O stated she had worked on the night shift in which Resident #1 had eloped on 8/16/25. CNA O stated she did not remember when she had last seen Resident #1 but that it could have been at 4:00 am, whenever Resident #1 received incontinent care in her room. During an observation with the Administrator and Maintenance Director on 8/18/25 from 8:05 am until 8:30 am all of the facility's exit doors and outside gates were checked for closure and alarm viability and found to be in good working order. The Administrator and Maintenance Director stated that all facility exit doors and outside gates would be checked twice a day seven days a week for closure function and alarm viability. Record review of the facility's policy titled, Nursing Policy and Procedure Manual TG 03-1.0, undated, revealed that Neglect; is the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 6 residents (Resident #1), reviewed for quality of care. The facility failed to supervise Resident #1 who eloped out of a side door of the facility on 2/17/25 at approximately 7:12 p.m. without staff knowledge, through a side door that the alarm had been turned off on and was found ambulating down the sidewalk approximately 400 feet from the facility. An Immediate Jeopardy was identified as past noncompliance on 4/23/25. The IJ began on 2/17/25 and ended on 2/18/25. The facility had corrected the noncompliance before the survey began. This failure could put residents at risk of accidents, and could result in serious injury, harm, impairment, and death. The findings were: Record review of Resident #1's face sheet dated 4/22/25 revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE] with readmission on [DATE]. The resident's diagnoses included non-traumatic subarachnoid hemorrhage, unspecified (bleeding in the space below one of the thin layers that cover and protect your brain not caused by caused by, or associated with trauma), schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), muscle weakness, and other abnormalities of gait and mobility (abnormal walking pattern and the ability to move freely, coordination). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 3 out of 15 indicating the resident was severely cognitively impaired. The resident had no behaviors and no wandering. The resident used a walker and was independent for lying to sitting on side of bed, required supervision, or touching assistance to stand, transfer, and walk 150 feet. Record review of Resident #1's undated care plan revealed a focus initiated on 2/18/25 for the resident to reside in the secure unit due to elopement, and the resident had an actual elopement. Interventions included encourage the resident to participate in activities and monitor for statements of wanting to go home or leave the facility and wandering, and to stay with the resident and notify the charge nurse if exit seeking. (There were no focus's for wandering or exit seeking prior to this incident). Record review of Resident #1 Elopement risk assessment, dated 1/11/25, had a score of 0 indicating the resident was not an elopement risk. (1-9 not a risk, 10 or greater is an elopement risk). Record review of the facility PIR for intake #565261 dated 2/24/25 revealed on 2/17/25 at approximately 7:12 p.m. the facility was notified Resident #1 had left the building by another resident sitting outside. The DON went out the front door and noted the resident walking with her walker on the sidewalk on the same side of the street as the facility walking towards local chicken restaurant next door to the facility. The DON caught up to Resident #1 at approximately 7:20 pm as she was walking down the sidewalk. The DON stayed with the resident and staff brought a wheelchair for the resident and she was back in the facility at 7:28 pm. The resident stated she was going home. The resident was assessed by the DON to have no injuries. The resident was placed on 1:1 supervision until she was moved to the secure unit. The MS checked all facility doors on 2/17/25 at approximately 8:20 p.m. and found the double doors by the B wing by the dining room were not functioning properly and were immediately fixed. Record review of Resident #1's event nurses' note for elopement dated 2/17/25 by the DON revealed she was notified by receptionist Resident #1 had left the building through double doors and was not out of the building more than 15 minutes. The Resident's physician who was also the facility Medical Director and the resident's RP were notified and the resident was moved to the secure unit. Record review of Resident #1's progress notes revealed a nurses' note dated 2/17/25 at 7:56 p.m. by the DON she was notified by the receptionist Resident #1 was outside the facility and she observed her walking on the sidewalk on the same side of the street as the facility and she was redirected back to the facility with no visible injuries. In an observation and interview on 4/22/25 at 11:10 a.m. Resident #1 was lying in bed on top of her covers and was dressed in a t-shirt and pants. Facility staff had assisted Resident #1's roommate and was leaving the room. Resident #1 was alert and oriented to person only. Resident #1 was unable to answer questions about the elopement. The resident stated she was happy living here and liked to watch the birds through the windows, felt safe, and liked the staff pointing to a staff member at the doorway and calling her by the wrong name and stated, she's good people and smiled. The resident was able to communicate well in English despite preferring Spanish. In an interview on 4/22/25 at 3:05 p.m. The DON stated on 2/17/25 at approximately 7:12 p.m. the receptionist was notified by another resident that was sitting outside that Resident #1 had been walking up the sidewalk on the side of the kitchen and lobby but still in front of the facility due to the shape of the building. The DON stated she immediately went out the front door and observed the resident walking on the sidewalk with her walker headed towards local chicken restaurant on the right next door to the facility. The DON stated she was unsure of the timeframes but it did not take her long to catch up to the resident. The DON stated Resident #1 was still in front of the facility on the edge of the property line when she caught up with her. The DON stated the resident did not cross the driveway into the local chicken restaurant that interrupted the sidewalk immediately after the facility fence line. The DON stated she pulled out her phone and called staff who brought out a wheelchair and she brought Resident #1 back inside the facility by wheelchair without resistance or issues. The DON stated Resident #1 had told her she was going home. The DON stated she assessed Resident #1 and she had no injuries. The DON stated she had notified the physician and RP and received verbal consent from the resident's RP to move the resident to the secure unit and the resident was moved that same evening, not sure of the time. The DON stated ADM D was notified and the MS came to the facility at about 8:20 p.m. and checked all the facility doors and found something wrong with the double doors between B wing and the dining room and they were immediately fixed and all doors rechecked and were working properly and all door codes were changed as well. The DON stated she started in-servicing staff the same night on 2/17/25 on ANE, Elopement response policy/code orange, and staff were not allowed to work until training was completed. The DON stated Resident #1 was not an elopement risk prior to this incident the resident would go places in the facility but did not attempt to elope. In an observation and interview on 4/23/25 at 12:30 p.m. the MS stated when he was checking the door alarms on the night of 2/17/25 he found the double doors between B hall and the dining room were not alarmed and had been turned off. He showed me the red stop sign box attached to the doors with a key slot and the words off and on next to the key slot. The key slot was turned to the on position. The MS demonstrated without disarming the alarm that a key had to be inserted to turn it from on to off and vice versa. The MS stated all the nurses had keys to turn the alarm off as well as himself and he was unsure of who else had keys. The MS then showed me the secondary alarms that were placed on all facility exit doors and the secure unit on 2/18/25 and stated they cannot be turned off and the alarms sound the entire time the doors were open. This was demonstrated by opening the secure unit doors after entering the code to enter, an alarm sounded until the door was closed. In an interview on 4/23/25 at 5:00 p.m. the ADM C stated he was not the Administrator at the time of this incident and was hired about 4 weeks ago, around 3/14/25. The ADM C stated he had continued with the elopement plan of action and had further trained staff on ANE and notifications to be made. In an interview on 4/25/25 3:05 p.m. the MS stated he knew the door alarms were working as they had been checked that day on 2/17/25. The alarmed door that was turned off was what the facility calls the kitchen staff emergency exit. The MS stated the front facility entrance already had a secondary alarm. The MS stated the push button release for the front entrance door was relocated on 2/18/25 to a hidden place inside the receptionist desk and mounted in place with screws and the drawer is locked and the receptionist has the key. Review of the facility policy on elopement prevention revised January 2023 indicated under environmental modification . 4. Use door alarms or monitoring devices to notify staff when residents try to leave the facility. It was determined the failure placed Resident #1 in an IJ situation on 4/23/25. The ADM C was notified on 4/23/25 at 3:18 p.m., that a PNC IJ had been identified due to the above failure. The facility implemented the following interventions: 1. Resident #1 was placed on 1:1 monitoring and then moved to the secure unit on 2/17/25. 2. All facility doors were checked and all alarms were verified to be on and working on 2/17/25. 3. The DON began in-servicing all staff on 2/17/25 for ANE, elopement response policy/code orange, elopement prevention policy, and door alarm safety, and staff were not allowed to work until training was completed. 4. On 2/17/25 at 8:50 pm an off-cycle QAPI by phone was conducted with the DON and Medical Director. 5. On 2/18/25 an ADHOC QAPI review of corrective action plan was conducted. 6. All new staff to be in-serviced during orientation and agency staff to have training prior to working if used. 7. On 2/18/25 Elopement risk assessments were completed and evaluated for changes on all residents in the facility. 8. On 2/18/25 secondary alarms were placed on all alarmed doors that cannot be turned off. 9. Door alarm checks daily and as needed 5 times weekly x 4weeks. 10. 5 staff members to be interviewed 3 times weekly on elopement prevention and response 5 times weekly for 4 weeks. Review of facility signature sheet for ADHOC QAPI meeting on 2/18/25 had 14 attendees and included the facility Medical Director, corporate compliance nurse, DON, ADON, director of rehabilitation, MDS nurse, SW, housekeeping, dietary, and nursing staff. Record review of elopement drills revealed drills were completed on 2/18/25, 2/21/25, 2/20/25, 2/28/25, and 3/19/25. Review of facility staff list revealed 8 newly hired staff from 2/17/25 to 4/23/25 employee files reviewed revealed they were ADM C, staff PP, QQ, RR, CNA SS, staff TT, UU, and CNA VV. The orientation training packet was included and signed by each staff for ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills training was completed. In interviews conducted on 4/24/25 starting at 11:27 p.m. to 4/25/25 at 12:22 a.m., 11 interviews of the night shift staff RN CC, LVN NN, LVN P, LVN DD, LVN Z, CNA X, CNA II, CNA S, CNA JJ, CNA R, and CNA U stated they had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and were able to state appropriate responses. During these interviews LVN NN, RN CC, CNA S, and CNA II stated they had been participants in elopement drills recently. Record review of the facility door alarm check log completed by MS or maintenance staff revealed they were completed daily on all wings on 2/17/25 through 2/24/25, 2/24/25 (different time) through- 2/27/25, 3/2/25, 3/10/25 through 3/14/25, 3/17/25 through 3/21/25, 3/24/25 through 3/28/25, 3/31/25 through 4/4/25, and 4/7/25 through 4/11/25. In an interview on 4/22/25 at 4:09 p.m. LVN E (6a-6p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In interviews conducted on 4/23/24 starting at 10:30 a.m. to 11:20 a.m. staff from shifts (7a-3p)- AA, Q, OO, FF, W, EE (6a-6p)- BB, LVN KK (8a-5p)- HH, MM, RN V, RN LL, and Y all stated they had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and were able to state appropriate responses. In an interview on 4/23/25 at 10:03 a.m. RN I (6a-6p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/23/25 at 3:26 p.m. the SW (8a-5p) stated he had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/23/25 at 5:10 p.m. CNA O (3p-11p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/24/25 at 11:43 a.m. staff M (8a-5p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/24/25 at 12:04 p.m. RN L (6a-6p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/24/25 at 12:15 p.m. CNA H (3p-11p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/24/25 at 12:50 p.m. LVN J (6a-6p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/24/25 at 1:15 p.m. CNA T (7a-3p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/24/25 at 3:30 p.m. CNA N (3p-11p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/25/25 at 11:22 a.m. LVN GG (6a-6p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse, neglect and misappropriation of property for 2 of 6 residents (Residents #2 and #3) reviewed for abuse, in that: 1. The facility failed to protect Resident #2 from physical abuse when Resident #1 grabbed, scratched and hit Resident #2 during a smoke break on [DATE]. The facility failed to respond to develop a plan of care, behavior monitoring, interventions or train staff on behaviors to prevent further abuse. 2. The facility failed to protect Resident #3 from physical and psychological abuse when Resident #1 repeatedly hit Resident #3 in the face and head and scratched him on [DATE] which resulted in swelling, redness, bruising to Resident #3's left eye, scratches to his face, neck, chest and arms and trauma. On [DATE] Resident #1 was arrested and charged with a class three felony for abuse of an elderly and currently resided in a local jail waiting indictment. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 8:17 p.m. While the IJ was removed on [DATE] at 6:57 p.m., the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to monitor the implementation of the plan of removal. These deficient practices could affect all residents and place them at risk for abuse, trauma, psychosocial harm, injuries, hospitalization and/or death. The findings included: 1. Record review of form 3613-A Provider Investigative Report dated [DATE] revealed the facility self-report of a resident-to-resident altercation and listed it as incident category other. The report indicated on [DATE] at 4:00 p.m., Resident #1 was found rummaging through another resident's purse during smoke break. Resident #2 intervened to remove the purse from Resident #1. Resident #1 slowly inched his way to Resident #2 striking him several times which resulted in scratches to neck, chest, bilateral arms (both arms) and ripping a small hole in Resident #2's shirt. A former Administrator (Administrator AA) marked the investigation as inconclusive. The facility documented their response as self-report protocols, in-service and re-education of staff initiated for abuse/neglect policy and an AD HOC QAPI meeting held. Record review of Resident #1's face sheet, dated [DATE], revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, schizophrenia and depression. Record review of Resident #1's hospital records for admission to the facility, dated [DATE], revealed Diagnosis, Assessment and Plan revealed [AGE] year-old male NF resident with history significant for schizophrenia, cirrhosis of the liver, behavior disorder and dementia brought to the ED for further evaluation of altered mental status. The physician documented he reviewed the electronic medical records from the previous NF that showed Resident #1 had a history of dementia, major depressive disorder, schizoaffective disorder, anxiety disorder, behavioral disturbance and epilepsy. On page 39 of hospital document titled discharge planning: revealed hospital case manager documented Resident #1's previous NF declined to accept Resident #1 back to their facility because they were concerned about the safety of the other residents. Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 12 which indicated a moderate cognitive impairment without behaviors or evidence of acute change in mental condition. Resident #1's functional status was listed as dependent on staff for ADL care, use of a wheelchair without assessment of transferring or walking functionality. Record review of Resident #1's Nurse Progress Note, dated [DATE] documented by RN C, revealed Resident #1 was seated in his wheelchair in the TV room .noted to have his right hand in a brown backpack on the sofa area. Seen with a soda and 1 dinner item. Verified the bag belonged to a staff (unspecified). Resident #1 advised not to take belongings of other. He stated he understood. Record review of Resident #1's Nurse Progress Noted, dated [DATE], revealed Resident #1 observed entering other resident's room and eating his jalapeno pork skins. Redirected to TV room and reminded not to enter other rooms. Resident pleasant and denies altered mental status. Record review of Resident #1's Physician's Progress Note, dated [DATE], revealed Nurses report some behaviors including going into other resident rooms and taking their things, requesting a visit for psychiatric services. Record review of Resident #1's Care Plan, last revised on [DATE], revealed Resident #1 required anti-psychotic and anti-depressant medications with interventions which included: monitor/record occurrence of target behavior systems (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. The care plan did not address any resident behaviors or behavior management. Record review of Resident #1's Nurse Progress Notes, dated [DATE], revealed Resident #1 entered other resident rooms and eats their snacks. Record review of Resident post-incident assessment, dated [DATE], revealed the AD came to nurses' station to inform nurse of an altercation between Resident #2 and another resident that occurred during smoke break. Resident #2 assessed and had noticeable random scratches to neck, chest, bilateral arms and had a torn shirt at the neckline. Resident had no complaints of pain. The assessment noted Resident #2 statement of the event He picked up her purse and hid it and I got it back and gave it back to resident's owner (sic) and the (sic) just started hitting and scratching me! Record Review of Resident #1's Nurse Progress Notes, dated [DATE], revealed LVN B documented that staff (unnamed) reported to nurse that Resident #1 had a physical altercation with another resident while in the smoking area. When asked what happened, Resident #1 stated He started it. Staff reported that Resident #1 had picked up a purse and was getting into it when another resident [Resident #2] took it from him. Resident #1 then stood up and began to hit and scratch the other resident causing scratches and a small bruise under the right eye, redness to the scratched areas and a torn shirt. The residents were separated, and Resident #1 was brought inside. He had no visible injuries. Record review of Resident #1's [DATE] MAR/TARs revealed no evidence of behavior monitoring. Record review of Resident #1's Psychological Initial Assessment, dated [DATE] (after incident with Resident #2 but before the incident with Resident #3), revealed diagnoses treating was antisocial personality disorder. Reason for referral: agitation, irritability, anger, paranoia, physical aggression. RN reports Resident #1 had been stealing from other patients at times and also becomes aggressive. Risk of aggression: None. Insight: Fair. Judgement: Fair. Short term memory: mildly impaired. Long-Term memory: intact. This document was signed by the psychological services physician. Record review of Resident #1 Psychological Services Progress Note, dated [DATE] (after incident with Resident #2 but before incident with Resident #3), revealed aggressive behavior was listed as none. Patient was polite. Patient reports having nothing to talk about and having no problems, struggles or worries. Patient displays depressive symptoms. This document was signed by psychological services LPC. Record review of Resident #2's face sheet, dated [DATE], revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: sequelae of cerebral infarction, hemiplegia (stroke with resulting paralysis on one side of the body) affecting right dominant side and schizoaffective disorder bipolar type and mild neurocognitive disorder due to known physiological condition with behavioral disturbance. Record review of Resident #2's Care Plan, last revised on [DATE], revealed the resident had wandering behaviors. No other behaviors were part of the plan of care. Record review of Resident #2's Nurse Progress Notes, dated [DATE], revealed Resident #2 was involved in an altercation during smoke break with Resident #1. Resident #2 was not faulted for the incident. Resident #1 was found rummaging through another resident's purse (unnamed). Resident #2 intervened to remove the purse from Resident #1. Resident #1 slowly inched his way to Resident #2, striking him several times, scratching him and ripping a small hole in his shirt. AA D (Activity Assistance D) and Laundry Attendant E peacefully diffused the incident, separating bath parties, Charge nurses notified, DON notified of incident. Documented by AA D. Record review of Resident #2's Psychiatric Clinical Treatment Plan, dated [DATE], revealed he was assessed for current mood and anxiety symptoms to ascertain current emotional functioning and process thoughts and feelings relative to recent physical altercation with another resident. The assessment listed his anxiety was moderate and rated as increased, his emotional withdrawal was listed as moderate and rated as increased, hostility was labeled as moderate and rated as increased and tension was labeled as moderate and rated as increased. The assessment noted he was moderately cognitively impaired. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 6 which indicated a severe cognitive impairment, with continuously present behaviors which included inattention, disorganized thinking and altered level of consciousness but no physical, verbal or other behaviors exhibited. Resident #2's functional status was recorded as independent with walking and transferring. During an interview on [DATE] at 11:01 a.m., AA D stated he was responsible for supervising smoke break ([DATE]) when the incident between Resident #1 and Resident #2 occurred. He stated he believed it was the 4:00 p.m. smoke break but could not be certain. He stated another staff in housekeeping (identified as LA E) was also there taking her own personal break. AA D stated it started when one of the female residents left the smoking area because she said it was too hot and she wanted to go back inside where it was cooler, but she left her purse behind on the floor. AA D stated he saw Resident #1 bend over and go through something on the floor. He stated before he could get to Resident #1, he saw Resident #2 grab a purse from Resident #1. Resident #2 then handed the purse to him (AA D). AA D stated, after Resident #2 handed him the purse, both residents sat back down and resumed the smoke break. He stated a little bit later, Resident #1 was quiet and calm but started inching closer and then suddenly took some swipes at Resident #2 but made no contact. AA D stated Resident #1 then grabbed Resident #2 by his shoulder, scratching him in the process. AA D stated both staff immediately pulled the two residents apart and both calmed down quickly. AA D stated Resident #1 stopped his aggressive behavior. AA D stated there had been no other altercations between the two residents who both attended every smoke break. He stated they had never exhibited any aggressive behaviors before. AA D stated he had been told by the nurse (unknown) on Resident #1's unit that Resident #1 had a history of stealing but was not told of any aggressive behaviors. He stated he had been in-serviced on abuse/neglect, reporting and treating residents with respect. He stated he was working on an on-going computerized training program for dementia residents called [NAME] which he believed stood for personal assistance care training. He stated he had not received any facility in-service or training on dealing with physical aggression or behavioral interventions. During an interview on [DATE] at 11:25 a.m., Resident #2 stated he remembered the incident with the purse ([DATE]). He stated he grabbed the purse from that other resident (Resident #1) because it did not belong to him. Resident #2 pointed to his right shoulder and chest indicating where he had been scratched by Resident #1. He stated he feels fine, no pain. Resident #2 stated he thought Resident #1 left because he had not seen him and there were no further incidents with the resident. He stated he felt safe at the facility. During an interview on [DATE] at 11:29 a.m., LVN B stated Resident #1 was very hard to understand. She stated Resident #1 could be aggressive, but she had never had any problems with him. She stated when he would get upset, she would talk to him to calm him down. LVN B stated Resident #1 did have a bad habit of going into other residents' rooms and stealing and he smoked a lot. LVN B stated she was informed he had an altercation with another resident in the smoking area. She stated she could not remember when this occurred or whom the other resident was. She stated she didn't remember a lot about the resident but does remember he could be talked down. LVN B stated for interventions she just kept an eye on him and tried to keep him separated to keep other residents safe. LVN B stated Resident #1 was not like that all the time, just certain things would make him agitated. She stated Resident #1 did not go up to people with no reason. LVN B stated she does not recall if anyone in management gave her any interventions or instructions. LVN B stated she was not sure anything was in his care plan about it. After looking at his care plan, LVN B stated there was nothing in Resident #1's care plan about his klepto or behaviors. LVN B stated she doesn't really use care plans for resident care . She stated she gets to know the residents and their personality and that was how she knows how to care for them. LVN B stated she was trained to separate residents who had conflict and then assess them, speak to both parties and then let the DON and Administrator know and also report to the RP. Record review of Resident #15's face sheet, dated [DATE], revealed an admission date of [DATE] and a readmission date of [DATE] with diagnoses which included: Alzheimer's disease, recurrent depressive disorders and unsteadiness on feet. Record review of Resident #15's Annual MDS, dated [DATE], revealed a BIMS score of 12 which indicated a moderate cognitive impairment. During an interview on [DATE] at 10:48 a.m., Resident #15 stated Resident #1 had sticky fingers (slang term to indicate someone who steals). Resident #15 stated Resident #1 would go into other residents' rooms and had stolen many things. He stated Resident #1 stole some $1 bills from his wallet in his room . He stated he told staff (unknown) and was told to keep his wallet put away and not in the open. He stated it was a resolved issue, but he was glad Resident #1 was gone. Resident #15 stated Resident #1 did not belong at the facility. He stated he had not witnessed any aggression or abuse. He stated he felt safe at the facility. During an interview on [DATE] at 11:00 a.m., CNA G stated she had not witnessed him be mean to residents. She stated she never worked directly with Resident #1. but he was mean (to staff). She stated when she went to check on him, he would tell her to get out and did not want help. She stated she had not received any training on resident behaviors. She stated she did not get any training following either incident with Resident #1. She stated if a resident had a behavior or acted aggressive, she would just go get the nurse to intervene. CNA G stated if she witnessed resident's arguing she would get in between them and try to get the aggressor away and let the nurse know. She stated if she saw a physical incident, she would go get help. She stated she was taught to tell the charge nurse and then let the administrator know if she saw abuse. Record review of Resident #4's face sheet, dated [DATE], revealed an admission date of [DATE] and readmission date of [DATE] with diagnoses which included: end stage renal disease with dependence on renal dialysis, major depressive disorder single episode moderate and generalized anxiety disorder. Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 00 which indicated a score could not be obtained. During an interview on [DATE] at 11:08 p.m., MA P stated Resident #1 demeanor was quiet. She stated he mumbled a lot. She stated she was in the building following Resident #1's altercation in the smoking area. She stated after the altercation he kept saying I am going to fuck you up. She stated the staff talked to him to get him to calm down and she told him it was considered assault what he did. She stated prior to this event she had never seen him with anger issues. MA P stated Resident #1 was a klepto (used as a slang word in this context, which is a shortened version of the word kleptomania, not the actual diagnosis of a mental health disorder. Kleptomania is a mental health disorder where a person feels an uncontrollable urge to steal things.). She stated he particularly targeted Resident #4's room for stealing. MA P stated Resident #4 went to dialysis three days a week and was gone from the facility a lot. She stated Resident #1 would go into Resident #4's room and steal his stuff. She stated after the second or third time the staff told the DON, and nothing was done. MA P stated the DON said she would speak to him (Resident #1) and the DON told the staff to watch him but nothing changed. MA P stated the CNA's had to handle it themselves. She stated they tried to keep an eye on Resident #1, and she kept Resident #4's door shut. She stated they would also give Resident #4's iPad to the nurses to lock up in their cart when Resident #4 was away. MA P stated she had received behavior training in [DATE]. She stated it was a computer-based training. She stated the training discussed how to interact with residents and how to report behaviors. She stated she was told to intervene and redirect and how to identify aggression when it first started. She stated she was also trained on abuse and was told to report abuse to the charge nurse, then the ADON and DON. Record review of Resident #53's face sheet, dated [DATE], revealed an admission date of [DATE] and readmission date of [DATE] with diagnosis which included: quadriplegia (paralysis of all 4 extremities), major depressive disorder and nicotine dependence. Record review of Resident #53's Annual MDS, dated [DATE], revealed a BIMS score of 15 which indicated the resident was cognitively intact. During an interview on [DATE] at 11:31 a.m., Resident #53 stated he had witnessed the incident involving Resident #1 and Resident #2 ([DATE]). He stated they were all out smoking as usual when a female resident started moving herself in her wheelchair towards the door to go back inside and dropped her purse on the ground. He stated the female resident did not appear to be know she had dropped her purse. Resident #53 stated he saw Resident #1 go towards the purse and start going through it. He stated he then saw Resident #2 get up and grab the purse, hand it to AA D and then sit back down. Resident #53 stated Resident #1 did not do anything at first, he was quiet. He stated a few minutes later he saw Resident #1 scoot his wheelchair towards Resident #2 and then grab his shirt and started hitting him. Resident #53 stated AA D pulled Resident #1 off Resident #2. He stated they (staff) took Resident #1 back inside. Resident #53 stated he felt safe and would tell staff if anyone threatened or hurt him. During an interview on [DATE] at 12:49 p.m., the DON and Regional Compliance Nurse stated the interim Administrator was not in the building. They stated the Administrator was the Abuse Coordinator and staff were trained to report abuse to the Administrator. During an interview on [DATE] at 1:45 p.m., LA E stated she was present during the altercation between Resident #1 and Resident #2 smoke break. She stated she thought it was the 1:30 p.m. smoke break but could not be certain. She stated she was there on her own personal smoke break. She stated she and AA D were talking when she saw a female resident go inside, wheeling herself in her wheelchair, but dropped her purse along the way. She stated AA D had gone to let the female resident inside, when she saw Resident #1 move toward the purse. She stated Resident #2 grabbed the purse from Resident #1 and handed it back to AA D. LA E stated Resident #1 was quiet for about 5 minutes and then started pushing himself in his wheelchair towards Resident #2. She stated as Resident #1 got closer to Resident #2, she saw Resident #1 saying something, like a whisper. She stated she could not hear what he was saying, but Resident #2 leaned forward to hear him. LA E stated Resident #1 stood up and grabbed Resident #2's shirt and started to hit him. She stated she did not know Resident #1 could stand before this occurred. She stated AA D moved Resident #1 away and she moved Resident #2 away and calmed him down by telling him it was going to be okay. LA E stated Resident #1 was moved inside and everyone calmed down. She stated she had not witnessed any other aggressive incidents between residents during smoke breaks and had not witnessed any other incidents involving Resident #1. LA E stated when she was first hired, she received training in abuse/neglect. She described abuse/neglect as a worker hitting a resident or not attending to their needs or even when two residents fought. She stated she was taught to report abuse/neglect immediately to the Administrator. She stated she had not received any training on how to deal with resident behaviors or fights. She stated she just followed her instinct to pull them apart when it happened. LA E stated she was frightened by Resident #1, but then was surprised when she saw both Resident #1 and Resident #2 together the next day at smoke break. She stated they acted like nothing had happened. 2. Record Review of Form 3613-A Provider Investigative Report dated [DATE] revealed the former Administrator self-reported resident-to-resident [abuse] under the category other for an incident that occurred on [DATE] at 5:50 p.m. between Resident #1 and Resident #3, The report indicated Resident #1 and #3 had a verbal altercation that lead to a physical altercation in which Resident #1 punched Resident #3 in the face while he was lying down and resulted in bruising under Resident #3's right eye, swelling aside {sic} of the right eye, and a scratch to the side of the right eyebrow. The report indicated the residents were separated and the aggressor (Resident #1) was placed on 1:1 supervision until police arrived and he was arrested. The investigative findings were listed as confirmed with a note that the aggressor (Resident #1) remained in jail at the time of the report and would not be allowed to return to the facility. The facility was conducting ongoing staff in-service on abuse, neglect and exploitation. Record review of Resident #1's Nurse Progress Notes, dated [DATE] at 5:45 p.m., ADON A documented while sitting in the dining room a CNA notified her that Resident #1 and another resident [Resident #3] had a verbal altercation. She told the CNA to move Resident #1 out of the room and the CNA agreed and stated okay. ADON A indicated she came back from the dining room and was at the nurses' station at 6:15 p.m., while the CNA was moving belongings into another room, she heard a scream for help and all staff ran to the room. ADON A documented Resident #1 was standing over [Resident #3] and throwing punches at the other resident's face. The CNA tried to stop Resident #1 as he continued to punch the other resident in the face. ADON A documented she grabbed Resident #1 by his shirt and pulled him off the other resident causing ADON A and Resident #1 to fall over the wheelchair. Resident #1 was breathing hard and was visibly mad at [Resident #3]. ADON A and the CNA assisted Resident #1 off the floor and back to his wheelchair and removed him from the room. He tried to go back into the room and continue to fight [Resident #3]. ADON A documented she told Resident #1 that she would call the police if he did not stop and he replied I don't care .ADON A notified the DON who stated to call 911. ADON A then notified Resident #1's physician who also stated to call 911. ADON A documented she called 911 and EMS to evaluation the other resident [Resident #3]. A report was made and (police) officers handcuffed Resident #1 while in the wheelchair and escorted him out of the building. Record review of Resident #1's Nurse Progress Notes, dated [DATE], at 8:22 p.m., ADON A documented Resident's #1's guardian was made aware that Resident #1 was arrested by police for attacking another resident [Resident #3] while the other resident was in bed and was currently at the magistrate's office. Record review of Resident #3's face sheet, dated [DATE], revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] and readmission date of [DATE] with diagnoses which included: senile degeneration of brain (dementia), schizoaffective disorder bipolar type (mental health disorder) and acquired absence of right leg below knee. Record review of Resident #3's Annual MDS, dated [DATE], revealed a BIMS of 5 which indicated a severe cognitive impairment with no behavior symptoms. A review of Resident #3's functional status revealed he used a wheelchair, was unable to walk or transfer himself and was totally dependent of staff for movement and ADL care. Record review of Resident #3's Care Plan, last revised on [DATE], revealed had a history of depression and impaired cognitive function related to dementia with impaired thought process with interventions which included monitor for changes in mood, discuss concerns for confusion and use task segmentation to support short term memory deficits. There were no behaviors documented in the plan of care. Record review of Resident #3's TAR for [DATE] revealed behavior monitoring with no behaviors documented on [DATE] (date of incident) or multiple days before and after the incident. Record review of Resident #3's Event Nurse's Note, dated [DATE], revealed Resident #1 was standing over the resident and was throwing punches at the other [Resident #3] face. An assessment was completed with notes of bruising under the right eye, swelling to the right cheek and scratch on the side of the right elbow. Tylenol was administered to Resident #3 for pain. Resident #3's physician was notified, and neuro checks were completed for 72 hours. Record review of Resident #3's Nurse Progress Notes, dated [DATE] documented by ADON A, revealed she was notified of a verbal altercation between Resident #1 and Resident #3 by a CNA. She instructed the CNA to move this resident (unspecified) out of the room and the CAN agreed and said OKAY. While sitting at the nurses' station after coming back from the dining room, she heard a scream for help and all staff ran to the room. She noted Resident #1 standing over Resident #3 throwing punches at his face. The CNA tried to stop the resident and he continued to punch .ADON A grabbed the resident (Resident #1) by the shirt and pulled the resident off the other resident causing them to fall over the wheelchair. After removing Resident #1 from the room, she notified Resident #3's physician and made her aware of the bruising under the right eye, swelling aside (sic) of the right eye, and scratch to the side of the right eyebrow. The physician did a video call with DON and resident (Resident #3), new order neuro's x 72 hours. Record review of Resident #3's Nurse Progress Notes, dated [DATE], revealed Resident #3 was alert and oriented to person, place but not day or time of day. Bruising noted around right orbital fossa (right eye). When asked what happened (sic) That guy that takes me stuff beat me up. I was telling him to stay out of my stuff (sic) he started hitting me. I tried to fight but I (sic) couldn't. The nurses took him away (sic) I am okay now. (sic) Record review of a local police report, dated [DATE], revealed Resident #1 was arrested and charged with Class 3 Felony Texas Penal Code 22.04 (A) (Injury to a child, elderly individual, or disabled individual). The report indicated the police responded to the NF for an assault in progress call. Upon arrival ADON A advised that Resident #1 and Resident #2 shared a room. ADON A advised Resident #3 was bedridden and could not get up on his own and Resident #1 used a wheelchair but could walk from time to time. She reported to police that Resident #1 and Resident #2 got into a verbal argument and Resident #1 had been removed from the room. She stated Resident #1 later returned to the room and she heard a disturbance. She stated when she went into the room, she observed Resident #1 standing over Resident #3's bed, punching Resident #3 multiple times. ADON A advised that her and other nurses had to physically pull Resident #1 away from Resident #3. The police report indicated police contacted Resident #3 who stated he was lying in bed when Resident #1 came into the room. Resident #3 stated they were arguing over whose diaper was changed first. Resident #3 stated Resident #1 went over to his bed and began punching him multiple times. The police officer documented he observed that Resident #3 had a black eye and that his eye was slightly swollen. EMS responded to the scene. The report indicated Resident #1 told police Resident #3 was talking shit about his family member who was deceased . Resident #1 admitted to assaulting Resident #3. The report indicated due to the victim (Resident #3) being [AGE] years of age, the suspect (Resident #1) was placed under arrest, transported to the city detention center and booked. During an interview on [DATE] at 10:47 a.m., Resident #1's legal guardian stated Resident #1 had been arrested at the NF was still in the local jail, charged with a third-degree felony with intent to cause bodily injury. The guardian stated when he had visited with Resident #1 in the past he always presented as very passive. The guardian stated that historically he was very aggressive. He stated he was unsure if the current NF was aware of Resident #1's history of aggression. He stated Resident #1 was discharged from the previous NF for aggression. He stated the previous NF took it upon themselves to discharge Resident #1 from their facility. He stated Resident #1 ended up at a local hospital and the hospital placed Resident #1 at the current NF. The legal guardian stated the incident that ended with Resident #1 in jail was not his first incident at the current NF. He stated he was notified of the incidents but was not given specific details. During an interview on [DATE] at 12:01 p.m., Resident #3's RP described Resident #3 as happy-go-lucky. She stated he liked to talk to people and touch them. She stated when people would pass by, he would hold his hand out to be touched. She stated Resident #3 did have a touch of dementia and had recently had a decline which worried her. She stated he never had any anger management problems. The RP stated staff from the facility had called her and told her Resident #3 had an altercation with a roommate. She stated she was told the roommate attached him while he was laying down and he suffered a black eye. She stated she did not see the eye or the bruises because she had not been able to visit during that time. She stated she did talk to him on the phone about the incident. The RP stated Resident #3 made a joke about it, in a macho sort of way. She stated he did not say anything else to her about the incident. She sta[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 4 residents (Residents #1, #2, and #3) reviewed for care plans, in that: 1. Facility failed to develop a person-centered care plan with interventions that addressed Resident #1's diagnoses of mental illness including depression, schizophrenia, dementia or antisocial personality disorder, and behaviors which included stealing, agitation, and aggression. 2. The facility failed to develop a person-centered care plan with interventions that addressed Resident #2's behaviors, specifically associated around smoke breaks, refusal of medications and mental illness or his altercation with Resident #1 associated with a smoke break and interventions to keep him safe from future events. 3. The facility failed to develop a person-centered care plan that addressed Resident #3's behaviors of screaming and crying out and cussing and his diagnosed mental illness, or his altercation with Resident #1 and follow up care for emotional evaluation/PTSD. An IJ was identified on 8/09/2024. The IJ template was provided to the facility on 8/09/2024 at 8:17 p.m. While the IJ was removed on 8/11/2024 at 6:57 p.m., 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 of the facility's need to monitor the implementation of the plan of removal. These deficient practices could affect residents and place them at risk for not having their needs and preferences met. The findings included: 1. Record review of Resident #1's face sheet, dated 8/08/2024, revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, schizophrenia (mental health disorder) and depression. Record review of Resident #1's hospital records for admission to the facility, dated 6/14/2024, revealed Diagnosis, Assessment and Plan revealed [AGE] year-old male NF resident with history significant for schizophrenia, cirrhosis of the liver, behavior disorder and dementia brought to the ED for further evaluation of altered mental status. The physician documented he reviewed the electronic medical records from the previous NF that showed Resident #1 had a history of dementia, major depressive disorder, schizoaffective disorder, anxiety disorder, behavioral disturbance and epilepsy. Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 12 which indicated a moderate cognitive impairment without behaviors or evidence of acute change in mental condition. The MDS assessment revealed related care area (CAA) triggers included cognitive loss/dementia, behaviors were not triggered on the assessment. Record review of Resident #1's Nurse Progress Note, dated 6/18/2024, revealed Resident #1 observed entering other resident's room and eating his jalapeno pork skins. Redirected to TV room and reminded not to enter other rooms. Resident pleasant and denies altered mental status. Record review of Resident #1's Nurse Progress Note, dated 6/20/2024, documented by RN C revealed Resident #1 was seated in his wheelchair in the TV room .noted to have his right hand in a brown backpack on the sofa area. Seen with a soda and 1 dinner item. Verified the bag belonged to a staff (unspecified). Resident #1 advised not to take belongings of other. He stated he understood. Record review of Resident #1's Physician's Progress Note, dated 6/25/2024, revealed Nurses report some behaviors including going into other resident rooms and taking their things, requesting a visit for psychiatric services. Record review of Resident #1's Care Plan, last revised on 6/25/2024, revealed Resident #1 required anti-psychotic and anti-depressant medications with interventions which included: monitor/record occurrence of target behavior systems (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. The care plan did not address any resident behaviors or behavior management. Record review of Resident #1's Nurse Progress Notes, dated 7/01/2024, revealed Resident #1 entered other resident rooms and eats their snacks. Record review of Resident post-incident assessment, dated 7/04/2024, revealed the AD came to nurses' station to inform nurse of an altercation between Resident #2 and another resident that occurred during smoke break. Resident #2 assessed and had noticeable random scratches to neck, chest, bilateral arms and had a torn shirt at the neckline. Resident had no complaints of pain. The assessment noted Resident #2 statement of the event He picked up her purse and hid it and I got it back and gave it back to resident's owner (sic) and the (sic) just started hitting and scratching me! Record Review of Resident #1's Nurse Progress Notes, dated 7/04/2024, revealed LVN B documented that staff (unnamed) reported to nurse that Resident #1 had a physical altercation with another resident while in the smoking area. Staff reported that Resident #1 had picked up a purse and was getting into it when another resident [Resident #2] took it from him. Resident #1 then stood up and began to hit and scratch the other resident causing scratches and a small bruise under the right eye, redness to the scratched areas and a torn shirt. Record review of Resident #1's Psychological Initial Assessment, dated 7/10/2024 (after incident with Resident #2 but before the incident with Resident #3), revealed diagnoses treating was antisocial personality disorder. Reason for referral: agitation, irritability, anger, paranoia, physical aggression. RN reports Resident #1 had been stealing from other patients at times and also becomes aggressive. Record review of Resident #1 Psychological Services Progress Note, dated 7/17/2024 (after incident with Resident #2 but before incident with Resident #3), revealed patient displays depressive symptoms. Record review of Resident #1's Nurse Progress Notes dated 7/23/2024 at 5:45 p.m., ADON A documented while sitting in the dining room a CNA notified her that Resident #1 and another resident [Resident #3] had a verbal altercation. She told the CNA to move Resident #1 out of the room and the CNA agreed and stated okay. ADON A indicated she came back from the dining room and was at the nurses' station at 6:15 p.m., while the CNA was moving belongings into another room, she heard a scream for help and all staff ran to the room. ADON A documented Resident #1 was standing over [Resident #3] and throwing punches at the other resident's face. The CNA tried to stop Resident #1 as he continued to punch the other resident in the face. ADON A documented she grabbed Resident #1 by his shirt and pulled him off the other resident causing ADON A and Resident #1 to fall over the wheelchair. Resident #1 was breathing hard and was visibly made at [Resident #3]. ADON A and the CNA assisted Resident #1 off the floor and back to his wheelchair and removed him from the room. He tried to go back into the room and continue to fight [Resident #3]. ADON A documented she told Resident #1 that she would call the police if he did not stop and he replied I don't care .ADON notified the DON who stated to call 911. ADON then notified Resident #1's physician who also stated to call 911. ADON A documented she called 911 and EMS to evaluation the other resident [Resident #3]. A report was made and (police) officers handcuffed Resident #1 while in the wheelchair and escorted him out of the building. Record review of a local police report dated 7/23/2024 revealed Resident #1 was arrested and charged with Class 3 Felony Texas Penal Code 22.04 (A) (Injury to a child, elderly individual, or disabled individual). Resident #1 admitted to assaulting Resident #3. The report indicated due to the victim (Resident #3) being [AGE] years of age, the suspect (Resident #1) was placed under arrest, transported to the city detention center and booked. During an interview on 8/07/2024 at 11:01 a.m., AA D stated he was responsible for supervising smoke break (7/04/2024) when the incident between Resident #1 and Resident #2 occurred. AA D stated it started when one of the female residents left the smoking area because she said it was too hot and she wanted to go back inside where it was cooler, but she left her purse behind on the floor. AA D stated he saw Resident #1 bend over and go through something on the floor. He stated before he could get to Resident #1, he saw Resident #2 grab a purse from Resident #1. Resident #2 then handed the purse to him (AA D). AA D stated, after Resident #2 handed him the purse, both residents sat back down and resumed the smoke break. He stated a little bit later, Resident #1 was quiet and calm but started inching closer and then suddenly took some swipes at Resident #2 but made no contact. AA D stated Resident #1 then grabbed Resident #2 by his shoulder, scratching him in the process. AA D stated both staff immediately pulled the two residents apart and both calmed down quickly. AA D stated Resident #1 stopped his aggressive behavior. AA D stated there had been no other altercations between the two residents who both attended every smoke break. He stated they had never exhibited any aggressive behaviors before. AA D stated he had been told by the nurse (unknown) on Resident #1's unit that Resident #1 had a history of stealing but was not told of any aggressive behaviors. During an interview on 8/09/2024 at 11:08 p.m., MA P stated she was in the building following Resident #1's altercation in the smoking area (with Resident #2). She stated after the altercation he kept saying I am going to fuck you up. She stated the staff talked to him to get him to calm down and she told him it was considered assault what he did. MA P stated Resident #1 was a klepto (used as a slang word in this context, which is a shortened version of the word kleptomania, not the actual diagnosis of a mental health disorder. Kleptomania is a mental health disorder where a person feels an uncontrollable urge to steal things.). She stated after the second or third time the staff told the DON, and nothing was done. MA P stated the DON said she would speak to him (Resident #1) and the DON told the staff to watch him but nothing changed. MA P stated the CNA's had to handle it themselves. She stated they tried to keep an eye on Resident #1, and she kept Resident #4's door shut. During an interview on 8/09/2024 at 11:29 a.m., LVN B stated Resident #1 could be aggressive, but she had never had any problems with him. LVN B stated Resident #1 did have a bad habit of going into other residents' rooms and stealing and he smoked a lot. LVN B stated she was informed he had an altercation with another resident in the smoking area. She stated she could not remember when this occurred or whom the other resident was. LVN B stated for interventions she just kept an eye on him and tried to keep him separated to keep other residents safe. LVN B stated she was not sure anything was in his care plan about it. After looking at his care plan, LVN B stated there was nothing in Resident #1's care plan about his klepto or behaviors/mental illness. LVN B stated she doesn't really sue care plans for resident care. She stated she gets to know the residents and their personality and that was how she knows how to care for them. LVN B stated charge nurses do not alter care plans and she was not sure who was responsible. During an interview on 8/09/2024 at 1:45 p.m., LA E stated she was present during the altercation between Resident #1 and Resident #2 smoke break. She stated she thought it was the 1:30 p.m. smoke break but could not be certain. She stated she was there on her own personal smoke break. She stated she and AA D were talking when she saw a female resident go inside, wheeling herself in her wheelchair, but dropped her purse along the way. She stated AA D had gone to let the female resident inside, when she saw Resident #1 move toward the purse. She stated Resident #2 grabbed the purse from Resident #1 and handed it back to AA D. LA E stated Resident #1 was quiet for about 5 minutes and then started pushing himself in his wheelchair towards Resident #2. She stated as Resident #1 got closer to Resident #2, she saw Resident #1 saying something, like a whisper. She stated she could not hear what he was saying, but Resident #2 leaned forward to hear him. LA E stated Resident #1 stood up and grabbed Resident #2's shirt and started to hit him. During an interview on 8/07/2024 at 10:47 a.m., Resident #1's legal guardian stated Resident #1 had been arrested at the NF was still in the local jail, charged with a third-degree felony with intent to cause bodily injury. The legal guardian stated the incident that ended with Resident #1 in jail was not his first incident at the current NF. He stated he was notified of the incidents but was not given specific details. 2. Record review of Resident #2's face sheet dated 8/10/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnosis which included: schizoaffective disorder bipolar type (mental illness with features of both schizophrenia and bipolar mood disorder with symptoms that include mania and heightened emotion). Major depressive disorder recurrent, generalized anxiety disorder, paranoid schizophrenia, paraphilia (preference for or obsession with unusual sexual practices) and mild neurocognitive disorder due to known physiological condition with behavioral disturbance (behavioral and psychological symptoms of dementia. Record review of Resident #2's Care Plan last revised on 4/29/2024 revealed the resident had wandering behaviors and exit seeking behaviors and resided in the locked unit. The care plan also addressed the use of antidepressant and anti-anxiety medication. The care plan did not address dementia or cognitive deficits related to understanding/communication, it did not address his mental health diagnoses and how to relate/approach/interventions for depression and anxiety and it did not address mental illness of schizoaffective disorder with bipolar symptoms and it did not address paraphilia or any behavior monitoring. The care plan also did not address Resident #2's altercation with another resident (Resident #1) with interventions to prevent recurrence. Record review of Resident #2's progress note, dated 6/20/2024, revealed Resident #2 actively involved in smoke break. He receives 5 smoke breaks daily. Behaviors (unspecified) present before the start of smoke break, nurse is aware. Record review of Resident #2's progress note, dated 6/21/2024, revealed he was refusing medications. Record review of Resident #2's progress note, dated 6/23/2024, revealed Resident refused all his medications this shift. Record review form 3613-A Provider Investigative Report, dated 7/04/2024, revealed the facility self-report a resident-to-resident altercation and listed it as incident category other. The report indicated on 7/04/2024 at 4:00 p.m., Resident #1 was found rummaging through another resident's purse during smoke break. Resident #2 intervened to remove the purse from Resident #1. Resident #1 slowly inched his way to Resident #2 striking him several times which resulted in scratches to neck, chest, bilateral arms (both arms) and ripping a small hole in Resident #2's shirt. A former Administrator (Administrator AA) marked the investigation as inconclusive. The facility documented their response as self-report protocols, in-service and re-education of staff initiated for abuse/neglect policy and an AD HOC QAPI meeting held. Record review of Resident #2's Nurse Progress Notes, dated 7/04/2024, revealed Resident #2 was involved in an altercation during smoke break with Resident #1. Resident #2 was not faulted for the incident. Resident #1 was found rummaging through another resident's purse (unnamed). Resident #2 intervened to remove the purse from Resident #1. Resident #1 slowly inched his way to Resident #2, striking him several times, scratching him and ripping a small hole in his shirt. AD (Activity Assistance D) and laundry attendant (LA-E) peacefully diffused the incident, separating bath parties, Charge nurses notified, DON notified of incident. Documented by AA D. Record review of Resident #2's Psychiatric Clinical Treatment Plan, dated 7/10/2024, revealed he was assessed for current mood and anxiety symptoms to ascertain current emotional functioning and process thoughts and feelings relative to recent physical altercation with another resident. The assessment listed his anxiety was moderate and rated as increased, his emotional withdrawal was listed as moderate and rated as increased, hostility was labeled as moderate and rated as increased and tension was labeled as moderate and rated as increased. The assessment noted he was moderately cognitively impaired. Record review of Resident #2's progress notes, dated 7/28/2024, revealed Resident #2 upset, yelling, being aggressive when told there was no one to take them to smoke. Resident yelling, cursing and demanding to smoke. Resident easily redirected to room. Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 6 which indicated a severe cognitive impairment, with continuously present behaviors which included inattention, disorganized thinking and altered level of consciousness but no physical, verbal or other behaviors exhibited. Resident #2's functional status was recorded as independent with walking and transferring. 3. Record review of Resident #3's face sheet, dated 8/08/2024, revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] and readmission date of 7/06/2024 with diagnoses which included: senile degeneration of brain (dementia), schizoaffective disorder bipolar type (mental health disorder), and anxiety disorder. Record review of Resident #3's Annual MDS, dated [DATE], revealed a BIMS of 5 which indicated a severe cognitive impairment with no behavior symptoms. Record review of Resident #3's Care Plan, last revised on 5/13/2024, revealed there were no behaviors documented in the plan of care and no interventions for behaviors. The Care Plan also did not address his mental health diagnosis of schizoaffective disorder bipolar type or diagnoses of anxiety. The care plan did not address Resident #3's altercation with another resident and/or interventions for potential PTSD. Record review of Resident #3's progress note dated 7/02/2024 revealed the resident was yelling Let me off this bus. During an interview on 8/09/2024 at 11:57 a.m., the MDS Coordinator stated she began working at the facility on 6/24/2024. She stated there were a lot of assessments (MDS) that were getting behind and since she was new some people in management had been helping her when she asked. She stated when a resident first admitted to the facility the admitting nurses completed a baseline care plan and then she does an admission assessment where she looks at the care plan. She stated she does care plans associated with assessments and the nurses were supposed to do acute care plans. She stated anything not acute and associated with an assessment would be her responsibility. She stated once admitted a comprehensive care plan should be completed by day 21. She stated she reviews all sorts of records for her assessments/care plans including admission records, history and physicals, therapy, nursing documentation, CNA documentation. She then does an interview with the resident or family member, social services, any ancillary services, and reviews dietary notes and assessments. She stated she took in all that knowledge for the MDS assessment and the care plan that followed. She stated she does not complete a physical examination of the resident. She stated she was taught that was not her role. She stated her role was to code what was documented by other nurses. She stated she was unsure if Resident #1's care plan was a baseline care plan or a comprehensive care plan. She stated she had not seen the facilities baseline care plans since she started working at the facility and did not know if the comprehensive was built on the baseline. She stated Resident #1 should have had a comprehensive care plan and acknowledge Resident #1, #2 and #3 were incomplete mental illness nor behaviors were care planned and it was her responsibility. She stated as of this interview, it was the first time she had looked at Resident #1's care plan. The MDS Coordinator stated when she went to write his care plan Resident #1 had already been discharged (7/23/2024) and she had not admitted him. She stated Resident #1 was not part of her assignment and was not on her radar. She stated she did not know who was responsible for completing Resident #1's care plan. The MDS Coordinator stated Resident #2 and Resident #3 did not have care plans that addressed their mental illness, behaviors or interventions. She stated the care plans of all residents should address their mental illness with interventions, not just management of their medication. She stated the facility used to have another MDS Coordinator, but she no longer worked at the facility. She stated she did not really have an assignment, she just worked on whomever was next. She stated Resident #1 was not due for a care plan. The MDS Coordinator stated she had heard about Resident #1's fight where he hit someone while they were in bed (Resident #3). She stated she did not realize there was a previous fight (Resident #2). She stated she did not remember and was not sure but she stated the two people were in the first fight were separated and were not in direct contact with each other so she could not say she would have put that in the resident's care plans. She stated she could not judge what she did not know. She stated it would have been important to add to the care plan so people could be aware Resident #1 was violent. The MDS Coordinator stated she had a lot of MDS assessments to complete and was getting behind. The MDS Coordinator stated she was aware there was a resident at the facility with stealing behaviors because she heard about it during morning meeting, but she did not know it was Resident #1. She stated they might have mentioned Resident #1's name during morning meeting but she was not good with names and could not remember. She stated multiple residents and behaviors were discussed during morning meetings. The MDS Coordinator stated Resident #1's stealing behaviors had not been care planned. The MDS Coordinator stated it was important for residents' behaviors and mental illness to be care planed because it was a behavior and that was reason alone. She stated they should have been care planned but she was completely overwhelmed by the RUGS/MDS system. She stated she was mostly focused on completing assessments and not on the care plans. . During an interview on 8/09/2024 at 11:19 p.m., CNA J stated Resident #1 had a temper and was always stealing money, tennis shoes and food, mostly from Resident #4. CNA J stated he stole tennis shoes from another resident (unknown name) and stole money from another resident. CNA J stated she told ADON A about the stealing and Resident #1 denied it. CNA J stated there was nothing on his Kardex (care plan) about his behaviors. During an interview on 8/09/2024 at 2:56 p.m., the SW stated he did have influence on the care plan and the social worker role was to add interventions especially if it was a social work goal or change in condition. He stated at this facility they documented interventions into the facility investigation incident report but not into the care plan. He said the incident is documented in a binder and not in a residents medical record. He stated he was told by a former administrator (unknown name, not current administrator) not to document behaviors in the care plan. He stated his role at the facility was case management. He stated Resident #3 did not have any behaviors that he was aware of but was grumpy at times. The SW stated the facility did not get much information about him initially because it was an emergency placement. He stated they reviewed the hospital records, and sometimes later, not at admission, they reviewed the records from his previous NF placement. The SW stated the records indicated he had a habit of theft, and he was moved from his last NF placement because he had an altercation at the NF and was either sent to jail or to the hospital. The SW stated the facility got Resident #1 from the hospital. He stated when he reviewed the reports from the previous facility the altercation was a physical altercation with unknown injuries. He stated other residents at the facility were telling him he was stealing. Staff were also reporting he was stealing. The SW stated Resident #1's behaviors were discussed during morning meetings. He stated the discussions were around what he had done. He stated they talked about what he had stolen, and which residents were accusing him of stealing. He stated they also discussed the incident between Resident #1 and #2. When asked if they discussed interventions to keep the other resident's safe the SW stated they encouraged other residents to keep their personal items put away. The SW stated Resident #1 did not have access to Resident #2 because Resident #2 resided in the locked unit and during smoke breaks, they encouraged them to sit farther away from each other. During an interview on 8/09/2024 at 4: 44 p.m., the DON said behaviors were discussed during morning meeting, and it was her expectation for the MDS Coordinator to document them in the residents' care plans. She stated behaviors were also discussed during evening stand down meetings (end of day meetings). The DON stated Resident #1's care plans should have been documented by a former MDS Coordinator. After reviewing the termination date of the former MDS Coordinator (6/22/2024), the DON stated she was not sure who was responsible. She stated she might have been a gap between, or one (MDS Coordinator) might of have in orientation for a few days. She stated right now the facility only had one MDS Coordinator. The DON stated the charge nurses completed the initial care plan and periodically reviewed the care plans as needed. She stated the care plan was part of the POC and Kardex for CNA's to review for care. She stated the staff should document behaviors in their notes, including CNA's who document in POC. The DON stated it was important for resident behaviors and mental illness to be care planned so they didn't have what they currently have going on (in reference to the investigation of the resident-to-resident abuse). She stated when Resident #1 first arrived at the facility he was fine. She stated he was going out for cigarette breaks. She stated on one of those smoke breaks Resident #1 found a purse and was going through it. She stated another resident, Resident #2 intervened and took the purse away. The DON stated Resident #1 retaliated by scratching Resident #2 all up on his arms and neck. The DON stated after this incident occurred, they kept an eye on Resident #1 during smoke breaks and in other areas. The DON stated most of the time Resident #1 was in a good mood. She stated Resident #1 thought everything belonged to him, which meant he stole items. She stated anything left out; he would take. The DON stated a CNA left her bag out and Resident #1 ate her lunch. The DON stated for interventions people were told to put things away and they monitored Resident #1. She stated monitored meant they just watched him through the day. The DON stated she did not think there was a place for staff to document the monitoring. The DON stated Resident #1 did not have any orders for behavior monitoring. She stated they were not doing behavior monitoring because the incident between Resident #1 and Resident #2 was a first-time occurrence and the incident was provoked by Resident #2 when he removed the purse from Resident #1. The DON stated she had not expected behaviors from Resident #1. She stated they were just watching him, not monitoring for behaviors. The DON stated the first time she became aware of the stealing behaviors was when Resident #1 stole the purse and when he stole the CNA's bag. The DON stated she did consider stealing a behavior, but they were just monitoring him as part of the incident reporting and not as part of Resident #1's medical record. The DON stated they had discussed behaviors during morning meetings and had expected the MDS Coordinator to document it in the care plan. The DON stated she expected the charge nurses to review the care plan upon admission and then periodically. She stated the care plan was part of POC and on the Kardex for the CNA's. The DON stated she would expect staff to respond to behaviors by following their dementia training which was to allow the resident space and allow them to calm down. The DON stated the facility was working on dementia training currently and it was not completed. The DON stated she expected the CNAs to report behaviors to the charge nurse and she expected the charge nurses to use basic nursing knowledge to intervene and was not based on interventions documented in a plan of care. The DON stated the staff should have taken Resident #2 out separately from Resident #1. She stated this was a verbal agreement with staff and not part of the care plan. The DON stated, IF I took something your you, you would probably act up too. It was an expected behavior. When asked about the other residents' safety the DON stated she did not feel like other residents were at risk The DON stated she had been monitoring UDAs for behaviors and had not seen any behaviors documented. When asked how she would see a UDA for behaviors if they were not monitoring for behaviors, she stated the ADON's look for behaviors in the medical record and she does the same. She stated if she saw a behavior in the medical record, she would tell the ADON to go check on it. During an interview on 8/12/2024 at 1:10 p.m., the Administrator stated she had been out of the facility from the time of surveyor arrival (8/07/2024) until today. She stated she was the interim Administrator until the facility could find a permanent Administrator. She stated she was hired on 7/20/2024 after the incidents between Resident #1 and #2 had occurred. She stated when she arrived, she did review and discuss the resident-to-resident altercations with the DON prior to surveyor arrival. The Administrator stated the nursing staff, SW and activities were responsible for the resident care plans. She stated all of them could alter/update the care plan. She stated the MDS Coordinator and IDT team provided oversight to ensure accurate and complete care plans. The Administrator stated the ADON and DON were responsible for monitoring nursing staff. She stated the DON could delegate quite a bit of her duties if needed. The Administrator stated the facility prevented harm by reviewing resident history, observation of resident behaviors. She stated everyone was responsible for resident safety. Record review of a facility policy, titled Behavior management Policy last revised April 19, 2005, revealed: Policy: Behavior management includes the management of anger, confusion, hallucination, and other behavior by utilizing techniques such as area limitation, self-responsibility, group interactions, limit setting, and behavior modifications depending on individual needs. Procedures: 15. Develop and facilitate a behavior modification program .19. Document behavior modification on the interdisciplinary plan of care. Monitor effectiveness of interventions. Record review of a facility policy, titled &[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to consult with the resident's physician when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #2) of 7 residents reviewed for resident rights. The facility failed to notify Resident #2's physician of her change of condition on [DATE]. Resident #2 continued to have these symptoms and was sent out to the hospital on [DATE]. On [DATE] at 4:30 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that was not an immediate jeopardy due to the facility continuing to monitor the implementation the effectiveness of their Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. Findings included: Record review of Resident #2's admission Record, dated [DATE], revealed Resident #2 was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. The diagnoses included: Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), acute kidney failure (condition in which kidneys suddenly are unable to filter waste from blood), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #2's Quarterly MDS assessment, dated [DATE], revealed Resident #2 had a BIMS score of 6 (suggesting severe impairment). Record review of Resident #2's Order Summary included: Behavior Monitoring Enter the code - 0. None 1. Panic 2. Agitated 3. Angry 4. Anxiety 5. Biting 6. Compulsive 7. Crying 8. Pacing 9. Screaming/yelling 10. Pull IV line/tubes 11. Poor eye contact 12. Depressed/withdrawn 13. Extreme fear 14. False beliefs 15. Fighting 16. Finger painting feces 17. Hallucinations/paranoia/delusion 18. Head banging 19. Insomnia 20. Jittery 21. Kicking 22. Noisy 23. Pinching 24.Restless 25. Scratching 26. Slapping 27. Suspiciousness 28. Throwing objects 29. Wandering 30. Other see progress notes; every shift, if any behaviors are noted, document details in a progress note. Record review of Resident #2's April TAR revealed: Behavior Monitoring Enter the code - 0. None 1. Panic 2. Agitated 3. Angry 4. Anxiety 5. Biting 6. Compulsive 7. Crying 8. Pacing 9. Screaming/yelling 10. Pull IV line/tubes 11. Poor eye contact 12. Depressed withdrawn 13. Extreme fear 14. False beliefs 15. Fighting 16. Finger painting feces 17. Hallucinations/paranoia/delusion 18. Head banging 19. lnsomnia 20. Jittery 21. Kicking 22. Noisy 23. Pinching 24. Restless 25. Scratching 26. Slapping 27. Suspiciousness 28. Throwing objects 29. Wandering 30. Other see progress notes every shift If any behaviors are noted, document details in a progress note. Further review of this document revealed: [DATE] - [DATE]: 0 (None) [DATE] - [DATE]: 19 (Insomnia) [DATE] and [DATE]: 4 and 13 (Anxiety and Extreme fear) [DATE] and [DATE]: 0 (None) [DATE] and [DATE]: 1 and 4 (Panic and Anxiety) Resident #2's April TAR also revealed: Side Effects - Enter the code - 0. None 1. Dystonia 2. Dry mouth 3. Constipation/urinary retention 4. Hypotension 5. Drowsiness/Sedation 6. Dizziness 7. Arrhythmias 8. Tardive dyskinesia 9. Rash 10. Headache 11. Urine retention 12. Weak 13. Cogwheel rigidity 14. Tremor 15. Appetite change 16. Insomnia 17. Confusion 18. Sore throat 19. Seizure 20. Photo-sensitivity 21. Suicidal Ideations 22.GI disturbance 23. Ataxia every shift If any side effects are noted, document details in a progress note. Further review of this document revealed: [DATE] - [DATE]: 0 (None) [DATE]: 5 (Drowsiness) [DATE]: 14 (Tremor) [DATE] - [DATE]: 0 (None) [DATE]: 8 and 14 (Tardive Dyskinesia and Tremor) [DATE] and [DATE]: 14 (Tremor) [DATE] and [DATE]: 0 (None) [DATE]: 6, 14, and 16 (Dizziness, Tremor, and Insomnia) [DATE]: 14 and 16 (Tremor and Insomnia) Record review of Resident #2's Progress Notes revealed: Effective Date: [DATE] 13:25 [1:25 pm] .Note Text: This nurse was called to resident room to assist with a transfer back to w/c from the bed. Once resident was in her w/c her eyes became fixated and shallow breathing. Resident then took her last breath and was placed on the floor. Another CNA went to call for help. This resident is a full code. CPR was initiated, with AED, ambu bag with 02 at 15L. 911 was called, family in hallway. Resident now breathing with a strong heartbeat [sic] EMS arrived and placed resident on stretcher, resident still incoherent. Resident was sent to [hospital] with RP at her side.MD, DON, and administrator aware. Author: [LVN B] . Record review of Resident #2's SBAR, dated [DATE], revealed Resident #2 had mental, functional, and neurological status change, with heightened emotional status of anxiety, panic, dizziness, fear, body was shaking, trembling, perspiring, VS were BP 157/80, Pulse 114-140, and respirations 28, symptoms started [DATE]. Record review of Resident #2's SBAR, dated [DATE], revealed Resident #2 had functional status change, needed more assistance with ADLs, falls, weakness, and was diaphoretic (sweating), VS were BP 109/62, Pulse 92, and respirations 20, symptoms started [DATE]. Further review of this documentation revealed the MD or NP were notified on [DATE] and RP was notified on [DATE]. Review of Resident #2's EMR revealed there was no documentation stating the MD/NP was notified of Resident #2's change in condition on [DATE]. Record review of Resident #2's hospital record, dated [DATE], revealed: .brought to the ED via EMS with reports of altered mental status. Per the ED physician the nursing facility reported that the patient was unresponsive, so EMS was called. The nurse at the outside facility started CPR .Upon arrival to the ED of EMS the patient was found to be hypotensive [low blood pressure] and tachycardic [elevated heart rate] .Initially on arrival the patient was unresponsive .ASSESSMENT/PLAN: 1. Sepsis .2. Acute encephalopathy .3. Dehydration .4. AKI . During interview on [DATE] at 9:38 am, RN A said, on [DATE] at approximately 10:00 am, Resident #2 was sitting in the dining room holding on very tightly to the table and the pillar and said she did not want to be left alone. RN A obtained VS and said the abnormal VS (BP 157/80, Pulse 114-140, and respirations 28) on [DATE] triggered the SBAR. RN A further stated she notified the MD about Resident #2's change in condition after completing the SBAR on [DATE] and did not receive any new orders from the MD. RN A said she must have documented the communication with the MD in a progress note. During interview on [DATE] at 11:57 am, the MD, she was not notified of the change in condition for Resident #2 on [DATE]. The MD said had she been notified; she would have sent Resident #2 to the hospital. The MD further stated there was a possibility the change in condition Resident #2 experienced on [DATE] may have led to the hospitalization on [DATE]. During interview on [DATE] at 4:09 pm, the DON said she was aware of the SBAR for [DATE] and had briefly read it. She further stated RN A reported that on [DATE] Resident #2 had gripped the table and was shaking, and RN A notified the MD. She further stated she was not aware of the symptoms listed on the SBAR for Resident #2 or the lack of documentation regarding notification or follow up to the MD/NP on [DATE] regarding Resident #2. The DON said she expected nurses to contact the MD once the resident was stabilized if there was a change in condition and document on the SBAR what the MD said. The DON further stated she audited resident records at least once a week, reviewed all the nurses notes every morning on Tuesday - Friday, and the 72-hour report on Monday mornings. The DON said she was not aware there were no progress notes for [DATE]. The DON said during her observations Resident #2 was fine but did not remember the exact date of the observation. During interview on [DATE] at 10:27 am, LVN D said Resident #2 had some neurological changes, excessive shaking, and trembling between [DATE] and [DATE]. LVN D further stated Resident #2 was more incontinent and needed more help with ADLs during this time, and on [DATE]. During interview on [DATE] at 10:30 am, CNA C said between [DATE] and [DATE], Resident #2 was shaking a lot, holding on to the table thinking she was going to fall, and was saying the police were coming. CNA C further stated Resident #2 was having delusions and kept saying I'm falling, I'm falling. During interview on [DATE] at 1:30 pm, the NP said she was not notified of the change in condition for Resident #2 on [DATE]. The NP further stated the facility was responsible for notifying the MD/NP of changes in resident condition so that they could intervene if needed. The NP further stated, had she been notified, she would have sent Resident #2 to the hospital. Record review of facility policy, titled Notifying the Physician of Changes in Status and revised [DATE], stated: The nurse will notify the physician immediately with significant changes in status . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:26 pm. The ADO and the DON were notified. The ADO and the DON were provided with the IJ template on [DATE] at 4:30 pm. The following POR submitted by the facility was accepted on [DATE] at 1:06 pm and reflected the following: [Facility] [DATE] Quality Assurance Problem: Facility failed to notify Physician/NP of resident change in condition. Interventions: The following in-services were initiated by the DON and the ADON on [DATE]. Any staff member not present or in-serviced on [DATE] will not be allowed to assume their duties until in-serviced. - In-service completed with the DON and the ADONs by the ADO and the RCN on [DATE] regarding reviewing and monitoring documentation in PCC to include review of the SBAR, and PCC clinical alerts. Licensed Nurses Certified Nurse Aides In-service licensed nursing staff to the following in the event of a resident change in condition: - Promptly and correctly assessing a resident when a change of condition has been identified / reported. - Unless it was an emergency situation, assessing a resident's change in condition and document change using a SBAR, so that all necessary information was communicated to the physician or nurse practitioner. The completion of the SBAR included documentation of the notification to the physician and any new orders, if any, the physician provided. - If an emergency situation, stabilize the resident as much as possible and notify 911. Notify the physician after transfer. - Initiate any orders provided. - Promptly and correctly assessing a resident when a change of condition has been [sic] identified. Communication of change in condition to other nurses, med aides, and nurse aides will occur during shift-to-shift change report. Documentation of change in condition will occur on the 24-hour report in PCC. In-service initiated for Certified Nurse Aides on [DATE] by the DON on the following: Any non-licensed nursing staff not present or in-serviced on [DATE] will not be allowed to assume their duties until in-serviced. - CNAS will verbally communicate any resident change of condition as well as document the change under point of care in PCC. - An adhoc QAPI meeting was conducted on [DATE] regarding this plan and monitoring. - The medical director [Medical Director] was notified of this plan and monitoring on [DATE]. Monitoring: The DON / designee will monitor PCC Dashboard alert documentation for all residents at least 5 times per week to ensure any potential change of condition has been addressed and the physician was notified timely. The DON / designee will ask 10 nursing staff (including at least 6 nurses) per week what they would do if a resident had a change of condition, or it was reported to them that a resident had a change in condition. All monitoring noted above will continue for at least 4 weeks. The QAPI Committee will review the findings and make changes to this plan as needed. The DON/designee will review all SBARs 5 times a week for 4 weeks and periodically there after to ensure all resident change in condition have been addressed. Verification of POR: Record review of facility's sign-in sheets on of [DATE] revealed 65 out of 65 nursing staff (100%) were in-serviced in-person, via text, and via telephone. Record review of facility's in-service Training Attendance Roster, Topic: Reviewing and Monitoring Documentation in PCC, dated [DATE], revealed it was completed by the ADO; Attendees: the DON, LVN D, and LVN H. In interviews between [DATE] at 5:13 pm and [DATE] at 11:34 am, with 4 nursing staff on the 6 am - 6 pm shift (2 RNs and 2 LVNs), 4 nursing staff on the 6 pm - 6 am shift (2 RNs and 2 LVNs), 6 CNAs on the 7 am - 3 pm shift, 4 CNAs on the 3 pm - 11 pm shift, and 5 CNAs on the 11 pm - 7 am shift, staff said they had been in-serviced regarding communication of changes of condition between shifts and to the charge nurse, documentation of SBAR, and notification of changes in resident condition to the MD. During interview on [DATE] at 5:13 pm, LVN A said she received an in-service on [DATE] that included when to complete an SBAR, what it entails (documentation, calling the MD), when to report changes in condition, documenting changes and notifying the MD, and documenting new orders. During interview on [DATE] at 5:16 pm, RN D said she received in-service on [DATE] that included SBAR, changes in condition, identifying changes and need for SBAR, full documentation of the SBAR and notification to the MD, family, and the DON. Communicating with our peers, and shift report. During interview on [DATE] at 5:22 pm, CNA E said she received an in-service on [DATE] that included changes for the residents, reporting changes, such as bruises or wounds, to the nurse and documentation of any changes in POC. During interview on [DATE] at 5:24 pm, CNA F said she received an in-service on [DATE] that included telling the nurse, the DON, or Administrator if we see anything like skin tears or bruising and documentation of changes in POC. During interview on [DATE] at 5:25 pm, LVN F said she received an in-service on [DATE] that included SBAR, changes in condition, calling the MD, documentation, notifying family, calling 911 for emergencies and contacting the RP. Documentation of the SBAR, such as what was going on, the change in condition, notifying the MD and documenting what the MD said regarding orders or what they want us to do, sometimes its medication or monitoring. During interview on [DATE] at 5:29 pm, CNA G said she received an in-service on [DATE] that included notifying the nurse if we see any signs of decline and documenting those changes in POC. During interview on [DATE] at 5:30 pm, CNA H said she received an in-service on [DATE] that included reporting any changes in condition or declines to the nurse and documentation in POC. During interview on [DATE] at 5:34 pm, RN B said she received in-service on [DATE] that included SBAR, calling the MD, the family, and contacting the Medical Director. She stated if the MD did not answer the medical director should be notify, and to notify the resident, family, and the medical director, if needed of new orders. CNAs were supposed to let us know if there were changes in condition, such as: loose stools, pain, fever, bruises, falls, decreases in appetite, and they document those changes in PCC. For emergencies, assess the resident, complete an SBAR, document any new orders, and make notifications. If we need to call 911, call them, document, and notify everyone. It also included the 24-report, which was a communication sheet used during shift change. During an interview on [DATE] at 2:01 am, LVN G said she received an in-service on [DATE] that included recording changes in condition, who to call if there were changes, what to do, notifying the MD, family, and stabilizing the resident. During an interview on [DATE] at 2:03 am, CNA I said she received an in-service on [DATE] that included reporting any changes in resident condition to the nurse and documenting in POC. During an interview on [DATE] at 2:04 am, CNA J said she received an in-service on [DATE] that included reporting of abuse/neglect, reporting any changes in condition to the nurse, and documenting changes in POC. During an interview on [DATE] at 2:06 am, RN F said she received an in-service on [DATE] that included contacting the MD when there were changes in condition, documentation of the changes, and completing the SBAR. During an interview on [DATE] at 2:07 am, CNA K said she received an in-service on [DATE] that included reporting any changes in condition to the nurse and documenting them in POC. During an interview on [DATE] at 2:10 am, RN G said she received an in-service on [DATE] that included how to complete an SBAR and notifying the MD. During an interview on [DATE] at 2:13 am, LVN H said she received an in-service on [DATE] that included SBAR, assessing the resident with changes in condition, notifying the MD, initiating new orders, communication of changes to nurses, Mas, and CNAs during shift report and documentation. During an interview on [DATE] at 2:14 am, CNA L said she received an in-service on [DATE] that included abuse, documentation of changes in condition, reporting to the nurse, and documenting in the POC. During an interview on [DATE] at 2:16 am, CNA M said she received an in-service on [DATE] that included abuse/neglect, documenting changes in condition, and communicating changes to the nurse. During an interview on [DATE] at 11:30 am, CNA N said she received an in-service on [DATE] that included if she saw something, such as skin tears, or if someone was hurt it should be reported to the nurse and documented. During an interview on [DATE] at 11:31 am, CNA O said she received an in-service on [DATE] that included if something happened to the residents or if there was a change in their condition, it should be reported to the nurses and then documented in the POC kiosk. When they shower the residents, if they saw anything, like a bruise, document it and report it to the nurse. During an interview on [DATE] at 11:34 am, CNA R said she received an in-service on [DATE] that included reporting changes in resident condition, such as bruising or changes in health, to the nurse, and documented in POC. During an interview on [DATE] at 11:36 am, CNA S said she received an in-service on [DATE] that included patient care, reporting changes in condition, skin, or health, to the nurses. During an interview on [DATE] at 11:40 am, the DON said she provided an in-service starting on [DATE] that included all nurses and CNAs. Topics included proper documentation and notification of SBARs regarding changes in resident condition and CNAs reporting changes to the nurses and documenting changes in POC. The DON further stated she completed a review of all resident SBARs for the months of April, May, and [DATE] and no concerns were identified. During an interview on [DATE] at 11:46 am, CNA B said she received an in-service on [DATE] that included reporting changes in resident condition to the nurse and documentation of changes in POC. During an interview on [DATE] at 11:47 am, CNA Q said she received an in-service on [DATE] that included a text message to receive an in-service before she started her shift on [DATE] at 7:00 am. She further stated on [DATE] she was told to report any changes that she had not seen before while caring for a resident to the nurse and document the change in Care Tracker/POC. Record review of facility policy, titled Notifying the Physician of Changes in Status and revised [DATE], revealed on was present and in effect. The ADO and the DON were informed the Immediate Jeopardy (IJ) was removed on [DATE] at 1:06 pm. The facility remained out of compliance at a severity of potential for more than minimal harm that was not an immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents and supervision, in that: Resident #1 eloped from the facility on 02/21/2024 and again on 03/04/2024. The facility failed to prevent Resident #1 from eloping on 2/21/24. Resident #1 eloped again when he was not being monitored on 3/4/24. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/18/2024. The non-compliance began on 02/21/2024 and ended on 03/05/2024. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings were: Record review of Resident #1's face sheet, dated 04/18/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: unspecified dementia (memory loss), alcohol dependence, epilepsy (a condition that causes frequent seizures) and depression. Further review revealed the resident was discharged from the facility on 4/11/2024 to home, and the resident's family member was the resident's Responsible Party. Record review of Resident #1's admission MDS, dated [DATE], revealed the resident had a BIMS score of 6 which indicated a sever cognitive impairment. Further review revealed resident did not have any behavioral issues, his level of ambulation was independent. Record review of Resident #1' doctor orders, dated 2/20/2024, revealed the resident was admitted to the secured unit upon admission. Record review of Resident #1's progress notes, dated 02/21/2024, revealed the resident had eloped from the facility via his bedroom window on 2/20/2024 at 5:05 p.m Further review revealed the resident had eloped from the facility by pulling out the glass windowpane from the window frame, and he was found walking back to the facility with beer and cigarettes. Record review of Resident #1's doctor orders, dated 2/21/2024, revealed the resident was placed on 15-minute checks. Record review of Resident #1's progress notes, dated 03/04/2024, revealed Resident #1 eloped on 03/04/2024 at 5:00 p.m Further review revealed the resident had eloped by breaking a window in another resident's room and was found sitting at a bus stop that was down the street from the facility. The resident returned to the facility with staff. Record review of Resident #1' doctor orders, dated 3/5/2024, revealed the resident was placed on 1:1 while in his room. Record review of Resident #1's care plan, dated 03/06/2024, revealed the facility implemented elopement precautions with interventions: the resident was placed on 1:1 observation while in his room and visual checks every 15 minutes checks when he was not in his room. Further review of other interventions also included: redirection, distraction, offering the resident a beer, inquiring as to why the resident wants to leave, phoning the resident's wife to speak to him to discourage the resident from eloping. During an interview with LVN B on 4/17/2024 at 9:40 a.m., LVN B stated Resident #1 was, very difficult to care for. LVN B further stated the resident would threaten staff when he was redirected from attempting to elope. During an interview with the DON on 4/17/2024 at 1:10 p.m., the DON stated that when it became apparent Resident #1 was missing on 2/20/2024 and 3/4/2024 the facility enacted their elopement response policy which included calling a code, Orange, notifying staff, performing a search of the facility and surrounding areas, assessing the resident once found and making notifications. The DON stated the resident had been discharged home after it was deemed safer for the resident. During an interview with CNA C on 04/18/2024 at 11:23 a.m., CNA C stated she was assigned to work on the resident hall where Resident #1 resided. CNA C stated Resident #1 would often verbalize that if he wanted to leave the facility, no one could stop him. During an interview with ADON A, the Unit Manager for the secure unit, on 04/18/2024 at 2:05 p.m., ADON A stated after Resident #1's first elopement on 02/21/2024 one of the interventions the facility implemented was changing the resident's room to a room across the hall from his original room. ADON A stated Resident #1's room, upon admission, had a window which faced the street, however, after the elopement on 02/21/2024 the resident was moved to a room with a window facing the facility's courtyard. ADON A further stated when the resident eloped on 03/04/2024 he went to another resident's room which had a window facing the street. During an interview with Resident #1's Responsible Party on 4/18/2024 at 4:08 p.m., Resident #1's Responsible Party stated the resident was doing fine at home, and he did not try to leave the house. The resident's Responsible Party stated that when the facility notified her of the resident's second elopement, she began going to the facility daily and stayed with the resident. Resident #1's Responsible Party further stated she was trying to find another, more appropriate facility for the resident as she had medical issues which would not allow her to care for the resident. The Administrator and DON were notified on 4/18/2024 at 6:53 p.m., that a past non-compliance IJ situation had been identified due to the above failures. The facility course of action prior to surveyor entrance included: Observations made by staff on the secured unit on 4/16/2024 at 10:11 a.m., showed that the door code, locking mechanism and door alarm were functioning properly. Observations made by staff on the secured unit on 4/17/2024 at 9:38 am, showed that the door code, locking mechanism and door alarm were functioning properly. Observations made by staff on the secured unit on 4/18/2024 at 2:03 p.m., showed that the door code, locking mechanism and door alarm were functioning properly. During an interview with the DON on 04/16/2024 at 12:15 p.m., the DON stated that Resident #1 no longer resided at the facility. During an interview with the DON on 04/17/2024 at 1:45 p.m., the DON stated the two in-service trainings for staff were developed and presented to staff as a result of Resident #1's elopement incidents on 02/21/2024 and 03/04/2024. Record review of the facility's training documentation revealed an in-service titled Elopement Response given by DON on 03/06/2024, which indicated that all 101 staff at the facility had been in-serviced regarding elopements. Summary: Staff must intervene when a resident attempts to elope, must notify Administrator, DON and ADONs and search must be conducted until the resident is found. Record review of document titled, Missing Resident/Elopement Monitoring, was completed 2/28/2024 through 3/31/2024 and included checking that the locking mechanism or alarm function properly, changing the secured unit door code, performing spot checks on Resident #1. Record review of an in-service training, dated 3/5/2024, related to Elopement Response revealed 101 of 101 staff member signatures. Interviews with 12 employees who consisted of RNs, LVNs, CNAs, Housekeeping, Activities and Dietary from 4/17/2024 at 10:30 a.m. to 4/18/2024 at 1:30 p.m. revealed they had received in-services on Elopement Response. All were able to state the key elements of the elopement policy, which include: If a resident is discovered missing: - Immediate search of the resident in resident rooms, bathrooms, showers, closets, recreation areas, outside area - Notify charge nurse/DON - Call Code Orange - Specifically, to the secure unit, since they know what the residents on the unit look like, describe what the resident looks like to staff outside the unit - After 30 minutes, if the resident had not been located, call the police, RP If a resident is observed trying to leave: - Attempt to stop the resident. Speak in a calm voice to the resident. - Get help if needed. - Tell another staff member to inform the charge nurse/DON.