**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure that the resident environment remained safe, clean, comfortable and homelike for 1 of 1 (Resident #8) resident reviewed. LVN A brought a handgun into the facility, unbeknownst to staff, hid in the oxygen supply closet, ran down the hallway into an empty room and broke a window. Then ran down another hallway into Resident #8's room while the resident was sleeping, hid in the closet, emerged from the closet, and pointed the gun at the BOM and Maintenance director who lured the LVN out of resident #8's room and told LVN A to leave the facility. The non-compliance was identified as past non-compliance IJ. The non-compliance began on 12/04/2023 and ended on 12/04/2023. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for harm due to not receiving protection for safe daily living. The findings include: 1. Record review of the facility's Provider Investigation Report (PIR) dated 12/04/23 revealed on 12/04/23 around 7:50 AM, the 10 PM to 6 AM nurse (LVN A) started acting erratic after he finished his shift. LVN A hid in the oxygen supply closet for approximately an hour before coming out of the closet with a gun in his hand, which was not seen by staff, and ran to room [ROOM NUMBER] which was empty and broke the window. He then proceeded to run down the hall into Resident #8's room into the closet while the resident was sleeping. BOM and the Maintenance Director were informed LVN A ran into a resident's room looking suspicious and when they went to investigate, LVN A came out of the closet in Resident #8's room, pointed the gun at them briefly before putting it in his pocket. Staff immediately called 911 and started closing residents' doors. Staff attempted to keep LVN A away from residents' rooms and at the nurses' station and attempted to get him to leave. LVN A left before the police arrived. LVN A was terminated and reported to the Texas Board of Nursing. The code on the back door was changed, the front door was kept locked for a month. The pharmacist representative did an audit of the medication carts with no discrepancies found. The window to room [ROOM NUMBER] was repaired. The social worker interviewed all residents on 200 hall to ensure they felt safe, which included Resident #8. The Medical Director was notified. Staff were in-serviced with in-service on active shooter and workplace violence. The local police department was asked to perform patrol car rounds at the facility. Record review of the undated In-Service Training Report, included in the PIR, for the topic Active Shooter revealed 26 employees had signed they were in-serviced. Record review of the undated In-Service Training Report, included in the PIR, for the topic Work Place Violence revealed 26 employees had signed they were in-serviced. Record review of the Texas Board of Nursing Complaint form, included in the PIR, was submitted on 12/04/23 at 10:56 AM and noted LVN A .went into a manic state. Pacing through the hallway breaking a back window and later pointing a gun at two staff members, BOM and Maintenance Director. The complaint form indicated no patient/resident harm occurred and LVN A was terminated. Record review of resident interviews included in the PIR revealed 8 residents who resided on the same hall as Resident #8 and Resident #8 were interviewed by the Social Worker on 12/04/23 with none of the residents reported any concerns with the way staff treated them and no reports of anything unusual happening that morning. Record review of Resident #8's face sheet, dated 3/12/24, revealed he was admitted to the facility on [DATE] with diagnoses which included swallowing difficulty, cognitive communication deficit (difficulty thinking and use of language), alcohol-induced dementia (decline in cognitive abilities that impacts a person's ability to perform daily tasks), and high blood pressure; and was discharged from the facility on 01/15/24. Record review of Resident #8's Social Services Note, dated 12/04/23, revealed the social worker was unable to ask Resident #8 questions about the incident that occurred in his room because he was asleep throughout the entire incident and remained asleep when the social worker tried to interview him. Record review of Resident #8's Nurse's Notes, dated 12/04/23, written by the ADON, revealed the resident's mood was pleasant and no injuries noted. Record review of Resident #8's Physician Progress Note, dated 12/04/23 revealed the resident had history of psychiatric disorder and alcohol abuse, was a poor historian, and the resident was doing well. Record review of Resident #8's Social Worker Note, dated 12/07/23 revealed the resident was not feeling down or depressed. Record review of Resident #8's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 5 out of 15, indication of severe cognitive impairment, and no signs that the resident was feeling down or sad. Record review of LVN A's employee file revealed he was hired on 10/24/23 as an LVN, his license was current, required background checks were conducted before employment without any restrictions against the LVN, and he was terminated on 12/04/23 for misconduct. Included in LVN A's employee file was an Acknowledgement Receipt form signed by LVN A on 10/24/23 in which he acknowledged receipt of the facility's Employee Handbook. Record review of the facility's Employee Handbook, revised March 2014, revealed on pages 9-10 under Employee Conduct and Work Rules was To ensure orderly operations and provide the best possible work environment, the Facility expects employees to follow rules of conduct that will protect the interests and safety of all employees, patients [residents] and the Facility .The following are examples of infractions of rules of conduct that may result in disciplinary action, up to and including termination of employment: .Possession of dangerous or unauthorized materials such as explosives or firearms (including concealed weapons carried under license), in the workplace . Record review of the undated facility's Disciplinary Action Policy revealed Employees are subject to disciplinary action according to the criteria outlined below. Employees discharged for cause under any part of this policy are not eligible for rehire Category I: These offenses are most serious and may subject an employee to immediate discharge without rehire privileges .9. Possession of a firearm or other weapon on the facility premises. Observation on 03/09/24 at 5:05 p.m. revealed a large sign was posted outside the facility near the front door that stated no firearms were permitted in the facility. In a telephone interview on 03/09/24 at 4:27 PM the former BOM stated she was the BOM for the facility when the incident occurred with LVN A. The BOM stated before the incident she had very little interaction with LVN A. On 12/04/23, the BOM stated she arrived at the facility at 7:30 AM, started her day as usual, when a CNA came to her office and told her LVN A was acting weird. The CNA left her office, came back, and said LVN A was still acting weird, and he ran into a resident's room, and advised the BOM to not go by herself when she investigated the situation. The BOM stated the Maintenance Director was in the facility and asked her if she heard the noise. The BOM said to the Maintenance Director what loud noise and he replied that a window had been broken. The BOM stated they were by the nurse's station and saw drops of blood on the floor. They followed the drops of blood on the floor down the hall into the second to the last room on the hall (Resident #8's room). The BOM said she knocked on Resident #8's door several times announcing the resident's name and she did not hear anything, so she slowly opened the door and walked into the room. Suddenly LVN A burst out of the closet in Resident #8's room and pointed a gun at the BOM. The BOM said he was waving the gun around briefly before he put the gun in his pocket and was saying They're here, they're out there, and they're after him. The BOM stated she slowly backed out of the room as LVN A was saying that people were after him and she told LVN A there was nothing going on. The BOM said she and the Maintenance Director were able to get LVN A out of Resident #8's room and down to the nurse's station and LVN A was dripping blood as he walked towards the nurse's station. The BOM stated she asked LVN A to get his belongings and leave and LVN A responded no he couldn't go. The BOM said the nurse who relieved LVN A was on the phone with the police while the BOM was luring LVN A out of the resident's room down to the nurses' station. The BOM stated LVN A went into the bathroom at the nurse's station and when he came out, he asked if the cops were on the way. The BOM said she did not answer this question because she knew LVN A had a gun in his pocket. The BOM stated LVN A then went around the nurse's station into the oxygen supply closet (located near the nurse's station), got his backpack and left the facility about five minutes before the police arrived at the facility. The BOM stated she called the Administrator, but LVN A left the facility before the Administrator arrived. In an interview on 03/10/24 at 9:31 AM, the Maintenance Director stated he usually arrives at the facility around 7 AM. On 12/04/23 he was in his office which was outside behind the facility in a shed when he heard a loud bang sound and got up to investigate. The Maintenance Director said he noticed a window was busted out from the inside with glass on the outside of the building on the 300 hall side which did not have any residents. He went inside and saw glass on the floor inside room [ROOM NUMBER], which was empty, and drops of blood on the floor. The Maintenance Director stated he followed the drops of blood up to the nurse's station where he ran into the BOM and a CNA. The Maintenance Director said they asked him did you see LVN A, he is running up and down, acting crazy, to which he replied no. The Maintenance Director stated he asked them if they had seen the blood on the floor and the BOM stated no, so he and the BOM followed the blood trail which led to Resident #8's room. The Maintenance Director said the BOM knocked on Resident #8's door, asked for the resident's name, and LVN A came out of the resident's closet, swung a gun at the BOM and the Maintenance Director, saying a curse word and asked, where are they. The Maintenance Director stated the BOM said to LVN A nobody is here, you are at work, you are alright, and LVN A put the gun in his sweatpants pocket and walked out of the room. The Maintenance Director stated he kept asking LVN A if he was ok and told him his shift ended. The Maintenance Director said as LVN A walked towards the nurse's station he was bleeding from his hand, so the Maintenance Director got LVN A a rag for his hand, then someone called LVN A on LVN A's cell phone and told him he needed to leave. The Maintenance Director stated LVN A then went into the oxygen supply closet, grabbed his backpack, and walked out of the facility. The Maintenance Director stated Resident #8 was no longer in the facility, his interaction with LVN A prior to this incident was brief only saying hi to him when the Maintenance Director entered the facility and he had not seen LVN A bring a gun to the facility before that day. In a telephone interview on 03/10/24 at 10:19 AM, CNA G revealed she worked the 10 PM to 6 AM shift with LVN A. CNA G stated LVN A was nice to the residents, he did his work, and she had not seen any erratic behavior from LVN A. CNA G said LVN A would bring food and energy drinks to work, saw him drink a lot of energy drinks and had not seen the nurse bring a weapon into the facility. CNA G stated she worked the night shift with LVN A on 12/03/23 into 12/04/23, she did not see any unusual behavior from the nurse during the shift and he was kind of tired. CNA G stated she would usually get a ride home from LVN A but that morning he was rushed at the end of the shift and by 6 AM she didn't want to wait for him to finish his work, so she left the facility. In an interview on 03/12/24 at 2:30 PM, LVN M stated she was the on-coming nurse on 12/04/23; she arrived at the facility at 6 AM, received report from LVN A, counted medications with him and he looked like he was a bit distracted. LVN M said she saw him walk towards the timeclock (located next to the oxygen supply closet), thought he clocked out and left the building. LVN M stated she last saw LVN A at 6:30 AM and did not see him until 8 AM when she saw him come out of Resident #8's room. LVN M said she called the Administrator, then called 911 and LVN A left before the administrator and the police arrived at the facility. LVN M stated LVN A was bleeding from his hand, he did not have his gun out when he came out of the resident's room and when he was at the nurse's station. LVN M stated LVN A would bring a backpack to work but she did not see a gun. In an interview on 03/10/24 at 8:48 a.m. the Administrator stated the Social Worker interviewed residents who resided on the hall where the incident happened. In a telephone interview on 03/10/24 at 10:47 AM, the Social Worker stated she works in a sister facility and had been assisting this facility since September 2023. The Social Worker said the facility contacted her about the situation with LVN A bringing a gun into the facility and asked her to talk with the residents who resided on the hall were LVN A went into Resident #8's room. The Social Worker stated she interviewed the residents who resided on the same hall as Resident #8, and none of them were aware of what happened which included Resident #8 who happened to be asleep when she tried to interview him. In an interview on 03/10/24 at 2:33 PM, the DON stated LVN A worked the night shift (10 PM to 6 AM), she had not seen any odd or erratic behavior from him before this incident and this was not something she expected from him. The DON said LVN A would bring a backpack to work, and she saw him pull out pens, notebook, stethoscope, and other nursing supplies, and had not seen a gun. In an interview on 03/10/24 at 3:32 PM, the Administrator stated he was not in the facility when the incident happened, he was on his way to an appointment when LVN M called him and told the Administrator to come to the facility because LVN A was acting weird. The Administrator said he told LVN M to call the police, ask LVN A to leave the building and he was on his way to the facility. The Administrator said LVN A had left the facility by the time he arrived, so the Administrator reviewed the camera footage which showed after LVN A's shift ended, he went into the oxygen supply closet and stayed there for over an hour. Then the cameras showed LVN A came out with a gun in his hand, he ran down to the 300 hall into an empty room and broke a window, then ran down the hall where Resident #8 resided and into Resident #8's room. The Administrator stated staff did not know LVN A had a gun at this point and the cameras showed the BOM and the Maintenance Director went down the hall were Resident #8 resided and they encouraged LVN A to come out of the resident's room to the nurses' station. The Administrator said the cameras showed staff were closing the doors to residents' rooms on the hall where Resident #8 resided and LVN A left the facility before the police arrived. The Administrator said he reviewed the camera footage for the night shift (on 12/03/23 and 12/04/23) that LVN A had just worked and LVN A appeared to be completely normal during his shift, he was passing medications and doing other nursing things. The Administrator stated LVN A was terminated and referred to the Board of Nursing. The Administrator said after the incident, the codes to the doors were changed, the front door was kept locked, police did frequent rounds by the facility. The Administrator said the pharmacist consultant did an audit of the medication carts with no discrepancies noted. In an interview on 03/11/24 at 4:50 PM, the Administrator stated the facility does not allow staff to bring handguns into the facility, a sign is posted outside the facility, and it was included in the Employee Handbook. When asked how he ensures handguns were not brought into the facility, he stated he would have staff follow the facility's polices by informing them of the policies, through the posting that handguns were not allowed in the facility, and it was covered in the employee orientation process. In an interview on 03/11/24 at 4:52 PM, the Regional Nurse Consultant stated staff were encouraged to keep their personal items in their vehicles or to not bring personal items into the facility. In an interview on 03/11/24 at 4:52 PM, the Administrator stated staff were in-serviced on 12/07/24 on workplace violence in addition to trainings done immediately after the incident. In an interview on 03/11/24 at 5:55 PM, the Administrator stated in December 2023 the facility had 28 employees. In an interview on 03/12/24 at 10:14 AM, the Administrator stated the facility had police do frequent rounds around the facility and the front door was kept locked for a month. In an interview on 03/12/24 at 11:43 AM, the Administrator stated there were only two ways into the facility, through the back door which had a code and the front door. The Administrator stated after LVN A left the building on 12/04/23, he immediately changed the code to the back door, the front door was kept locked and visitors had to ring a doorbell to be let into the facility. The Administrator stated LVN A's paycheck was sent to him via direct deposit. The Administrator said when he called LVN A to inform him he was terminated, the call went directly to voicemail, the LVN did not call him back, and he did not have any contact with the LVN after the incident. The Administrator was notified of a Past-Noncompliance Immediate Jeopardy (IJ) on 03/12/2024 at 1:27 PM and was given a copy of the IJ Template. It was determined these failures placed Resident #8 in an Immediate Jeopardy (IJ) situation from 12/04/2023 through 12/04/2023. The facility took the following actions to correct the non-compliance following the incident, to include: 1. The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date:12/04/2023) -The social worker completed random resident interviews that included Resident #8, none were aware of the incident and no distress noted. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. -LVN A was immediately located and escorted away from resident living areas and voluntarily exited the facility before police arrived. Completion date: 12/4/2023 -Staff immediately called 911 and notified the facility Administrator. Police arrived. Completion date: 12/4/2023 -LVN A was immediately terminated and LVN A nurse's license was reported to the Texas Board of Nursing. Completion date: 12/4/2023 -Active shooter in service conducted with 26 of 28 employees on 12/4/2023. The two employees not in serviced were PRN and didn't pick up any shifts during that time frame. Completion date: 12/4/2023 -The facility has a sign in front of the facility by the front door that states handguns are not permitted in the facility. Completion date: has been in place for years. -The employee handbook presented to all employees during facility orientation states that handguns are not permitted in the facility. Completion date: 10/23/2023 -Law enforcement stated that they would do frequent rounds at the facility for the rest of the week. Date completed: 12/8/2023 -The front door always remained locked for a month to ensure the facility was secure. Completion date: 1/4/2024 -The code to the back door was changed. Completion date: 12/4/2023 -Pharmacy consultant was contacted to perform a medication review with no errors found. Completion date: 12/4/2023 3. The facility completed a reportable to HHSC (Intake # 468258) on 12/04/2023 in reference to the initial case from 12/04/2023. Interviews on 03/12/24 from 1:33 PM to 2:45 PM with 3 CNAs (one from each shift), 2 nurses, 3 dietary employees, 1 housekeeping staff, and 1 laundry staff revealed they had been in-serviced in December 2023 on workplace violence and how to handle an active shooter in the facility. The non-compliance was identified as past non-compliance IJ. The non-compliance began on 12/04/2023 and ended on 12/04/2023. The facility had corrected the non-compliance before the survey began. The facility implemented interventions listed above to prevent LVN A from entering the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 (Resident #6) residents reviewed for accidents. Resident #6 eloped from the facility on 03/07/24 after a visitor opened the front door, pushed Resident #6 in her wheelchair out of the facility and another individual pushed Resident #6 across the street to Hospital C where she was found several hours later. This non-compliance was identified as past non-compliance IJ. The non-compliance began on 3/07/2024 and removed on 3/07/2024. The facility had corrected the noncompliance before survey began. This failure could place residents at risk for harm due to risk of elopement. The findings included: Record review of Resident #6's face sheet, dated 3/12/24, revealed she was admitted to the facility from an acute care hospital (Hospital D) on 03/01/24 with diagnoses which included schizophrenia (a mental disorder characterized by reoccurring episodes of psychosis), bipolar disorder (mental disorder characterized by periods of depressing and periods of abnormally elevated mood), heart failure, osteoarthritis (degenerative joint disease that results from breakdown of joint cartilage and bone) of right knee, and right artificial knee joint. Further review of the face sheet revealed Resident #6 was discharged from the facility on 03/08/24 to Nursing Home H. Record review of Resident #6's paperwork from Hospital D from 2/20/24 to 03/01/24, provided to the facility upon admission, revealed no notation of elopement behaviors or need for one-on-one monitoring for Resident #6. Record review of Resident #6's facility's Skilled Nursing Evaluation, completed 03/01/24 at admission, revealed the resident used a manual wheelchair to propel herself around the facility. Record review of Resident #6's Physician Progress Note, dated 03/01/24, revealed the resident was admitted to the facility after hospitalization at a local rehabilitation hospital, had a total knee replacement in January 2024, and quit tobacco use 2 years ago. Record review of Resident #6's nurses' notes from 3/1/24 to 3/6/24 indicated the resident would propel herself around the facility in her wheelchair, did not have any exit seeking behaviors and did not ask for cigarettes. Record review of Resident #6's nurses' note, dated 03/07/24, by the DON revealed she was notified by staff nurse at approximately 8:30 PM Resident #6 could not be located. A sweep of all the rooms and bathrooms was completed by onsite staff along with a sweep of the facility perimeter and nearby street. The Administrator reviewed facility camera footage and noted a male visitor assisted the resident outside. The resident was sitting outside in her wheelchair when a male walking by spoke to the resident, and he assisted her over to Hospital C across the street. Resident #6 was found in the hospital at 9:30 PM. The DON spoke to Resident #6 who initially refused to return to the facility, and stated she went to the hospital to get help. When the DON asked what she needed help with, Resident #6 asked for cigarettes. Resident #6 agreed to return to the facility after the DON informed the resident her family would be contacted and asked if they could bring the resident some cigarettes. Resident #6 was brought back to the facility via wheelchair, assessed for pain and injuries. Resident #6 denied pain and no apparent new injuries were noted. Resident #6's Responsible Party and physician were notified. Record review of Resident #6's nurses' note, dated 03/08/24, by the DON revealed Resident #6's RP was contacted and the RP verbalized understanding that Resident #6 was exit seeking trying to get cigarettes and agreed to transfer the resident to another facility that had a wander guard system. DON informed RP the facility would arrange transport to the agreed upon facility. Record review of Resident #6's March 2024 Physician Orders revealed an order dated 03/08/24 to discharge the resident to Nursing Home H. Record review of Resident #6's Interdisciplinary Discharge summary, dated [DATE], revealed the resident was transferred on 03/08/24 to Nursing Home H with a wander guard system after the resident exited the facility. The transfer was initiated for resident safety with the assistance and support of family after Resident #6 eloped from facility. Record review of Resident #6's MDS revealed a Quarterly/Medicare 5-day assessment was in progress. Record review of Resident #6's BIMS Evaluation, dated 03/01/24, revealed a score of 11 out of 15, indication of moderate cognitive impairment in making decisions about tasks of daily life. Record review of Resident #6's Elopement Evaluation, dated 03/07/24 at 10:40 PM, revealed the resident did not have a history of elopement when at home, did not have a history of elopement or attempted leaving the facility without informing staff, and did not wander aimlessly or had non-goal-directed wandering. It was checked the resident had verbally expressed the desire to go home or stayed near an exit door and the resident had recently been admitted and was not accepting the situation, and a risk for wandering was identified. Record review of Resident #6's Care Plans revealed a care plan initiated on 03/07/24 for the Risk for Elopement related to wanting to smoke outside. Elopement on 3/7/24 - Resident #6 exited the facility .to find someone to borrow cigarettes from. Resident educated on not leaving facility. Admin [Administrator] working on alternative placement at a smoking facility/wander guard per resident request. Record review of the Provider Investigation Report, dated 3/13/24 revealed on 03/07/24, Resident #6, who had the capacity to make informed decisions and was not independently ambulatory, was discovered missing from the facility around 8 PM during room rounds. The DON and Administrator were notified, arrived at the facility, and determined a time frame of when the resident was last seen. The Administrator was able to locate the resident on the facility's cameras and determined at approximately 6:15 PM, Resident #6 was seen in the front lobby area in her wheelchair when a visitor was seen holding the door open and assisted Resident #6 out of the facility. Resident #6 remained in the front area for several minutes before she propelled herself towards the sidewalk. A stranger walked by, had a discussion with Resident #6 and then pushed her across the street to Hospital C. The Administrator and DON went to the hospital to find the resident and found Resident #6 propelling herself in the hospital hallway. Resident #6 was assisted back to the facility, assessed by the DON with no injuries noted. Resident #6's physician and responsible party were notified. Resident #6 remained on elopement watch until she was discharged to another facility with a wander guard system. Staff were in-serviced on Elopement Policy and Procedure. Resident #6's care plan was updated to reflect the resident's risk of elopement. The Elopement Monitoring sheet for Resident #6 was included in the PIR along with Resident #6's updated care plan. Observation on 03/09/24 at 7:55 AM revealed the front door of the facility faced a street, and was located across from Hospital C. The front door was not locked and there was no code to punch to open the door when the surveyor entered the facility. Inside the front lobby a female staff member (HR Employee) sat at the desk in the lobby area. In an interview on 03/09/24 at 8:24 AM, HR Employee stated Resident #6 had been transferred to another nursing home on [DATE]. In a telephone interview on 03/09/24 at 9:01 AM, the Regional Nurse Consultant stated the facility had recently reported the elopement of Resident #6 [to HHSC] when a visitor had let the resident out of the facility. The Regional Nurse Consultant stated Resident #6 wanted to go out of the facility to get a cigarette, she was in a wheelchair and physically could not open the front door because it was too heavy for the resident. The Regional Nurse stated Resident #6 was slightly cognitively impaired due to the resident's mental diagnoses but Resident #6 could present herself as being cognitively with it to someone who did not know her. The Regional Nurse Consultant said Resident #6 was transferred to another facility that allowed smoking, had a wander guard system, and because the resident could try to convince someone to let her out of the facility and this facility did not have a wander guard system (a device placed on a resident who was confused that would cause the door to lock and not open when the resident was near the door preventing them from leaving the facility). In an interview on 03/09/24 at 10:47 AM, CNA E stated Resident #6 would be in the hallway in her wheelchair asking for ice, would sit in the front lobby area, and had not tried to exit the facility. CNA E stated on 03/07/24 she saw Resident #6 in the dining room during the evening meal, then she thought the resident went to her room. CNA E stated around 8 PM when she was doing room rounds, she did not see Resident #6, informed the nurse, they searched the building, the patio area and they could not find the resident. CNA E stated the nurse notified the DON and Administrator who came to the facility. The CNA thought the Administrator found Resident #6. In an interview on 03/09/24 at 2:50 PM, the Activity Director stated Resident #6 had been in the facility for one week, liked to sit outside in front of the building in view of the front receptionist/HR employee and could not open the front door herself. Observation on 03/10/24 at 7:55 AM revealed the front door was not locked, there was no keypad to punch to unlock the door, and no alarm sounded when the surveyor entered the facility, and there was no signage directing visitors to not let residents out of the facility without notifying staff. Inside the front lobby the HR Employee sat at the desk in the lobby area. In an interview on 03/10/24 at 9:08 AM, CNA F stated Resident #6 would propel herself around the facility in the hallways and could not open the front door by herself. In a telephone interview on 03/10/24 at 10:19 AM, CNA G stated she worked the 10 PM to 6 AM shift and Resident #6 would sleep a couple of hours at night, would propel herself around the facility in her wheelchair, sit at the front door and the CNA never saw the resident touch the front door or try to leave the facility. CNA G said she worked the night shift on 03/07/24 (into 03/08/24) after Resident #6 had eloped and the CNA had to lay eyes on the resident every 30 minutes which was documented on an elopement monitoring form and was in-serviced on elopement. In an interview on 03/10/24 at 2:33 PM, the DON stated Resident #6 wanted to be independent, would propel herself around in the hallways, would sit in the front and out in front of the facility and the HR Employee would watch Resident #6. The DON said Resident #6 could not open the front door herself, had not tried to do it before the elopement and a visitor assisted the resident out of the facility the evening she eloped. The DON stated Resident #6 was found across the street at Hospital C, she was assessed for injuries with none noted, the resident's family and physician were notified. After Resident #6 was brought back to the facility, the DON said monitoring was done on Resident #6 every 30 minutes until an alternative facility was found for Resident #6 where she could be more secured. The DON stated the facility did not have a wander guard system. In an interview on 03/10/24 at 3:32 PM the Administrator stated he was at home when the DON informed him staff could not find Resident #6 in her room. They looked in all the rooms and immediate area outside the facility, could not find the resident and contacted the DON and him. The Administrator said he looked at the facility's cameras which showed Resident #6 left the dining room after the evening meal, then down 300 hall (which was between the hall w/ the dining room and the front area) into the front lobby. A visitor went out the front door and pushed Resident #6 out the front door. Resident #6 was in front of the facility and another stranger assisted Resident #6 by pushing her across the street to the hospital. The Administrator stated he and the DON went to the hospital, searched the hospital halls and found Resident #6, brought her back to the facility, started 30-minute monitoring of the resident which was documented until Resident #6 was transferred to another facility that had a wander guard system. The Administrator said there was nothing in Resident #6's prior history that indicated the resident was an elopement risk, the resident could not open the front door herself and if it had not been for the visitor, Resident #6 would not have gotten out of the facility by herself. Observation and interview on 03/11/24 at 8:15 AM of Resident #6 in Nursing Home H, revealed the resident was in a wheelchair and could propel herself without assistance. Resident #6 stated she went to the hospital because she wanted her leg to be looked at. Resident #6 pulled her gown up over her right knee and showed the surveyor a healed surgical scar over the knee cap. Resident #6 said she had someone help her walk across to the hospital. When asked if she could open the front door of the facility without assistance, Resident #6 became agitated and asked, why are you asking these questions? Observation on 03/11/24 at 9:15 AM revealed when the surveyor entered the facility, the front door was unlocked, there was no signage at the entrance directing visitors to not let residents out of the facility without notifying staff, and the HR Employee was at the front desk in the lobby area. In an interview on 03/11/24 at 9:47 AM, the Administrator stated the facility's cameras showed a visitor held the door open, let Resident #6 go out of the building and assisted with pushing her over the door threshold. Resident #6 sat in front of the building for about 10 minutes, then propelled herself to the edge of the driveway when a person walking by stopped to talk with Resident #6 and then pushed her across the street to the hospital. The Administrator said the time from when Resident #6 was pushed out of the facility and then across the street was about 30 minutes. The Administrator stated since this incident, staff had been in-serviced on elopements and the red-alarm on top of the front door would be turned on when the HR employee was not at the front desk. In a further interview on 03/11/24 at 10:31 AM, the Administrator stated half of the staff had been in-serviced on Elopement and the other half would be in-serviced on 03/11/24. In an interview on 03/11/24 at 10:44 AM, MA I stated on 03/07/24 she saw Resident #6 sitting in front of the Administrator's office, in the font lobby with HR Employee and did not remember the resident talk about cigarettes. In an interview on 03/11/24 at 10:51 AM, CNA F stated on 03/07/24 Resident #6 was propelling herself around the facility in her wheelchair, asking for coffee, then she sat by the nurse's station, and did not mention anything about cigarettes to the CNA during the day. CNA F said, I didn't know she smoked. In an interview on 03/11/24 at 10:55 AM, HR Employee said Resident #6 would frequently be in the front lobby and if the resident wanted to go outside she would assist the resident outside and have her in front of the window to watch the resident. HR Employee stated on 03/07/24 she took Resident #6 outside and watched her through the window, the resident requested coffee, candy and only mentioned she wanted to put a cigarette into her mouth which the HR Employee discouraged the resident from doing so. The HR Employee said she took Resident #6 to the nurse's station when she left the facility at 5 PM. In an interview on 03/11/24 at 11:27 AM LVN J stated she worked the 2 PM to 10 PM shift on 03/07/24. LVN J said Resident #6 was propelling herself in the hallways and had asked for ice. LVN J stated she directed Resident #6 to the dining room around dinner time. LVN J stated when the CNAs were doing their last rounds for the evening, they could not find Resident #6. LVN J said she asked the aides when they last saw the resident which was when she had been in the dining room at the dinner meal. LVJ J stated they started to look for Resident #6 and when they could not find her they called the DON and Administrator. LVN J stated on 03/08/24 she monitored Resident #6 by making sure the resident was in her visual line of sight which was recorded on the monitoring sheet until the resident was transferred to another facility. In a telephone interview on 03/11/24 at 11:54 AM CNA E, who worked from 6 AM to 10 PM on 03/07/24, stated Resident #6 had mentioned she wanted to call her family, did not mention cigarettes or about wanting to try to leave the facility. CNA E stated around 6 PM a family member rang the doorbell because the front door was locked, she let them into the facility, made sure the door was closed after she let them into the building because it would make a locking sound when pulled all the way shut, and the red alarm on the front door was not turned on. In a telephone interview on 03/11/24 at 12:06 PM CNA K stated he worked the 2 PM to 10 PM shift on 03/07/24, he did not remember Resident #6 asking for cigarettes that day, had not seen the resident try to push the front door open and the last time he saw the resident was after dinner in front of her room. CNA K stated after Resident #6 was brought back to the facility a visual eye was kept on the resident and recorded on the monitoring log. In an interview on 03/11/24 at 12:17 PM, HR Employee stated when the front door was locked, visitors and staff could not enter the facility without ringing the doorbell but staff and visitors inside the building could exit the facility when the front door was locked by pushing on the bar. In a telephone interview on 03/11/24 at 12:20 PM CNA L stated she worked the 2 PM to 10 PM shift on 03/07/24 and Resident #6 was asking for ice, propelled herself around the facility, she did not ask for any cigarettes and last saw the resident in the dining room after dinner around 6 PM. CNA L said she was on her dinner break at 8 PM when CNA E asked CNA L when she last saw Resident #6 because they could not find her. CNA L stated they looked around the facility for the resident and the DON and Administrator came to assist with searching for the resident. CNA L stated the next day there was a monitoring sheet kept at the nurse's station that staff would initial that Resident #6 had been seen and she was in-serviced on elopement. In an interview on 03/11/24 at 1:24 PM, the Administrator stated because the facility does not have a wander guard system they would never accept any resident who had a history of elopement or elopement type behaviors. The Administrator said the red alarm on the top of the front door had been there when Resident #6 eloped from the facility, was not on when she left the building and after her elopement they started to turn it on when there was no one at the front desk. In an interview on 03/11/24 at 1:25 PM, the Regional Nurse Consultant said she completed the pre-admission screening for Resident #6 and there was no indication in the preadmission paperwork or hospital paperwork that the resident was an elopement risk or required one-on-one monitoring. The Regional Nurse stated if Resident #6 had a history of elopement, the resident would have been referred to a facility that had a wander guard system. Further interview on 03/11/24 at 4:20 PM, the Regional Nurse Consultant stated Resident #6's Hospital D's paperwork did not indicate Resident had eloped, therefore Resident #6's baseline care plan assessment was not checked that the resident was at risk for elopement because there had not been any previous elopements. Observation on 03/12/24 at 8:10 AM revealed there was no signage on the front door directing visitors to not let residents out of the facility without notifying staff. Record review of the policy Elopements, dated December 2023, revealed Staff shall investigate and report all cases of missing residents 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing services or Charge Nurse shall: a. Examine the resident for injuries; b. Notify the Attending Physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on a authorized leave or pass; b. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative; d. Notify search teams that the resident has been located; e. Complete and file an incident report; and f. Document relevant information in the resident's medical record. This non-compliance was identified as past non-compliance IJ. The non-compliance began on 3/07/2024 and removed on 3/07/2024. The facility had corrected the noncompliance before survey began.