Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 21 residents (Resident #170) reviewed for supervision.The facility failed to ensure Resident #170 eloped (via foot) from the facility to a local energy service company (0.7 miles) on the night of 06/13/25 at 7:45 PM. Resident was found 4 1/2 hours later at 12:24 am on 6/14/25.The noncompliance was identified as PNC. The IJ began on 6/13/25 and ended on 6/14/25. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk for injuries due to not receiving the appropriate level of supervisionFindings included:Record Review of profile sheet dated 6/24/25 at 12:20 p.m., indicated, Resident #170 was diagnosed with dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life).Record Review of Resident #1's care plan, dated on 06/13/25, indicated Resident #170 resided in the secure unit related to risk for elopement. The care plan goal included: Safety will be maintained, and resident will wander about unit without the occurrence of any injury through the next review date. The care plan interventions included: Activity Director to monitor/discuss activity preferences; Call by name when providing care, involve in care as much as possible; Explain procedures, using terms/gestures resident can understand-repeat PRN; Keep environment free of possible hazards and Monitor to assure resident safety.Record Review of observation detail report on Resident #170 dated on 6/13/25 at 0027 indicated, Resident #170 had a history of wandering prior to admission; resident exhibits wandering behavior; resident had (1) or more occasions attempted to exit or had exited the facility in a effort to wander away; resident follows others around, if someone exits the facility the resident will follow; resident had a medical diagnosis associated with confusion; resident experienced increased confusion, occurring with high risk factors; resident exhibits behavior typical boredom, (1) goes to door, turns doorknob, but does not exit (2) walks to window and gazes outside,(3) wanders into other resident or facility rooms to observe and or engage in conversation with other residents and or staff members, etc. The observation report indicated the potential interventions included the secure unit. The observation report indicated the safety awareness: resident recognized stop lights and signs; resident knew precautions when crossing the street; resident can state name; resident did not know the location of current residence; resident physical needs.Record Review of progress Note from LVN G dated 6/13/25 at 7:54 pm indicated, Resident #170, Resident up walking in common area adjusting well to surroundings makes needs known denies pain or discomfort.Record Review of Event report dated 6/13/25 at 10:30 pm indicated, resident was located approximately 1 mile from the facility at 0024; Possible contributing factors: Alzheimer's Disease, Dementia, and terminal illness; Unsettled relationships: Absence of personal contact with family/friends and does not adjust easily to change in routine; Inventions: Resident was taken back home with family.Record Review of a typed note by the Administrator dated on 6/13/25 at 10:30 pm indicated, Notifications were made to the medical director, Administrator, DON, Hospice company, LTC management team and family members. Record Review of the EMS report on Resident #170 on 6/14/25 at 0029 indicated, Resident #170 did not need treatment or transport. EMS released the resident to resident #170's family member.Record Review of progress note from RN H on 6/14/24 at 1:15 am indicated, Writer was notified by charge nurse at approximately 20:30 resident could not be located within secured unit, or facility. Facility grounds and surrounding areas searched. Unable to locate resident. Local police department contacted for assistance. Family and hospice company, MD contacted. Resident located off facility property at approx. 00:24. Head to toe assessment completed by local fire department with 0 injuries or skin concerns reported to writer. Resident ambulating, talking with 0 concerns visualized. Family along with local police department retuned resident to facility, family gathered medications and belongings and resident was discharged into family care at this time. Hospice and MD aware.Record review of provider self-reporting of LTC incident dated 6/14/25 at 12:52 pm indicated, this incident occurred on 6/13/25 at 8:30 pm regarding a missing Resident #170. The report indicated at approximately 2021 on June 13, 2025, the director of nursing notified the Administrator that a resident was unaccounted for and potentially missing from the facility. The Administrator immediately contacted the corporate team and instructed all departmental staff to return to the facility to assist in a coordinated search effort. The report indicated immediate facility actions taken elopement risks assessments were reviewed and updated; abuse and neglect in-services provided to all staff; elopement prevention and response in service training was conducted; Notification made: Administrator, DON resident's family, Hospice provider, Medical director, corporate oversight team and police notified. The report indicated a brief narrative of the incident: At approximately 2021 on June 13th, 2025, the Director of Nursing notified the Administrator that a resident was unaccounted for potentially missing from the facility. The Administrator immediately contacted corporate team and instructed all staff to return to the facility to assist in a coordinated search effort. A through room-by-room search of the building was conducted and confirmed the resident was not present within the facility. Immediately following staff conducted a search of the facility grounds and surrounding areas, law enforcement, the resident family and hospice team were notified at that time, at approximately 0050 on June 14th, 2025, the resident was found unharmed with no visible injuries or signs of distress. Upon medical clearance the resident was turned over to her family. At 0115 the family returned to the facility to retrieve the resident's personal belongings and formally discharged the resident into their care.Record Review of the facility investigation report undated, indicated, According to nursing staff, resident was last seen between 1925 -1945 on 6/13/2025 on Whisper Lane. Nurse stated that all meds were given after the evening meal and resident had gone to her room for the evening. At 2021, the DON contacted the administrator to Inform him that resident was missing, and staff had been unable to locate her for the previous 10-15 minutes. Administrator and DON immediately implemented elopement protocol for the building. The administrator and DON called in all department heads that live nearby into the building to help with the search efforts. At 2023, Administrator notified RDO (Regional Director of Operations) of missing resident and staff began a room by room sweep of the building and grounds immediately around the facility. At 2107, the administrator called Police Department Ref# 25-002512 and reported a missing resident. Concurrently, MD, family, and hospice were notified as well, and search efforts were expanded to nearby streets, residential areas and places of business. Police showed up shortly after 2115 to receive information related to the resident and to expand search efforts by employing Volunteer Fire Department. Roughly around 2140, an expanded search was being conducted further out from the nursing facility during this search the resident was located at 0024, 06/14/2025 at Energy Company. Resident was medically assessed by EMS services and found to have no injuries or adverse effects relating to the incident. On 6/14/2025 at 0045, EMS released resident to her family where she was transported back to the facility so family could pick up the remaining items from her stay. Resident was officially discharged from the facility on 6/14/2025 at 0115. Investigation Findings: The maintenance director checked all doors, alarms, and keypads at 2040 and found that all were closed, locked and functioning properly. With this information the facility can only speculate that the resident was able to exit Whisper Lane at the same time a visitor was entering/exiting Whisper Lane and was not aware that the resident was actually a resident and not a visitor herself. Immediate Actions Taken: Maintenance director checked all doors, alarms, and keypads at 2040: all functioned properly; Police were notified after resident was not located on facility grounds; MD, family and hospice were promptly notified of the missing resident; Fire Department located the resident at 0024: resident was medically assessed by EMS and released to family at 0045; Resident returned to facility with family to pick up remaining items and officially discharged home to family at 0115.During record review on 6/24/25 at 10:16 a.m., the facility completed elopement risks for all residents residing in the secure unit following this incident on 6/13/25.During record review on 6/24/25 at 10:46 a.m., the facility completed in services on abuse and reporting on 6/13/25; Elopement policy and prevention on 6/13/25; Nursing policy and Procedure and Door codes a secure unit safety on 6/14/25.During record Review on 6/24/25 at 10:57 a.m., Door/gate checkoffs dated May 2025 was reviewed by the Maintenance Director and Administrator. During record Review on 6/24/25 at 11:00 a.m., monthly and daily coded door inspection in-service was reviewed; this in-service was signed by the maintenance director on 6/16/25. The in-service objective: to ensure the safety and security of all residents by maintain fully functional coded exits and gates. All coded doors and gates must be checked daily for proper functioning and coded lock integrity. Additionally, codes must be changed out and tested monthly to mitigate risk of unauthorized exit; Responsibility of Maintenance Director: (1) perform a physical check of each listed door and gate to ensure close a lock securely (2) check door alarms and coded lock function to verify proper operation. (3) Document all daily door checks on the log sheet provided (4) change and test all coded door/gate locks once every month (5) immediately report and correct any malfunction or failure to lock/alarm (6) participate in quarterly safety meetings and submit log summaries to the Administrator.Record Review of the official police report was requested by the Administrator on 6/24/25 at 11:50 a.m., police report was not received prior to exit on 6/25/25.Record Review on 6/24/25 at 4:35 p.m., of the monthly/daily summary door and gate checkoff for the month of June 2025 indicated, daily checks on exit door, courtyard, courtyard gate, side door to laundry, dining south exit, Texas, Blvd. exit, Park ave exit and back nurse Exit were completed Monday thru Friday from 6/11/25 to 6/24/25. During a return phone call interview on 6/24/25 at Resident #170 RP stated on the night of June 13th her Resident#170 RP called her about 9 pm stating that Resident #170 was missing from the nursing home. Resident #170 RP stated her was notified by hospice company that was missing from the facility. Resident #170 RP stated she and her whole family went to go look for Resident#170. Resident #170 RP stated upon admission she was supposed to be in a locked unit. Resident #170 RP stated had memory issues. Resident #170 RP stated Resident #170 called her Mom and called her husband Pawpaw. Resident #170 RP stated when she arrived at the facility that no staff member at the facility could tell her what time her went missing. Resident #170 RP stated she was not sure where Resident #170 was found. Resident #170 RP stated she estimated to be gone from the facility for at least 5 to 6 hours. Resident #170 RP stated she was found by fire department trying to enter an unknown building. Resident #170 RP stated a police report had been filed but she did not have a copy of the report. Resident #170 RP stated when she was outside the nursing home and the police officer had gathered everyone at the facility and a staff member had told the police that he gave her medicine around 7:45 pm on that Friday (6/13/25). Resident #170 RP stated her had posted on her Facebook page that her had been missing. Resident #170 RP stated someone from Facebook had reached out to her and stating they believed to had seen her around 7 pm on that Friday night 6/13/25 but they did not know who was at the time until they seen the Facebook post online. Resident #170 RP stated the police told her that he had gotten conflicting stories from the nursing facility. Resident #170 RP stated was back at home following this incident. Resident #170 RP stated her (Resident #170) was set up for respite care in her home and was doing fine. During a returned phone call interview on 6/24/25 at 9:57 am., LVN G stated the last time he had seen the resident was around 7:45 pm on 6/13/25. LVN G stated shortly after he had seen the resident in the facility an aide in the secure unit had come and asked him if he had seen Resident #170. LVN G stated he had started looking for the resident and he could not locate the resident in the secure unit. LVN G stated he checked closets and residents' room and could not locate the resident. LVN G stated he called the DON and notified the DON of the resident missing. LVN G stated the DON got the search party going. LVN G stated staff continued looking for the residents while he stayed back with the other residents. LVN G stated at shift change he gave a report to the oncoming nurse about the elopement of Resident #170. LVN G stated after his shift, he stayed and talked to the police officer, DON, and Administrator. LVN G stated following his shift the resident had not been located. LVN G stated he was told after the resident was found by the police station that the resident did not have any injuries. LVN G stated he was told the resident was okay. LVN G stated staff was trained on elopement following this incident. LVN G stated the facility had changed a lot since this incident. LVN G stated family members who came to visit loved ones did not come and go freely on their own in the secure unit. LVN G stated the family members were let in and out of the secure unit by staff only. LVN G stated he worked the 2 pm to 10 pm shift on the day of this incident and he was the charge nurse in the secure unit.During an interview on 6/24/25 at 8:45 a.m., CNA F stated she was not sure what took place. CNA F stated she just noticed the resident was at the facility and then the resident went missing. CNA F stated she did not know how long the resident was missing. CNA F stated she did know where the resident was located at. CNA F stated the resident family took the resident back home when she was located on 6/14/25. CNA F stated she was not aware of the residents having any issues. CNA F stated she worked the 2 to 10 pm shift at the facility. CNA F stated she was informed that resident was missing when she came back from break. CNA F stated she did not remember what time she had taken her break. CNA F stated she had been employed at the facility for 6 months. CNA F stated she received training on what to do when a resident eloped from the facility. During an interview on 6/24/25 at 2:53 p.m., the Maintenance Director stated he a performed a physical check of each listed door and gate on 6/13/25 to ensure they closed and locked. The Maintenance Director stated he checked the door alarms and coded locks on 6/13/25 and had no issues. The Maintenance Director stated he tested all coded door/gate locks monthly. The maintenance Director stated he documented monthly door checks but since this elopement incident he documented daily door checks. The Maintenance Director stated he reported malfunction locks and alarms to the Administrator and corporate office. The Maintenance Director stated he submitted monthly summary logs to the Administrator and participated in quarterly safety meetings. The Maintenance Director stated he did not have any summary logs to provide for review. The Maintenance Director stated he was the Maintenance Director at the time of this incident. The Maintenance Director stated that he had been the Maintenance Director for 5 years. The Maintenance Director stated following this incident that the facility conducted in-services on door alarms and locks. During an interview on 6/24/25 at 3:10 p.m., the DON stated she was the DON at the time of this incident. The DON stated she got a phone call from the charge nurse stating they could not locate the resident in the facility. The DON stated she informed the Administrator that the resident was missing from the facility. The DON stated from the time she was notified to the time the resident was found it was about 4 hours. The DON stated the resident was found by the local fire department. The DON stated the resident was attempting to enter a closed business and that's how the resident was located. The DON stated she did not assess the resident and EMS reported to her that she did not have any injuries. The DON stated EMS stated the resident did not appear hungry or thirsty. The DON stated the police was notified. The DON stated interviews from staff member were collected by the Administrator and herself. The DON stated the facility changed the codes to the entrance. The DON stated since this incident families were escorted off and on the facility. The DON stated before this incident family were able to enter the facility because they had the codes to the facility. The DON stated the family, hospice and the medical director was notified of this incident. The DON stated after this incident the family brought the resident to the facility and gathered the rest of the resident's belonging. The DON stated the resident was residing in the secure unit at the time of the elopement. The DON stated the only assumption of how the resident was able to leave was that the resident exited the facility with a family member. The DON stated the resident was very mobile and looked young. The DON stated the facility was responsible was responsible for ensuring the residents did not elope from the facility. The DON stated the risk for elopement was injury and harm. The DON stated staff were in-serviced on elopement policy and procedures, but staff were not in service on exit seeking behaviors. During an interview on 6/24/25 at 3:43 p.m., the Administrator stated he was the Administrator at the time of this incident. The Administrator stated he had been the Administrator for 2 1/2 months. The Administrator stated he was notified by the DON via phone call. he stated he told the DON to go into policy and procedure and lock down the building. The Administrator stated he had department heads do an inside sweep of the building to search for the resident. The Administrator stated he was told the resident had been missing for 10 to 15 minutes. The Administrator stated the fire department found the resident near key energy services which was 100 yards from the police and fire department. The Administrator stated the resident did not have any injuries. The Administrator stated the polices was notified at 2107 on 6/13/25. The Administrator stated he received two written statements from staff on what happened. The Administrator stated he changed his door codes monthly. The Administrator stated he had daily monitoring on all door and access point. The Administrator stated since the elopement that he conducted daily rounds, and he checked the door and locks randomly. The Administrator stated he discussed safety in QAPI meetings. The Administrator stated he audible alarms on all the door if the keypad system was to go down, that the facility had a backup system in place of the keypad system. The Administrator stated after this elopement the resident discharged home. The Administrator stated the resident was residing in the secure unit at the time of this elopement. The Administrator stated he did not know how the resident was able to leave the secure unit. The Administrator stated all staff was responsible for ensuring the resident did not elope from the facility. The Administrator stated the family, medical director and ombudsman was notified of the elopement. The Administrator stated the risk for elopement was injury or harm. During a phone interview on 06/24/25 at 05:10 p.m., LVN A stated she worked the 10pm to -6 am shift 4 days on and 2 off. LVN A stated she had been employed at the facility for 8 months. LVN A stated she worked the night shift on that night of the elopement. LVN A stated when she got to work Resident #170 was gone already. LVN A stated when the resident was found that the DON called her about 12:30 AM and said the family wanted her medications and belongings and she gathered them and met family at the front door to give the belongings to the police officers. Stated she staff received a refresher of an in-service over elopement. LVN A stated she did not work the night before. he Stated they had a few different in-services over elopement including exit seeking behaviors. LVN A stated staff changed all the codes on the doors in the unit and the other doors to the facility. LVN A stated the 3 doors in the unit have a chime noise it makes when anyone enters or exits. LVN A stated no visitors have any of the codes and the staff have to allow them visitors in and out. During a phone interview on 6/24/25 at 5:11 pm CNA B stated she came in at 10 pm on 6/13/25 and she was notified that the resident was missing upon entering the facility. CNA B stated in-services was completed following this incident. CNA B stated in-services on elopement, abuse and neglect, door alarms. CNA B stated staff had changed all the codes to the building. CNA B stated the facility had alarms on the doors and windows. CNA B stated the facility upgraded the doors. CNA B stated family members and guest did not know the codes to the door. CNA B stated she worked the night shifts. CNA B stated she worked the 10 pm to 6 pm. stated she had been employed at the facility for 14 years. CNA B stated was a CNA. CNA B stated she worked in the secure unit. During an interview on 06/24/25 at 05:09 p.m., CNA C stated she worked the 2-10 pm shift normally. CNA C stated she had no idea how the resident got out of the facility. CNA C stated, You can't miss the resident because the resident hovers over you. CNA C stated she remembered staff serving and then the resident was helping staff pick up trays. CNA C stated staff took the trays back and the resident was around the desk. CNA C stated staff then laid a few residents down and Resident #170 was in the dining room. CNA C stated CNA F had asked her if she could go on lunch and she told CNA F, Yes. CNA C stated doing this time Resident #170 was at the nurse's desk. CNA C stated next, she went to lay another resident down (Resident#270) and Resident #170 was around the nurse's station. CNA C stated after she laid her down and upon coming out from Resident #270's room Resident #170 disappear. CNA C stated staff started looking by checking the rooms, opening bathrooms door and staff could not find Resident #170. CNA C stated the charge nurse (LVN G) called the DON. CNA C stated Resident #170 was at the facility when CNA F went to lunch. CNA C stated staff started looking for the resident before CNA F came back from break. CNA C stated when CNA F came back from break that, she helped staff look for the resident. CNA C stated to her knowledge, there were no family members at the facility when the resident disappeared. CNA C stated the aide CNA F had been gone to lunch when Resident #170 went missing and LVN G had not left the unit. Stated someone checked the windows in the secure unit. CNA C stated all 3 doors had a code to enter and exit. CNA C stated she received education on elopement, plan-to look in all room, notify the DON and notify the police. CNA C stated staff also went over if a resident was exit seeking and to keep your eye on the residents. CNA C stated Resident #170 never said she wanted to get out of the facility to her. CNA C stated the resident was only at the facility for respite for 5 days. CNA C stated it was usually 2 aides and 1 nurse or 1 nurse and 1 aide but mostly 3 staff in the secure unit. CNA C stated if a resident wanted or attempted to leave the facility that she would redirect the resident and keep an eye on the resident.During an interview on 06/24/25 at 05:30 p.m., CNA D stated she had been employed at the facility for over a year. CNA D stated she was not at the facility on the day of the elopement (6/13/25). CNA D stated she usually worked 10pm to 6am shift and most residents were asleep during her shift. CNA D stated she received education on the door code, keeping the doors locked, checking on the residents, elopement and exit seeking behaviors. CNA D stated if a resident was trying to exit seek staff were to watch the residents and redirect the residents. CNA D stated on the night shift that it was 1 nurse and 1 aide.During an interview on 06/24/25 at 05:34 p.m., RN E stated she worked PRN at the facility. RN E stated she never met Resident #170. RN E stated she was gone for over 2 weeks from the facility. RN E stated she received education on not letting anyone know the codes to the doors. RN E stated if a resident was to attempt to exit seek that she would redirect the resident and watch the resident closely. Record Review of the Elopement policy dated 12/2017 indicated, Policy: It is the policy of this home to provide a systematic approach to searching for a resident who may have left the home and/or grounds; Procedure: The following steps are to be followed when a resident leaves the home grounds without staff notification; Home staff will: search the home and grounds, send staff member(s) out to locate the resident, notify Administrator or on-call person immediately, if resident is not located, call the police for assistance; Charge nurse will: Notify responsible party(this may be done when the search is initiated), notify the resident physician, assess the resident on return to the home, document the time resident absence is noted, time of return, assessment of resident and notification of the physician and responsible party; complete incident report in the clinical software; follow-up charting for 24hours if no injuries: follow up charting on injuries until resolved; administrative/Supervisory staff will: determine if elopement is reportable to state regulatory agency, interview staff and obtain written statements. If resident was returned by outside personnel, obtain name, phone number and details with any information of where resident was found and under what circumstances the resident was found, establish a monitoring system for resident until flight risk is resolved determine what measures can be taken to prevent it from happening again, if elopement is reported, contact appropriate corporate personnel.The noncompliance was identified as PNC. The IJ began on 6/13/25 and ended on 6/14/25. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 2 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 was adequately supervised which resulted in Resident #1 leaving the facility on 08/12/24, walking approximately 0.5 miles , and crossing a busy 2 lane road. The facility failed to ensure the ADON put measures in place to keep Resident #1 from leaving the facility when she said she saw Resident #1 climb the fence. The facility failed to monitor and put measures in place to keep Resident #1, who was high risk for elopement, from eloping after voicing wanting to go home. The noncompliance was identified as PNC. The IJ began on 08/12/24 and ended on 08/14/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of potential accidents, injuries, harm, or death. Findings included: Record review of Resident #1's face sheet dated 03/04/25, indicated a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had diagnoses of dementia (memory loss) with behaviors, anxiety (mental health condition characterized by excessive worry, fear, and nervousness), depression (mental health condition characterized by persistent feeling of sadness, loss of interest, and low energy that can significantly interfere with daily life), and hypertension (high blood pressure). Record review of Resident #1's admission MDS assessment dated [DATE], indicated Resident #1 was usually understood and sometimes understood others. Resident #1 had a BIMS score of 4, which indicated his cognition was severely impaired. Resident #1 had delusions and received hospice care. The MDS assessment indicated Resident #1 did not wander. Resident #1 required setup or clean up assistance with eating, oral hygiene, toileting, and personal hygiene. Record review of Resident #1's comprehensive care plan dated 08/12/24 and last revised on 08/14/24 indicated Resident #1 was at risk for elopement as evidenced by repetitive statements of going home. The care plan interventions indicated staff to orient and redirect resident as needed, attempt to find the source of behaviors, divert resident's attention, and refocus attention elsewhere, elopement assessment performed quarterly, with significant change, and as needed, monitor and record behaviors, when it occurred and notify physician and family of any further concerns. Record review of Resident #1's physician order reported dated 08/01/24-08/31/24 indicated Resident #1 had the following orders: o Depakote 125mg give one tablet by mouth once a day for dementia with behavioral disturbances and a start date of 06/11/24. o Donepezil 10mg give one tablet by mouth once a day for dementia with behavioral disturbances and a start date of 06/11/24. o Quetiapine 25mg give one tablet by mouth once a day for dementia with behavioral disturbances and a start date of 06/11/24. o Lorazepam 1mg give one tablet by mouth twice a day for anxiety with a start date of 06/13/24. o Paroxetine 20mg give one tablet by mouth once a day for depression with a start date of 07/12/24. o Vistaril 25mg give 2 tablets by mouth every 8 hours as needed for anxiety with a start date of 08/12/24. o Do not send to ER without calling [hospice company] first with a start date of 06/06/24. o May transfer to [behavioral health facility] for evaluation with a start date of 08/14/24. Record review of Resident #1's elopement/wandering assessment dated [DATE], completed by RN F, indicated Resident #1 exhibited 1 or more high risk factors to wander, which indicated he was classified as a high risk to wander. The elopement/wandering assessment for Resident #1 indicated he had the following high-risk factors to wander: a history of wandering prior to admission to the facility, exhibited wandering behavior, resident followed others around, verbalized the need and or desire to go home or to another location and had the ability to act on that verbalization. The assessment indicated the intervention was the secured unit. The assessment also indicated Resident #1 did not know the location of his current residence. Record review of Resident #1's progress note dated 08/07/24 at 11:43 PM signed by RN F indicated .Resident awake and very agitated. Refuses to go to bed and keeps saying that he drove himself here in his mother's car, and that she will need it to drive to work in the morning. States that we are holding him against his will and has torn down all of the notes we had hanging up to remind him of why he was here. He says that his Dr did not put him here, and that he doesn't have a wife, He went to door at NS and shook it very hard, He also said he is going to sue this company, and burn it down, He says he does not mind going to jail, because that would be better than staying here. Sitting in recliner at NS at this time. Trying to redirect him we offered to call his wife for him, but he refused saying that we were lying to him about him having a wife. When I suggested we just call her and see if she answers and was adamant that he did not want me to call anyone. Record review of Resident #1's progress note dated 08/08/24 at 12:33 AM and signed by RN F indicated . Resident continues to escalate with his behaviors. He is shoving on doors and hitting them with his hand. DON notified and she asked if he had had his PRNs. I said yes and she said called [MD]. [MD] said send him to ER. EMS arrived and we talked him into getting on the stretcher by telling him he was going to get outside of these doors. EMS is gone with him. Record review of Resident #1's progress note dated 08/08/24 at 4:30 AM and signed by RN F indicated . Resident returned from ER. Alert and ambulatory. Pacing and carrying his personal possessions with him. He is shadowing everyone that starts toward an exit door, and muttering something about he has to get home. We are monitoring him closely. Notified [hospice company] that resident was back in the building. Record review of Resident #1's progress note dated 08/08/24 at 6:17 AM and signed by RN G indicated . Resident exhibits increase agitation, approaches nurses station asking this write to leave facility. Resident noted to have personal belongings packed within personal reach. Writer attempts to redirect to other activities, currently unsuccessful at this time. Resident refusing vital sign checks and medication administration at this time. Will attempt to redirect and provide care as resident tolerates. Record review of Resident #1's progress note dated 08/08/24 at 08:00 AM and signed by RN G indicated . Resident continues to push on exit doors, making verbal demands to leave secured unit. Writer attempts to redirect resident to other activities, currently unsuccessful at this time. Resident continues to refuse foods, fluids, vital sign checks, and scheduled medication at this time. Will continue to attempt to redirect and offer care as resident tolerates. Record review of Resident #1's elopement/wandering assessment dated [DATE], completed by RN G, indicated Resident #1 exhibited 1 or more high risk factors to wander, which indicated he was classified as a high risk to wander. The elopement/wandering assessment for Resident #1 indicated he had the following high risk factors to wander: *a history of wandering prior to admission to the facility, *exhibited wandering behavior, *resident had on (1) or more occasions attempted to exit or has exited the facility in an effort to wander away, whether intentionally or due to confusion, *resident followed others around, *verbalized the need and or desire to go home or to another location and had the ability to act on that verbalization. The assessment indicated the potential interventions were secured unit, review medications, recreational activities, personalization of room with familiar objects and photographs, staff aware of resident's elopement risk, and staff aware of resident's wander risk. The assessment indicated Resident #1 did not recognize stop lights and signs, and he did not know precautions when crossing streets or the location of his current residence and was not able to recognize physical needs. Record review of Resident #1's progress note dated 08/12/24 at 4:28 PM and signed by the DON indicated . Family and CNA reported to writer that resident is making threats to self-harm. Stating 'if I have to stay here, I am going to kill myself'. When staff attempted to redirect resident became agitated and threatened to kill staff member. Staff report Resident has been increasingly agitated, and hospice had been notified for med management. All attempts to redirection unsuccessful at this time. MD, family aware. Suggestion to send to behavioral health for safety needs at this time. [family member] at bedside and aware. Resident on 1:1 care at this time. Record review of Resident #1's progress note dated 08/12/24 at 6:42 PM and signed by LVN B indicated . at 15:00 (3:00 PM) resident went outside for scheduled break with CNA. At the end of the scheduled break at approximately 15:15 (3:15 PM) resident refused to come back inside. Resident then made threats to the CNA and continued to refuse to come inside. SN approached resident and asked him to come incident and resident then made references to self-harm. SN then contacted Hospice Services about resident escalating behavior. SN then contacted resident's RP who stated she would come up to the facility to talk with resident. RP arrived at approximately 16:45 (4:45 PM) and was able to talk to resident into coming back inside. Hospice nurse arrived shortly after and contacted MD and received an order for hydroxyzine 50mg PO Q8 hrs. PRN. Medication was administered at approximately 17:30 (5:30 PM). At approximately 18:00 (6:00 PM) resident is resting in bed with eyes closed, resident now has a one-on-one nurse to monitor for the remainder of this shift. SN will follow up. Record review of Resident #1's hospice visit note dated 08/12/24 at 11:54 AM completed by Hospice RN A indicated . Pt was sitting outside in the courtyard. He had just finished his lunch. He was pleasant. No complaints voiced. The nurse stated that earlier the pt refused to come inside and he had to work with him a long time to get him to come in. The [Resident #1's family member] stated when I spoke to her that he prefers to be outside. Pt was not anxious or agitated. Record review of Resident #1's elopement/wandering assessment with an observation date of 08/12/24 completed by the DON on 08/13/24, indicated Resident #1 exhibited 1 or more high risk factors to wander, which indicated he was classified as a high risk to wander. The elopement/wandering assessment for Resident #1 indicated he had the following high-risk factors to wander: *a history of wandering prior to admission to the facility, *exhibited wandering behavior, *resident followed others around, *verbalized the need and or desire to go home or to another location and had the ability to act on that verbalization. The assessment was answered No to the question asking if Resident #1 had on (1) or more occasions attempted to exit or had exited the facility in an effort to wander away, whether intentionally or due to confusion. The assessment indicated the potential interventions were secured unit, review medications, recreational activities, music, personalization of room with familiar objects and photographs, staff aware of resident's elopement risk, and staff aware of resident's wander risk. The assessment indicated Resident #1 did not know precautions when crossing streets, and he did not know the location of his current residence. Record review of Resident #1's hospice client coordination note dated 08/13/24, indicated on 8/12/24 the following occurred: 15:03 (3:03 PM) received a call from [hospice staff] at the office that [LVN B] had called and said that [Resident #1] behavior was escalating. He is out in the courtyard and had removed his shirt, swearing and refusing to come inside. He asked the aide to kill him. 1514 (3:14 PM) I called [Resident #1's family member] and updated her and I was headed to the facility. [Resident #1's family member] said her and [another family member] would be there ASAP. 1545 (3:45 PM) I was driving south on [name] st on the way to the facility when I spotted [Resident #1] walking north. I turned around to keep a visual on him as I called [Resident #1's family member]. She was walking looking for him. [Resident #1's other family member] pulled up and got him in the car. 1600 (4:00 PM) updated [MD]. 1600 (4:00 PM) Pt is sitting in the lobby at the facility with [his family member]. He is always calm [with family member]. After meeting with staff and the family it was decided that the best action for the pt is for him to go to a behavioral unit bc he is a danger to himself. He has been discussing wanting someone to kill him. 1700 (5:00 PM) A bed will be available in the am. The facility placed with the pt 1:1 spoke with [MD]. New order received for hydroxyzine 50mg q 8 hrs PRN. Order written. Educated staff and family on new meds, actions and side effects. Staff is aware to call the emergency number with any questions changes or concerns. Record review of Resident #1's hospice discharge visit note dated 08/14/24 and signed by Hospice RN A, indicated under discharge summary . pt was admitted to hospice after a decline in physical status. admitted to [facility] memory care bc he was no longer safe at home. Pt did not do well at the facility. He eventually got out of the facility. Pt was sent to [behavioral unit]. Record review of the facility incident and accident reports from July 2024-February 2025 did not indicate any elopement incidents. During an interview on 03/03/25 at 09:53 AM, Resident #1's family member said the day of the incident (08/12/24), they received a call from the facility regarding Resident #1's behaviors. Resident #1's family member said they told the nurse they would return to the facility. Resident #1's family member said they called the hospice nurse to meet them there to see what could be done regarding Resident # 1's behaviors. Resident #1's family member said when they arrived at the facility, Resident #1 was not there. Resident #1's family member said the facility staff were unable to locate Resident #1. Resident #1's family member said no one at the facility knew Resident #1 was missing or how long he had been missing. Resident #1's family member said Resident #1 had escaped out the fence and the hospice nurse (unsure of name) found him 3 miles down the road past the middle school. Resident #1's family member said the hospice nurse was the one that followed him until they got there to get him in the car. Resident #1's family member said she wrote the facility a statement when they returned Resident #1 to the facility. Resident #1's family member said Resident #1 was being unmonitored by the facility staff. During an interview on 03/03/25 at 10:47 AM, the Hospice Patient Care Manager said there had been an incident where Resident #1 climbed the fence and left the facility. The Hospice Patient Care Manager said Hospice RN A was on her way to the facility, Hospice RN A happened to turn to look at a person who was walking by, and realized it was Resident #1, so she turned around and followed him. During an interview on 03/03/25 at 11:37 AM, Hospice RN A said the day of the incident (08/12/24) she had been at the facility earlier that day and Resident #1 had been calm. She said she knew what Resident #1 was wearing that day. Hospice RN A said around 4:00 pm, she received a call from his nurse that Resident #1 was agitated. Hospice RN A said they had instructed the facility staff to call them with any behaviors because Resident #1's family member had the ability to calm him down. Hospice RN A said she told the facility she was on her way and then called Resident #1's family member. Hospice RN A said she had been on [name] street, a street close to the local pharmacy, when a longhorns shirt caught her eye. She said she turned to look and realized it was Resident #1. She said, There goes my patient. Hospice RN A said she turned around and called Resident #1's family member. Hospice RN A said Resident #1's family member was screaming we can't find him. She said she told her she knew where Resident #1 was, and they came and got him. Hospice RN A said Resident #1 was placed on one on one when he returned to the facility, and he was sent to a behavioral hospital on [DATE]. During an observation on 03/03/25 at 12:25 PM, the middle school was observed to be located north of the facility, approximately 0.5 miles crossing a busy 2 lane road. During an interview on 03/03/25 12:43 PM, LVN B said he was no longer employed at the facility but had worked the secure unit on the 2:00 PM - 10:00 PM shift. LVN B said Resident #1 had not eloped on 08/12/24. LVN B said he had eyes on Resident #1 the whole time. LVN B said Resident #1 was the resident that did not want to come back inside. LVN B said Resident #1 was hard to handle, but he had not run away that he was aware of. He said Resident #1 was placed on one-on-one monitoring due to his behaviors. LVN B said he was unsure of who sat with him, since management did that. He said he notified hospice regarding Resident #1's behaviors. He said if he had a resident who eloped he would notify the supervisor and follow the facility's protocol, call the MD, call the family and call 911, if the resident was out of sight. During an interview on 03/03/25 at 2:19 PM, CNA C said she had been working in the secure unit on 08/12/24. CNA C said she remembered Resident #1's family member visited with him the morning of 08/12/24. CNA C said Resident #1 wanted to go home with his family member, and he wanted to go out of the facility. CNA C said they took Resident #1 out to smoke in the secured smoking area by the unit around 3 PM. CNA C said when Resident #1 went outside to smoke they could not get him back inside the facility, and he refused to go back into the facility. CNA C said she kept an eye on him and at one point he hid behind a tree. She said all of a sudden, she could not see him. CNA C said they found him close unsure of location. She said the Maintenance Supervisor was out looking for him, and she was unsure of who else. CNA C said she was keeping an eye on Resident #1 by peeking through the door occasionally after providing care to other residents. CNA C said she reported to the charge nurse Resident #1 was no longer outside and he alerted everyone else. CNA C said the charge nurse was also keeping an eye on him. CNA C said they thought fresh air would help him with his behaviors. She said she never imagined Resident #1 would climb over the fence. CNA C said if she had a resident that voiced wanting to leave or trying to elope, she would notify the DON and charge nurse and not take the resident outside. During an interview on 03/03/25 at 2:29 PM, the SW on 8/12/24, she knew that a staff member followed him (unsure of who) down the street. She said she did not know how far he went or who brought him back. The SW said Resident #1 was sent to a behavioral hospital first, and then to another facility. During an interview on 03/03/25 at 2:30 PM, the DON said Resident #1 did not elope because he was followed by the ADON. The DON said Resident #1 was walking down the road by the school. The DON said when Resident #1 was in the facility's parking lot he told the ADON he was not getting in the car. The DON said the ADON followed him until the family got there. The DON said family and hospice was called and they were on the way to the facility. The DON said they provided staff with elopement in-services and completed elopement assessments for all residents in the secure unit. The DON said they in-serviced staff because had the ADON not been out there to see him, it would have been an elopement and there could have been a worse outcome. During an interview on 03/03/25 at 2:31 PM, the Administrator said the day of the incident the ADON was with Resident #1, and he did not want to get in her car. She said she did not remember how far he had gone but believed it was by the mobile home park in front of the facility. The Administrator said she was unsure if Resident #1 had voiced he wanted to leave. The Administrator said she expected when a resident eloped or was trying to elope that they get them back in the facility safely. She said they had educated staff if a resident was not found a code pink (missing resident) should be called, the police should be notified, and everyone for all hands-on deck for a successful trip back home. During an interview on 03/03/25 at 2:36 PM, the ADON said Resident #1 did leave the facility. The ADON said she was outside in her car on 08/12/24 and saw Resident #1 climb the fence. She said she had tried to get him in the car, but he refused. She said she followed him at a safe distance in her car. The ADON said Resident #1 walked straight and crossed the road toward the school. The ADON said the family met him where we were and brought him back to the facility. The ADON said she had called the DON. The ADON said they had called hospice and family to let them know Resident #1 had been trying to beat up the staff, and Resident #1's family was headed to the facility. The ADON said she was unaware of who all knew but the DON knew I was following him. The ADON said if Resident #1 had actually eloped, the DON and Administrator would have notified all channels, family, and MD. The ADON said it was best to keep eyes on him. During an interview on 03/03/25 at 2:56 PM, Hospice RN A said the SW found him right after she did, and the SW had made eye contact with her. She said she did not recall if the ADON was at the site where Resident #1 had been picked up. During an interview on 03/03/25 at 3:03 PM, Resident #1's family member said there was no facility staff at the site where Resident #1 was found that they were aware of. Resident #1's family member said the hospice nurse told them she was on [name] street. Resident #1's family member told the hospice nurse he was not going to get in her car with her because he did not know her, and they did not want the hospice nurse to set him off. Resident #1's family member said she walked to him and the other family member drove. Resident #1's family member said the facility staff had no clue he was missing. During an interview on 03/04/25 at 09:05 AM, the Regional Director of Operations said he had asked the ADON if she had provided a written statement to the surveyor regarding the incident that occurred on 08/12/24. The Regional Director of Operations said the ADON told him they did not provide a written statement to the surveyor. The Regional Director of Operations said he had asked the ADON if she had her phone with her that day and she said she did and that she had called the DON. He said LVN B was also keeping an eye on Resident #1 by looking out through the door of the secure unit. During an interview on 03/04/25 at 10:06 AM with the Regional Director of Operations, Regional Nurse Consultant, the Administrator, the DON, and ADON, the DON said she had spoken to [LVN B] that morning and he had told her it was not considered an elopement if it was witnessed. State Surveyor questioned how come the incident was not documented anywhere in Resident #1's electronic medical record, and the DON said she had educated [LVN B] on documentation and he had walked off when they were trying to educate him. The DON said LVN B said, he was not going to work like this and left. State surveyor questioned how come no other staff member went to assist the ADON, the DON said she went out the front door and did not see him, and she called hospice and the family. The DON said the family did not answer. The DON said they did not go because Resident #1 was being belligerent, to not make the situation worse and the ADON was already in her car and was following him. The ADON said she did not see Resident #1 jump the fence she saw him outside the fence. The DON said the family had not arrived at the facility prior to the incident and the family was seen when they were bringing him back to the facility. The DON said the family had told the Administrator and herself that they had seen the ADON in her car. The DON said when she became aware of Resident #1's negative statements, he was placed on one on one. Record review of a typed statement provided on 03/04/25 at 10:25 AM signed by the ADON and dated 08/12/24, indicated . I, [ADON's name], witnessed [Resident #1], walking outside the fenced area toward the parking lot at approximately 1615 (4:15 PM). Staff nurse was at opened glass door of courtyard visualizing resident as I approached him on foot in attempt to get him to return to the facility. He became physically and verbally aggressive stating that if I did not leave him alone, he would kill me. I got back into my car to follow beside him until other help arrived. I phoned the facility to ensure they were aware of what was happening. My car remained on the left and he was on the right. There was no oncoming traffic. [Resident #1] paused before crossing the highway while continuing to yell at me to stop following him. I continued to follow until the family arrived in their vehicle and persuaded him to get into their car. I at no time lost eyesight of resident, until he was placed in his private family car. The resident returned to the facility at approximately 1625 (4:25 PM) and was escorted back into the secured unit by family and DON and placed on 1:1 care. Record review of a typed statement provided on 03/04/25 at 10:25 AM signed by the DON and dated 08/12/24, indicated . Writer spoke to nurse [LVN B] to obtain statement of incident. [LVN B] stated he had been watching [Resident #1] on the courtyard and attempted to re-direct him back inside. He became belligerent so he stood at a safe distance in the doorway. When he walked away from the door, he ensured another staff member was present. [LVN B] stated he did not feel this was an elopement based on the fact the incident was witnessed. Interviews on 03/04/25 between 10:30 AM and 12:15 PM with (RN G, CNA L, Maintenance Assistant M, Director of Rehabilitation O, CNA N, LVN P, CNA Q, Housekeeping R, LVN S, LVN T, CNA U, LVN V, CNA W, Dietary Aide X, CNA Y, LVN Z, LVN AA, CNA BB, the Maintenance Supervisor, the ADON, COTA, MDS Coordinator, Activity Director and the Dietary Manager) revealed they were able to answer questions regarding abuse and neglect in-service, who to contact, when to contact and types of abuse. Staff was able to answer questions on elopement in-service regarding code pink, immediately contacting the Administrator and DON, searching facility on and off grounds, and calling the police if resident was not found within 30 minutes. During an interview on 03/06/25 at 09:55 AM, CNA H said she had worked on 08/12/24. She said she recalled Resident #1 being restless, had gotten out, and had walked down the road. She said everyone was looking for him. During an interview on 03/06/25 at 12:23 PM, LVN B said Resident #1 went outside and he had eyes on him at all times. He said he alerted management and DON when Resident #1 was outside of the fence, and they handled everything after that. LVN B said he had the back door open and contacted the DON by phone. LVN B said he was not sure if Resident #1 left the facility property. LVN B said he continued with his duties since he had other residents to take care of. He said the Maintenance Supervisor and the SW assisted with bringing him back. LVN B said he did not receive any education on documentation that he could recall. He said the facility staff tried to blame him for the incident that was why he became upset at them. He said he had kept them in the loop of Resident #1's behaviors. During an interview on 3/6/25 at 12:46 PM, the Maintenance Supervisor said the day of the incident, 08/12/24, someone (unsure of who) had asked him if he had seen Resident #1. He said he then started to coordinate people and started looking for him. He said he was able to get on the intercom with his phone and announced Resident #1 was missing. He said he helped the family bring him back from their car. He said to his knowledge, Resident #1 was missing. He said people left in their cars to search off ground. During an interview on 03/06/25 at 1:28 PM, the SW said there was a mass text indicating the ADON was following Resident #1. She said she had just gotten back to the facility, got back in her car and when she got to where Resident #1 was, which was by the school, Resident #1's family members were talking to him and were getting him in the car. She said they brought him back to the facility. The SW said she saw the hospice nurse in her car by the school as well. She said they spoke to each other. She said there was no mention that Resident #1 was missing. She said the ADON was with him and had had eyes on him. During an interview on 03/06/25 at 2:20 PM, CNA C said no one was constantly with Resident #1 on 08/12/24. She said the nurse was the one that did not see him, and he started calling the Administrator and putting the alert out that he was not where he was supposed to be. She said everyone started looking. CNA C said they did not know which direction he had gone but he had not gone very far. Record review of the elopement assessments completed for the 15 residents who resided in the secure unit were dated 08/13/24 and 08/14/24. Record review of 13 resident safe assessments completed on 08/12/24 with no concerns noted. Record review of 13 employee (CNA DD, CNA EE, LVN FF, LVN Z, CNA GG, CNA N, CNA L, [NAME] HH, LVN KK, the Treatment Nurse, MA LL, [NAME] MM, and the Dietary Supervisor, abuse and neglect questionnaire completed on 08/12/24 indicated staff was able to answer who to report abuse and neglect, when to report abuse or neglect, and the types of abuse. Record review of the in-services dated 08/12/24, indicated staff was in-serviced on elopement, code pink, best practice if a resident cannot be located, immediately contacting the Administrator, DON, regardless of the time or day of the week, and it was imperative to have sense of urgency in order to ensure resident safety, abuse and neglect, immediately contacting the Administrator, and types of abuse. Record review of weekly monitoring indicated Administrator/designee will interview 2 staff members a day 5 times a week for 4 weeks with a start date of 08/12/24 and end date of 09/06/24 had been completed. Record review of facility's policy Elopement with an effective date of 12/2017 indicated: Policy It is the policy of this home to provide a systematic approach to searching for a resident who may have left the home and/or home grounds. PROCEDURE The following steps are to be followed when a resident is noted absent and is not found on initial search of the home. This also includes when a resident leaves the home grounds without staff notification. Home Staff will: o Search the home and grounds o Send staff member(s) out to locate the resident o Notify Administrator or on-call person immediately o If resident is not located within 30 minutes, call the local police Charge[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for 1 of 6 residents (Resident #1) reviewed for smoking safety. RN A did not ensure Resident #1 was not using Oxygen while smoking. RN A lit a cigarette for Resident #1 while Oxygen was on and being delivered thought a nasal cannula causing second degree burns to Resident #1's face. An Immediate Jeopardy (IJ) situation was identified on 04/30/23 at 2:15 p.m. While the IJ was removed on 05/01/23, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of physical harm, mental anguish, emotional distress, or death. Findings included: During an observation and interview on 04/29/23 at 10:25 a.m. Resident #1 had a large fluid fill blister, white in color, on his right cheek that extended to the top of his upper lip. There was another fluid filled blister on the right side of his nose that extended to the tip of his nose. Facial hair on his right upper lip appeared to be shorter than the left side of his lip. Resident #1 said he was not in pain. He said he was smoking the night before (04/28/23) and did not realize that Oxygen was flammable. He said he was wearing his Oxygen while smoking. He said he normally does not have his Oxygen on while smoking and does not use Oxygen all the time. He said while smoking the Oxygen caught fire. He said it was storming and he thought at first it was a lightning flash. He said RN A was there and quickly put out the flame. (Within a few seconds) He said he went to the doctor the next day. (04/29/23). He said he did not feel he was abused or neglected. Record review of face sheet dated 04/30/23, indicated Resident #1 was a [AGE] year-old male, last admitted on [DATE] and his diagnoses included Transient cerebral ischemic attack, (a stroke that lasts only a few minutes), hypertension, Dyspnea (Shortness of Breath), dementia, cognitive communication deficit, muscle weakness, Bipolar disorder, Chronic obstructive pulmonary disease (COPD), schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms), and Pulmonary hypertension (A type of high blood pressure that affects the arteries in the lungs and the right side of the heart). Record review of consolidated physician orders dated 02/26/23, reflected Resident #1 may have O2 2L/min via NC PRN for oxygen sat below 92%. Every shift Days 6:00 AM - 2:00 PM, Evenings 2:00 PM - 10:00 PM, and Nights 10:00 PM - 6:00 AM. Record review of MDS dated [DATE] indicated Resident #1 was able to express ideas and wants, was alert to person, place, and time, was able to understand others, and was cognitively intact. Resident #1 required supervision and set-up assistance of 1 person for all ADLs other than hygiene where he required assistance of 2 persons. He was able to transfer independently and used a wheelchair. Record review of Resident #1's care plan initiated 12/19/22 and revised on 04/30/23 indicated he was a smoker and at risk of injury. He was to wear a smoking apron during smoke breaks. Staff were to supervise him during smoking. The care plan was updated on 04/29/23 to show staff are to ensure that resident is not in the smoking area with Oxygen tank or tubing/nasal canula. Record review of progress note dated 04/28/23 at 06:40 p.m., RN A recorded he went to the smoking area to observe resident smoke break. Resident #1 was already outside with his smoking apron on. Cigarettes were handed out and lit. RN A did not recognize Resident #1 had Oxygen on. A small flame was extinguished, and Oxygen was turned off. Resident #1 was assessed for injuries with left cheek and nose light pink with no open areas or blisters noted. Resident #1 denied pain. Resident sitting up at nurse's station with no signs of distress. The Responsible party and physician were notified. There were no new orders from the physician. Record review of an incident report dated 04/29/23, completed by the administrator indicated on 04/28/23 at 6:30 p.m., Resident #1 was smoking in the designated smoke area when RN A lit his cigarette while he was wearing oxygen. The Oxygen flashed causing his beard to singe. The next morning at 10:00 a.m. redness and blistering was discovered to Resident #1's face. The Doctor was notified and new orders for Silvadene (silver sulfadiazine) cream 1% to be applied to the affected area once a day were received. Resident #1 was sent to the hospital on [DATE] for evaluation and returned the same day with no new orders. Record review of progress note dated 04/29/23 at 11:30 a.m. reflected LVN A recorded she contacted the physician to report a need for wound care orders to Resident #1's face after a smoking incident last evening. The Nurse reported areas of burns and appearance of areas of concern. New orders were received of Silvadene (silver sulfadiazine) cream 1% once a day. The Resident reports no pain/discomfort in area currently. Record review of progress note dated 04/29/23 at 3:16 p.m. reflected the DON recorded she noticed Resident #1 to have newly onset and slight difficulty breathing. Upon further assessment, swelling was noted to Resident #1's right inner nare (Opening of the nose). The Physician was contacted with orders to send to hospital for evaluation. Record review of hospital records dated 04/29/23 indicated Resident #1 was seen at the hospital for facial burn. Diagnosis was Facial burn, second degree (Involves the top two layers of the skin, might have blisters over the burn area. The burn may leave a scar). New orders to gently clean with soap and water and apply bacitracin (topical antibiotic ointment) were received. Follow-up was to be scheduled by facility staff. Review of progress note dated 04/29/23 at 4:58 p.m. Resident #1 returned from the emergency room with new orders for bacitracin ointment, apply BID. The Physician was contacted and ordered to discontinue bacitracin and continue with Silvadene as previously ordered. The Resident continues to have difficulty breathing through nose. No distress was noted. (After return from hospital) The Resident is at nurses' station currently. Resident #1 states He can breathe though his nose and that is does not hurt to breathe. During an observation and interview on 04/29/23 at 10:45 a.m. six residents was observed in the smoking area including Resident #1. Three of the residents were wearing smoking aprons including Resident #1. There were no Oxygen tanks in the smoking area. The fire extinguisher was available and last serviced April 2023. Ash trays were appropriate for safety. Residents were being supervised by a nurse. Resident #2 said she was present when Resident #1's Oxygen ignited on 04/28/23 around 6:30 p.m. She said RN A was helping her to her table and Resident #1 was already in the smoking area with his safety apron on when she arrived. She said after RN A assisted her to her normal table and Resident #1 was sitting behind her. She said it was storming and darker than usual. Resident #1 asked RN A to light his cigarette. She said RN A turned around, lit Resident #1's cigarette and turned and lit hers. She said the next thing she knew, there was a flash. She said she thought it was a lighting flash, but she saw there was a flame at Resident #1's face. She said RN A quickly turned and extinguished the flame. She said they all went back inside the building and RN A took Resident #1 to his room. During an interview on 04/30/23 at 9:45 a.m., the Administrator said on 04/28/23 at 6:30 p.m., RN A was taking residents out for a smoke break. Resident #1 was already in the smoking area with his apron on when RN A arrived with 2 other residents. The Administrator said RN A lit Resident #1's cigarette without noticing he had his Oxygen on. The Administrator said RN A was assisting the two other residents when Resident #1's Oxygen ignited and singed Resident #1's facial hair. The Administrator said RN A immediately responded and assessed Resident #1 for injury. The Administrator said there was some redness to Resident #1's cheek and nose. There were no other injuries found at that time. The Physician, family, and Administrator were notified of the incident. The Administrator said he asked questions about the incident, and it was determined that the incident was not a reportable incident at the time, because there was no major injury to Resident #1. The Administrator said the next morning (04/29/23) around 10:00 a.m. during an assessment LVN A, found blisters to Resident #1's face. The Administrator said all residents were re-assessed for Smoking Safety and RN A was suspended pending investigation. The Administrator said RN A should have monitored to ensure there was no Oxygen in the area prior to lighting a cigarette. The Administrator said it is the policy of the facility that Oxygen should not be within 50 feet of the smoking area. During an interview on 04/30/23 at 9:45 a.m. the DON said RN-A should have noticed that Resident #1 was using Oxygen and should have not lit any cigarettes before making sure there was no Oxygen in or near the area. The DON said it is the facility policy that Oxygen should not be within 50 feet of the smoking area. The DON said Residents are not allowed to have Oxygen in the smoking area whether it is on or off. The DON said all Oxygen should be left inside the building or in the resident's rooms. DON said there are ten residents who smoke and out of those ten residents, six use Oxygen. During an interview on 05/01/23 at 4:10 p.m., RN A stated he was working as a charge nurse on 04/28/23 on the 2:00 PM to 10:00 PM shift. RN A said at 6:30 PM, he took three residents out for a smoke break. He said when he arrived at the smoking area, Resident #1 was already outside in the smoking area with his safety apron on. He said he assisted the other two residents outside. RN A said he was standing at the table and Resident #1 was behind him. He said Resident #1 asked him to light his cigarette. He said he turned around and lit the cigarette for Resident #1. RN A said he did not notice Resident #1 had his nasal canula under his nose and did not know his Oxygen was on. RN A said he should have checked before lighting the cigarette, but he did not. He said it was only a few seconds when he saw a flame and turned around and put out the fire. RN A said he assessed Resident #1 and Resident #1 said he was not in pain. RN A said he immediately ended the smoke break, and all three residents went back inside. RN A said he took Resident #1 to his room so he would assess him better in the light. RN A said he observed some pink areas to Resident #1's nose and cheek, but there was no blistering. RN A said he asked Resident #1 to stay at the nurse's station so he could keep an eye on him. RN A said he notified the ADON, who said she would notify the Administrator and DON. RN A said he called the doctor and reported the incident with no new orders. RN A said he got off at 10:00 PM and there were no blisters when he ended his shift, and the area was a light pink. RN A said he was notified by the ADON the next morning that blisters had formed on Resident #1's nose and cheek. RN A said this was the first time he knew about the blistering. RN A said he was suspended at the time and was informed today (05/01/23) at 1:40 p.m., that he was being terminated. RN A said he felt bad about what happened, and he should have seen Resident #1 had his Oxygen on in the smoking area. RN A said he had been a nurse for 17 years and had never hurt a resident and he felt horrible. RN A said it was his fault. During an interview on 04/30/23 at 10:45 a.m., Resident #2 said she was in the smoking area on 04/28/23 at 6:30. She said there were three residents in the smoking area at the time. Resident #2 said RN A had taken them out for the break. Resident #2 said Resident #1 was already in the smoking area with his apron on when they arrived. Resident #2 said RN A assisted her to the table, turned and lit Resident #1's cigarette. Resident #2 said she saw a flash and thought it was a lighting flash because it was storming at the time, until RN A turned around and put out the flames on Resident #1's face. Resident #2 said RN A took all three residents including Resident #1 into the building. Resident #2 said she had never seen other residents using oxygen in the smoking area. Review of the facility's smoking policy dated 01-2023 showed . It is the policy of this home that: * All residents who smoke will be supervised. * Smoking will be permitted in designated safe area(s) only. * Oxygen equipment is not permitted in the smoking area(s). The minimum safe distance for Oxygen equipment from the smoking area is 50 feet . The facility was notified of the Immediate Jeopardy on 04/30/23 at 2:15 p.m. and the Administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/01/23 at 1:44 p.m. and reflected the following: Plan of Removal - F 689 Accidents & Supervision Immediate Action Taken - Resident Specific o Small flame extinguished, and oxygen immediately removed. o Resident #1 was assessed for injury on 4/28/2023 at 6:40 p.m. by RN with no open areas or blisters noted. o MD notified of the incident on 4/28/2023 at 6:40 p.m. by RN, no new orders received. o Resident #1 noted to have open areas to face on 4/29/2023 10:00 a.m., MD notified and new orders for wound care received and implemented. o Resident #1 sent to ER for evaluation on 4/29/2023 at 3:16 p.m. and returned on 4/29/2023 at 4:58 p.m. with no new orders received. System Changes o Safety checklist implemented to be filled out with each smoke break. Staff member responsible for supervising the smoke break will complete this checklist once all residents are outside, prior to lighting any cigarettes. - completed 4/29/2023 o Updated smoking safety assessments performed by DON and Social Worker, done for all residents that smoke - completed 4/29/2023 o Updated BIMS assessments done on all residents that smoke, to assess cognitive function - completed 4/29/2023 o All care plans of residents that smoke reviewed and updated as needed to reflect current smoking needs, safety needs, and oxygen use - completed 4/29/2023 o Smoking Areas inspected, by administrator to verified that all smoking safety equipment in place and properly functioning - completed 4/29/2023 o Any oxygen tanks/tubing that are removed prior to entering the smoke area, will be stored inside the building, in an oxygen tank holder and/or in the resident's room. o Once all residents are outside and ready for smoke break, safety checklist will be completed. Then staff will safely light each individual's cigarette and remain outside during the entire duration of the smoke break. Education o Director of Nursing providing education to all staff regarding smoking safety and oxygen use, as well as abuse/neglect. Any staff member not present on 4/30/2023, will receive the education prior to working their next shift. o Director of Nursing providing education to all staff regarding Smoking Safety Checklist, including when it is to be completed (prior to any cigarettes being lit.) Any staff not present on 4/30/2023, will receive the education prior to working their next shift. o Social Services Director providing education to all smokers with the ability to understand, regarding smoking safety and oxygen use. Any resident that smokes that is not in the facility on 4/30/2023 will receive the education upon their return, prior to the next smoke break. Monitoring o Administrator/designee to review Smoking Safety Checklist 5 times per week for a minimum of 4 weeks to ensure any necessary interventions occurred. QAPI team to review monthly and make changes as needed. o Administrator/designee to randomly supervise 1 -2 smoke breaks a day, 5 times a week, for a minimum of 4 weeks to ensure that required safety interventions are in place, and initial Smoking Safety Checklist. QAPI team to review monthly and changes as needed. On 05/01/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations, interviews, and record reviews were conducted on 05/01/23 from 2:30 p.m. through 4:20 p.m. and included 4 other alert residents,(Not including Resident #1) nurses including 3 RN, 3 LVNs, Social Worker, ADON, Housekeeping Supervisor, and DON. Staff were able to identify residents requiring supervision while smoking and the need for aprons and protective equipment. Staff were able to confirm that only licensed nurses can supervise residents during smoking breaks and Nurses had been trained on completing the smoking check list prior to starting smoke breaks. Nursing Staff provided appropriate resident supervision during smoke breaks. There were no observed concerns. Staff were able to discuss the required level of staff assistance for residents in the smoking area and the requirement for Oxygen not being allowed in the smoking areas. Show knowledge of only licensed nurses are allowed to supervise Residents during smoke breaks. All residents who smoke were assessed for safety needs including BIMS and smoking safety assessments were completed by Social Worker and DON. Staff were using the Smoking check list prior to starting smoking break. Staff were able to identify the Abuse Coordinator, indicated reporting was immediate to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. Nursing staff were in-serviced on monitoring residents during smoking breaks, completing smoking safety check, Storing Oxygen, and Abuse/Neglect. The training was completed on 04/29/23 and is ongoing. Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. Staff were in-service on abuse and neglect. The training was completed on 04/29/23. Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. There were no additional allegations of abuse or smoking incidents identified during the investigation. No residents indicated they were afraid during care or had complaints of their care. The facility Administrator and the DON will continue to monitor smoking areas as shown in the Plan of Removal and will ensure all residents are safe in the smoking area. were provided education on abuse/neglect on 04/29/23. On 05/01/23 at 4:24 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.