**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to assess all residents so they could safely and independently leave the facility property specifically for the identified five of 63 residents in the survey sample, Residents #421, #164, #155, #52 and #125. Resident #421 left the facility and was involved in a hit-and-run accident with life-threatening injuries on [NAME] Pike, the four-lane divided highway in front of the facility, which placed this resident in the presence of immediate jeopardy at the time of the accident. The extent of this issue could result in serious injury, harm, impairment, or death, which constituted the determination of Immediate Jeopardy (IJ), as cited at level K. After Immediate Jeopardy was removed, the scope and severity were lowered to a level 3 isolated (G). The findings include: 1. For Resident #421 (R421), the facility staff failed to assess the resident to safely leave the facility property independently. Resident #421 left the faciity on 9/12/24 and was hit by a car when crossing [NAME] Pike, a four-lane divided highway resulting in life threatening injuries and admission to the local hospital's Intensive Care Unit. R421 was admitted to the facility with diagnoses that included but were not limited to history of falling, fracture of lumbar vertebra (1), traumatic spondylolisthesis of second cervical vertebra (2), alcohol use and major depressive disorder (3). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/14/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment further documented functional limitations in range of motion to both lower extremities, normally using a manual wheelchair and able to walk 150 feet in a corridor independently. It documented R421 having an external catheter, being frequently incontinent of bowel, receiving scheduled and as needed pain medication, and having had one fall with minor injury since admission or the previous assessment. On 10/7/24 a facility synopsis of events for R421 dated 9/13/24 was reviewed. It documented in part, .Describe incident, including location: [Name of R421] who resides in [Room number] and is a [Age and Sex of R421] with a BIMS score of 15, and diagnosis of Alcohol use unspecified with withdrawal, fall resulting in traumatic vertebral fracture, and chronic venous hypertension, Resident was out of the facility on LOA (leave of absence) and nurse supervisor notified by residents sister who confirmed that resident was involved in MVA (motor vehicle accident) and was taken to [Name of hospital] where he was admitted as a result of his injuries. Resident was involved in an MVA that was reported as a possible hit and run. Police initiated an on-going investigation. Ombudsman/APS (adult protective services)/RP (responsible party)/ MD (medical doctor)/ ED (executive director) and DON (director of nursing) notified . A Leave of Absence form dated 9/12/24 for R421 was included in the file which documented the time left as 1:50 p.m. with anticipated return time of 11:00 p.m. The LOA form documented the resident leaving independently. The final investigation summary dated 9/13/24 documented in part, .Nature of Incident: Unusual Occurrence/Collision with MVA while on LOA/Possible hit and run. Staff member: None. Including location: [Name of R421] who resides in [Room number] and is a [Age and Sex of R421] with a BIMS score of 15, and diagnosis of Alcohol use unspecified with withdrawal, fall resulting in traumatic vertebral fracture, and chronic venous hypertension. [Name of R421] signed himself out of the facility on LOA per his normal daily routine in the am, and failed to return to the facility at his signed expected time of return, the nurse supervisor- initiated call inquiry to nearby hospitals and was informed by [Name of hospital] nursing staff that resident was there but were unable to provide facility staff with any information, and advised supervisor to contact resident representative for further information. The facility nurse supervisor placed a call to resident representative (sister), no answer received, a message was left to return call to the facility. Resident sister returned call to the facility and supervisor confirmed admission to [Name of hospital] due to being involved in an MVA that resulted in major injuries and stated that the incident was a possible hit and run. On the following day [Name of R421]'s sister contacted social services to inform of resident in ICU (intensive care unit) pending surgical intervention, and that she would be coming to the facility to pick up residents' personal items due to discharging to the hospital. [Name of county police department] initiated and concluded post confirmation of signed LOA and the unusual occurrence transpired while on LOA . The physician orders for R421 documented in part, - May go out on pass with or without meds. Order Date: 5/7/24. End date: 9/13/24. - Aspen collar (4) on at all times. every shift Document refusal to wear. Order Date: 5/7/24. End date: 9/13/24. - Wear t shirt underneath the back brace. Monitor skin under the brace for redness or skin irritation. Do not sleep in TLSO (thoracic lumbar sacral orthosis) back brace (5) but keep Aspen collar on every shift. Order Date: 5/7/24. End date: 9/13/24. A review of the PT (physical therapy) evaluation dated 6/17/24 and the OT (occupational therapy) evaluation dated 5/8/24, progress report dated 5/21/24, and OT Discharge summary dated [DATE] failed to reveal evidence that the resident was assessed for safety outside the building. Review of the completed Leave of Absence forms for R421 documented the resident leaving the facility independently on 96 occasions between 5/7/24 and 9/12/24. Review of the progress notes for R421 documented the resident returning from leave of absence intoxicated on 12 dates. Further review of the progress notes documented the police responding to staff calls for R421 being intoxicated at the facility on four dates and the police returning R421 to the facility from the community intoxicated once. A progress note dated 9/12/24 documented, Late Entry. Note Text: Resident alert and oriented to person, place, time and situation. He signed himself out on LOA from facility at 1:50 pm in an alert and stable condition with expected returned time of 11:00 pm on the same day. Around 9:10 pm, writer was informed that resident was involved in a motor vehicle accident while on LOA and was taken to the hospital via ambulance. [Name of hospital] ER called but writer was not able to get any information regarding resident's current status. ER nurse advised writer to call again later. Call placed to resident's sister, [Name of sister] and was updated about incident. On a follow up call to sister, she confirmed that upon calling the hospital, it was confirmed that resident was hit by a car while outside facility and is now in ICU. Telehealth was called and updated. Nursing staff will continue to follow up. Further review of the progress notes documented a follow up note dated 9/18/24 which documented, Note Text: Writer followed up on resident at the hospital, per the nurse report resident is still at the ICU intubated and waiting for spine effusion tonight. MD updated. The comprehensive care plan for R421 documented in part, [Name of R421] has history of falling with injury. At risk for further falling. had a fall with injury Abrasion to right shoulder. Date Initiated: 05/01/2024. Revision on: 08/05/2024. The emergency provider notes from [Name of hospital] for R421 dated 9/13/24 4:49 a.m. documented in part, . [Name, age and sex of R421] who presents with unknown past medical history presenting with pedestrian strike. EMS (emergency medical services) reports he was witnessed being hit by a jeep wrangler going 35 to 45 mph on the turnpike prompting EMS visit to ED. EMS states patient was in a c-collar (cervical collar) prior to arrival . Critical diagnosis: 1. Contusion of head, subsequent encounter. 2. Trauma shock, initial encounter . The history and physical for R421 from [Name of hospital] dated 9/12/24 at 10:47 p.m. documented in part, .Patient was a modified trauma activation status post pedestrian struck. In the trauma bay, patient was awake and following commands but confused. He was initially normotensive. He was noted to have facial lacerations, forehead hematoma, bilateral hip bruising and what appeared to be chronic bilateral toe wounds. [NAME] report, patient was noted to have a cervical spine prior to the arrival presumably from recent injury. Patient then became combative and therefore received 4mg of IM (intramuscular) Versed. Soon after, patient became hypotensive and lethargic. At this point, patient was upgraded to a full trauma activation .Given patient's ongoing hypotension, patient received units of whole blood .GI (gastrointestinal): Grade IV liver injury with active subcapsular hematoma and hemoperitoneum. Grade 2 splenic laceration w/subcapsular hematoma, anterior pancreas hematoma .Pt in critical condition . The discharge summary for R421 from [Name of hospital] dated 10/10/24 documented in part, .Hospital Course: Patient went to the OR for ex-lap (exploratory laparoscopy) and had ileum resection and packing. He was eventually closed and had return of bowel function. NSGY (neurosurgery) was consulted, and patient did not need aspen for dens fx and went for posterior decompression and fusion. He required a TLSO brace when OOB (out of bed). Patient was extubated but required a corpak 2/2 (secondary to) dysphagia. He was able to work with SLP (speech language pathologist) and his diet was advanced to a regular diet. His abdominal staples were removed and there was some superficial wound dehiscence that required iodofoam packing and dressing changes. He was restarted on his home medications. PT/OT worked with patient and recommended SNF (skilled nursing facility). At the time of discharge the patient was afebrile and his vital signs were within normal limits . On 10/2/24 at 3:49 p.m., ASM (administrative staff member) #5, the regional director of operations, was interviewed. She stated her understanding is that as long as residents have a BIMS score that is high enough, and the residents have been physically assessed as safe, the residents are allowed to sign themselves out on a leave of absence from the facility. On 10/2/24 at 4:52 p.m., an interview was conducted with ASM #1, the executive director and ASM #3, the regional director of clinical operations. ASM #1 stated that the resident needs an order to go out on LOA, needs to be assessed that they can go out, and typically by nursing, a cognition assessment. He stated that a functionally mobility is done by the IDT (interdisciplinary team). ASM #1 stated therapy is involved in the screening in Section GG on the MDS, when the admission and discharge from therapy assessment are completed. He stated that the MDS staff codes the functional abilities, goals and mobility devices used. ASM #3, the regional director of clinical operations, stated that if a resident wants to go out, the nurse initiates the Leave of Absence Form, and then the resident brings it to the executive director or director of nursing to sign. She stated that any nurse, executive director or director of nursing, could sign off this form. ASM #3 stated that the resident then takes the form to the front desk and gives it to the receptionist, who then logs it into the daily log. She stated that if the resident does not return at the anticipated time, the staff will call the resident or responsible party, then the staff calls 911. ASM #3 stated it is the nurse who monitors when the resident returns. On 10/2/24 at 5:05 p.m., an interview was conducted with ASM #1, the executive director, ASM #2, the director of nursing, and ASM #5, the regional director of operations. ASM #2 stated the facility uses the BIMS is used to assess a resident's ability to safely leave the facility. ASM #5 stated the BIMS assesses a resident for their ability to process new information and ability to recall. She stated the BIMS does not assess a resident's ability to determine danger from safety. On 10/7/24 at 12:31 p.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that the facility staff had received a report that R421 had been involved in a hit and run and the staff had contacted the sister and the hospital who confirmed the resident was involved. She stated that R421 had signed out on LOA earlier that day and when he did not come back at the expected time, they had started calling around to the local hospitals checking and calling the family. She stated that she was not sure of the exact location of the hit and run other than it was the cross section outside of the facility on [NAME] Pike. She stated that the police had responded and spoken to the executive director and as far as she knew there were no witnesses to the accident. She stated that R421 would catch the bus sometimes when he went out on LOA and used a manual wheelchair. On 10/7/24 at 12:43 p.m., an interview was conducted with ASM #1, the executive director. ASM #1 stated that the police had come to the facility to ask him if there were any witnesses to the accident involving R421. He stated that there was a former resident of the facility who witnessed the accident, and he was unsure if the police officer questioned them or not. He stated that the hit and run happened on [NAME] Pike in the evening after he had left for the day and staff had called him at home. He stated that R421 would sign out LOA and catch the bus to go shopping or visit family using the manual wheelchair or walking behind it using it as a walker. He stated that no staff witnessed the accident that they knew of. ASM #1 stated that they had previously spoken to the police, VDOT and the county regarding the crosswalk. He stated that VDOT told them that the crosswalk was safe to be used the way it was designed, and the police told them that the residents were not violating any laws so they could not stop them from using it. He stated that the residents had to be in that corner to catch bus and the county told them that the facility could pursue getting a light put in, so they had contacted the North Virginia Emergency Response System however, they said that they did not see a need. He stated that if the resident was in an electric wheelchair or they could walk, there was no way to prohibit them if they were alert and oriented, were care planned, made their own decisions, and they signed themselves out. He stated that if they were to go out and be in a hit and run, they were not able to do anything. He stated that it was difficult due to having authorities tell them that residents were allowed to make bad decisions and as citizens they had rights that could not be taken away. On 10/7/24 at 2:43 p.m., an interview was conducted with RN (registered nurse) #3, MDS coordinator. RN #3 stated she completes functional abilities and goals assessments based on documentation the CNAs (certified nursing assistants) chart in the clinical record. RN #3 stated the assessments demonstrate what the residents can do in terms of their activities of daily living. RN #3 stated she did not think the assessments determined residents' safety abilities. RN #3 stated maybe the BIMS assessments determined residents' safety abilities but that would be hard to determine because she is not with the residents and does not know what they do when they leave the property. On 10/7/24 at 2:59 p.m., an interview was conducted with ASM #7, physician. ASM #7 stated that the leave of absence orders for the residents were intended for residents to go out with families for extended periods and then return to the facility. He stated that there were residents at the facility for long term care who had family that wanted to take them home for a long weekend or overnight and the order was intended for them to be able to do that and take their medications with them for the leave of absence. On 10/7/24 at 3:11 p.m., an interview was conducted with OSM (other staff member) #6, physical therapist. She stated she has never assessed a resident for his or her ability to maneuver safely outside of the facility on a daily basis. She stated she has told residents that attempting to cross the divided highway in front of the facility is not safe, and that she would not attempt it herself. She stated physical therapy assessments are designed to treat a resident with the goal of becoming as functional as possible in the facility, not out outside of it on a day-to-day basis. OSM #6 stated that all assessments and treatments completed for R421 were done in the facility gym or hallways. On 10/8/24 at 1:51 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated the executive director was initially signing for residents to go out on LOA but then the nurses were allowed to sign residents out on LOA. LPN #7 stated the nurses write a note that documents the time residents leave the facility then write a note when the residents return. LPN #7 stated there were no assessments completed to determine if residents are physically or mentally safe to leave the property. On 10/8/24 at 6:05 p.m., an interview was conducted with RN #1. RN #1 stated that another resident (identified as Resident #96) informed him around 9:00 p.m. on 9/12/24 that they thought R421 had been hit by a car outside of the facility. RN #1 stated that he had started calling around to the hospitals in the area and [Name of hospital] had confirmed that R421 was there and had been in an accident but could not give them any other information, so they had called R421's sister. He stated that R421's sister had contacted the hospital and called them back confirming that the resident had been in a hit in run on [NAME] Pike in front of the facility. He stated that he was unsure how the other resident knew that R421 had been hit by the car and he had started calling around because of the report from the other resident. He stated that Resident #96 did not say that R421 had been hit in front of the facility, that he witnessed the accident or how he knew that R421 had been hit by the car. RN #1 stated that he did not go outside or see the accident. He stated that he called and reported the incident to the director of nursing that night. On 10/9/24 at 7:49 a.m., an interview was conducted with RN #6. RN #6 stated that she was inside the facility and heard the sirens and saw the ambulance across the street on 9/12/24 as it was leaving the scene. She stated that several residents were coming inside the entrance and told her that R421 had been hit by a car crossing the street and was being taken to the hospital. She stated that she had checked the LOA form to see that the resident was actually out of the facility and then she and RN #1 had called the sister who confirmed that the resident was involved in a hit and run while crossing the street from the park bus stop on the opposite side of [NAME] Parkway. She stated that it was around 8:30 p.m. when the residents reported this, and it was dark outside. She stated that they expected the police to come to the facility, but no one ever did. She stated that they had reported the incident to the director of nursing and the physician. She stated that she did not recall the specific residents that reported the incident to her but there were a lot of them all rushing inside the lobby. On 10/9/24 at 8:25 a.m., an interview was conducted with Resident #96 (R96) in their room. R96 stated that they were sitting outside of the facility at the entrance the evening of 9/12/24 when they witnessed R421 get off the bus on the furthest side of [NAME] Pike and cross the road in the cross walk. R96 stated that R421 was almost across [NAME] Pike and was in the right lane closest to the facility when a car hit him, and he saw the car spin around and then keep going. He stated that he had reported it to multiple nurses but did not know their names and the next day the former social worker came in to speak with him and said that the police may come talk to him, but no one had. Review of the most recent MDS assessment for R96, a quarterly assessment with an ARD of 7/11/24 documented the resident being cognitively intact for making daily decisions. On 10/9/24 at 8:36 a.m., an interview was conducted with OSM (other staff member) #13, occupational therapist. OSM #13 stated the only time she completes an evaluation to determine if a resident can safely go outside of the building and into the community is if a resident is being discharged home. OSM #13 stated she has not completed any evaluation to determine if R421 can safely and independently go outside and off the facility property. On 10/9/24 at 10:53 a.m., an interview was conducted with OSM #21, detective. OSM #21 stated that the case involving R421 was still active and not completed at this time. He stated that they could only confirm that R421 was involved in the incident and the other person had left the scene. Additional interviews with staff identified on the as-worked schedule for 9/12/24 evening shift failed to evidence firsthand witnesses of the hit and run accident involving R421. Reference: (1) fracture lumbar vertebra The spine is made up of 33 bones. The individual bones of the spine are called vertebrae. The spine is divided into three sections: Cervical (upper), Thoracic (midback), Lumbar (lower back). Most spinal fractures occur in the thoracic and lumbar spine, or at the connection of the two (called the thoracolumbar junction). This information was obtained from the website: https://orthoinfo.aaos.org/en/diseases--conditions/fractures-of-the-thoracic-and-lumbar-spine/ (2) traumatic spondylolisthesis of second cervical vertebra Spondylolisthesis is a condition in which a bone (vertebra) in the spine moves forward out of the proper position onto the bone below it. This information was obtained from the website: https://medlineplus.gov/ency/article/001260.htm (3) major depressive disorder Major depression is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/000945.htm. (4) Aspen Collar A cervical collar provides support and restricts movement in your neck while bones and tissues heal in the area where you had surgery. The Aspen collar is plastic with front and back panels lined with removable padding. It provides comfort and keeps sweat away from your skin. Openings on the front and the back panel of the collar allow your skin to breathe. This information was obtained from the website: https://www.healthsystem.virginia.edu/docs/per/at-home-with-aspen-cervical-collar/handout_view_patient/@@getDocument (5) TLSO brace If you have back pain, your physician or physical therapist may prescribe a brace to help control motion of your spine. A special back brace called a thoracic lumbar sacral orthosis (TLSO) may be prescribed for this. A TLSO is a brace that limits movement in your spine from the thoracic area (mid back) to your sacrum (low back). It does allow your neck to move freely. If you have a problem with your back that requires it to be kept in a neutral position while limiting excessive spinal motion, then a TLSO may be an option for you. Knowing what it is and how it is used can help you make an informed decision about using a TLSO. This information was obtained from the website: https://www.verywellhealth.com/thoracic-lumbar-sacral-orthosis-5203250 2. For Resident #164 (R164), the facility staff failed to assess the resident the resident to safely leave the facility property independently. Resident #164 was observed getting off public transportation in a motorized wheelchair onto the pavement linking [NAME] Pike and the [NAME] Pike service road, maneuvering around a van waiting to turn onto [NAME] Pike, meeting another resident in the parking lot and then was observed sitting in the wheelchair in the road on [NAME] Pike Service Road. R164 was admitted to the facility with diagnoses that included but were not limited to hemiplegia and hemiparesis (1), bipolar disorder (2) and supraventricular tachycardia (3). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/24/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment further documented functional limitations in range of motion to both lower extremities, normally using a motorized wheelchair and being occasionally incontinent of urine and frequently incontinent of bowel. It further documented R164 receiving as needed pain medication, taking antipsychotic, antidepressant and opioid medications. The assessment documented no falls since the previous assessment. On 10/2/24 at 3:22 p.m., Resident #164 was observed getting off public transportation in a motorized wheelchair onto the pavement linking [NAME] Pike and the service road, maneuvering around a van waiting to turn onto [NAME] Pike, into the facility parking lot. At 3:35 p.m., R164 was observed sitting in the right lane of [NAME] Pike Service Road on the west side of the facility with another resident. The physician orders for R164 documented an order dated 11/15/2023 May go out on pass with or without meds. A review of the PT (physical therapy) Discharge summary dated [DATE] and the OT (occupational therapy) Discharge summary dated [DATE] failed to reveal evidence that the resident was assessed for safety outside the building. Review of the completed Leave of Absence forms for R164 documented the resident leaving the facility independently on 22 occasions between 9/1/24 and 10/2/24. The comprehensive care plan for R164 documented in part, Fall: [Name of R164] is at risk for falls Gait/balance problems, Hemiplegia/Hemiparesis. Date Initiated: 02/28/2024. On 10/2/24 at 3:49 p.m., ASM (administrative staff member) #5, the regional director of operations, was interviewed. She stated her understanding is that as long as residents have a BIMS (brief interview for mental status) score that is high enough, and the residents have been physically assessed as safe, the residents are allowed to sign themselves out on a leave of absence from the facility. On 10/2/24 at 4:52 p.m., an interview was conducted with ASM #1, the executive director. ASM #1 stated the resident needs an order to go out on LOA, the resident has been assessed that they can go out, and typically by nursing, a cognition assessment. He stated that a functionally mobility is done by the IDT (interdisciplinary team). ASM #1 stated therapy is involved in the screening in Section GG on the MDS, when the admission and discharge from therapy assessment are completed. He stated that the MDS codes the functional abilities, goals and mobility devices used. ASM #3, the regional director of clinical operations, stated, if a resident wants to go out, the nurse initiates the Leave of Absence Form, the resident brings it to the executive director or director of nursing, to sign. She stated that any nurse, executive director or director of nursing, can sign off this form. ASM #3 stated that the resident then takes the form to the front desk and hands it to the receptionist, who then logs it into the daily log. She stated that if the resident does not return at the anticipate time, the staff will call the resident or responsible party, then the staff calls 911. ASM #3 stated it is the nurse who monitors when the resident returns. On 10/2/24 at 5:05 p.m., ASM #1, the executive director, ASM #2, the director of nursing, and ASM #5 were interviewed. ASM #2 stated the facility uses the BIMS is used to assess a resident's ability to safely leave the facility. ASM #5 stated the BIMS assesses a resident for their ability to process new information and ability to recall. She stated the BIMS does not assess a resident's ability to determine danger from safety. On 10/7/24 at 2:43 p.m., an interview was conducted with RN (registered nurse) #3, MDS coordinator). RN #3 stated she completes functional abilities and goals assessments based on documentation the CNAs (certified nursing assistants) chart in the clinical record. RN #3 stated the assessments demonstrate what the residents can do in terms of their activities of daily living. RN #3 stated she did not think the assessments determined residents' safety abilities. RN #3 stated maybe the BIMS assessments determined residents' safety abilities but that would be hard to determine because she is not with the residents and does not know what they do when they leave the property. On 10/7/24 at 2:51 p.m., an interview was conducted with OSM (other staff member) #5, PT (physical therapist). OSM #5 stated that PT staff did not do a formal safety assessment on residents for leaving the facility independently in the community. He stated that they barely took residents outside and did some wheelchair training with residents but did not leave the property. He stated that they had not been doing any formal safety assessments since he had been working at the facility in July of 2024. He stated that the assessments that he completed on Resident #164 were completed in the hallway of the facility or the gym. On 10/7/24 at 2:59 p.m., an interview was conducted with ASM #7, physician. ASM #7 stated that the leave of absence orders for the residents were intended for residents to go out with families for extended periods and then return to the facility. He stated that there were residents at the facility for long term care who had family that wanted to take them home for a long weekend or overnight and the order was intended for them to be able to do that and take their medications with them for the leave of absence. On 10/8/24 at 1:51 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated the executive director was initially signing for residents to go out on LOA but then the nurses were allowed to sign residents out on LOA. LPN #7 stated the nurses write a note that documents the time residents leave the facility then write a note when the residents return. LPN #7 stated there were no assessments completed to determine if residents are physically or mentally safe to leave the property. On 10/9/24 at 7:40 a.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated that he was coming in to work the evening shift on 10/2/24 when he saw the residents outside and came out to speak with them. He stated that he told them to move from the right end of the road because he thought it was not safe because they were in the street too much. He stated that there may be a serious accident, outcome, or someone could get harmed. On 10/9/24 at 8:36 a.m., an interview was conducted with OSM #13, occupational therapist. OSM #13 stated the only time she completes an evaluation to determine if a resident can safely go outside of the building and into the community is if a resident is being discharged home. OSM #13 stated she has not completed any evaluation to determine if R164 can safely and independently go outside and off the facility property. On 10/2/24 at 5:50 p.m., ASM #1, the executive director, ASM #2, the director of nursing, ASM #4, the regional director of clinical operations, and ASM #5, the regional director of operations were informed of these concerns, and of immediate jeopardy. No further information was provided prior to exit. Reference: (1) hemiplegia and hemiparesis Also called: Hemiplegia,