**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents were free from abuse affecting 2 of 11 residents (R7 and R5) reviewed for abuse concerns.On 7/17/25, R6 punched R7 in the head and mouth, resulting in R7 having a bloody lip. R6 was placed on 1 on 1 supervision for a short period of time. The facility indicated they did not have the staffing to keep a person on 1 on 1 supervision long term. R6 was then put on 15-minute checks. R6 continued to demonstrate aggressive behaviors where staff needed to intervene before the behaviors escalated. On 8/27/25, R6 hit R5 multiple times over the head with a cane. R5 was sent to the hospital where R5 was diagnosed with a Traumatic Brain Injury (TBI) - subdural hematoma (a collection of blood between the brain's outer covering and the surface of the brain,) small traumatic subarachnoid hemorrhage (a bleeding that occurs in the space between the brain and the arachnoid mater, one of the membranes covering of the brain,) and acute (sudden onset of symptoms and injury) left frontal ischemia (Occurs when blood flow to brain tissue is blocked or reduced. This deprives the cells of oxygen and nutrients, causing them to begin dying within minutes,) likely traumatic (Points to a head injury as the probable cause, rather than a typical stroke from a pre-existing condition like a blood clot from atherosclerosis), per hospital documentation. R5 was returned to the facility on 8/28/25 and required follow up with neurosurgery.The facility's failure to keep R7 and R5 free from abuse created a finding of immediate jeopardy that began on 7/17/25. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 9/17/25 at 11:37 a.m. The immediate jeopardy was removed on 9/18/25 when the facility completed an IJ removal plan.Findings include:The facility's policy titled Prohibition and Prevention of member Abuse, Neglect, and Exploitation with a last revision date of 07/2024, documents in part, .Facility shall attempt to identify members exhibiting abusive behavior toward staff and/or other members and shall make referrals to appropriate agencies as needed.R6's most recent MDS, dated [DATE], documents R6 has a BIMS score of 4 indicating severe cognitive impairment, had wandering behaviors 1 to 3 days, no impairment in upper or lower extremities, uses a cane for mobility, and receives antipsychotic medications.R6 was admitted to the facility on [DATE] with diagnoses including Dementia with mood disturbances and psychotic disturbances. R6 is on the memory care unit following an altercation with another resident and has been receiving Behavior Psychiatric services since 09/03/2024. Surveyor noted R6 has 8 documented incidents of aggressive behaviors since receiving Behavior Psychiatric Services. On 9/15/2025, 10:33 AM, Surveyor interviewed RN-BB (Registered Nurse). RN-BB explained to Surveyor, RN-BB has worked at the facility since 2017 and worked with R6 since admission. RN-BB indicated R6 has had numerous resident to resident altercations. When R6 is on a 1:1 supervision, R6 does great but a couple days will go by after R6 comes of the 1:1 and R6 will be back in other resident rooms. RN-BB believes R6 has exhibited this repeated pattern of behavior.1. Surveyor reviewed the Facility Reported Incident involving a resident-to-resident altercation that occurred on 7/17/2025 with R7. R7 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline).R7's most recent MDS, dated [DATE], documents R7 has a BIMS score of 14 indicating R7 is cognitively intact, has no behaviors, has no impairment in upper or lower extremities, and uses a walker as a mobility device.The facility's incident report documents R6 walked into R7's room and hit R7 in the mouth and head. Certified Nursing Assistant (CNA)-II was checking on residents in the dining room and noticed R6 was not in the recliner where R6 had previously been sitting. CNA-II walked toward R6's room to locate R6 and heard R7 yelling out for help. CNA-II observed R6 standing over R7. R7 was sitting in R7's recliner while R6 had ahold of R7's wrists. R7 was attempting to get R6 away from R7, using R7's legs. CNA-II was able to separate R6 and R7. CNA-II then walked R6 down the hall and informed the Nurse immediately, who then went and assessed R7. R6 was immediately placed on a 1:1 supervision. On 7/18/25, the Intradisciplinary Team (IDT) met to discuss R6 and R7's altercation and documented a stop sign will be placed across R7's door, R6 and R7 will not sit together during activities or during meals and will be kept separated in the hallways and elevators and R6 will remain on 1:1 supervision.Surveyor noted R6's Care Plan documents the follow for interventions following the 7/17/25 altercation: -A stop sign banner will be placed across the other Member's doorway.-Members will not sit together during activities, during mealtime and will be kept separated in hallways and/or elevators. All parties aware of interventions and in agreement with treatment plan. -Members will not sit together during activities, during mealtime and will be kept separated in hallways and/or elevators. Date Initiated: 07/17/2025 Revision on: 07/23/2025On 9/15/25, at 1:06 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B indicated that after R6 punched R7 in the mouth, family members and other residents expressed being fearful of R6 and uneasy around R6. At that point, the facility began to realize R6 required more services than the facility could provide to keep other residents safe. DON-B explained the facility cannot provide staffing for residents to be 1:1 supervision indefinitely and believed R6 required that level of supervision. DON-B informed Surveyor that the facility has sent R6 to the hospital for evaluations in the past, but nothing comes from it. DON-B indicates the facility has been attempting to find alternative placement for R6 but would need to clarify with Director of Social Services-D. DON-B indicated the facility kept other residents safe by initiating temporary 1:1 supervision for R6 and monitoring R6's behaviors.On 7/22/25, Director of Social Services-D created a progress note and documented the following: Director of Social Services-D met with R6 to talk about a recent incident where R6 hit R7 in the face multiple times after entering R7's room. R6 did not recall the situation, does not recall hitting anyone or entering anyone else's room. Director of Social Services-D asked what makes R6 upset, R6 stated kids. R6 talked about kids making R6 upset. R6 went on to indicate that R6 does not like being instigated or being told what to do. R6 shared R6 becomes agitated by this. R6 then started to discuss with Director of Social Services-D about a doll indicating, she is not real. R6 mentioned that She can't understand what we are talking about because she is just a doll.Survey noted R6 was taken off 1:1 supervision on 7/23/25 and was placed on 15-minute checks for R6's whereabouts, per the IDT progress note dated 7/23/25.A progress note dated 7/24/25 documents R6 glared at residents, causing a staff member to be concerned enough to stop what the staff member was doing and to briskly walk toward R6 and intervene.A progress note dated 8/1/25 documents R6 had multiple attempts to wander down the hall with R7. R6 became visibly irritated/agitated and began pushing staff when redirection was attempted. The progress note documents staff were making great attempts to keep other residents safe by keeping R6 from going into other resident rooms.On 8/4/25, R6 was evaluated by Psych Nurse Practitioner (NP)-JJ, who documented R6 has a significant history of physical and verbal aggression, sexual inappropriateness, generalized anxiety disorder, dementia with anxiety, mood disorder, and insomnia. Plan: continue vpa (valproic acid/Depakote) risperidone, Duloxetine, emotional support no change, recent increase in vpa, taper to DC (discontinue) namenda, continue emotional support and behavior interventions; follow up 1 month, sooner prn.A progress note dated 8/8/25, documented R6 entered another resident's room and was escorted out.A progress note dated 8/14/25 documented R6 wandered into another resident's room and the other resident expressed frustration with R6 going into resident's room.On 8/21/25, at 3:51 PM, Director of Social Services-D met with R6 to conduct an annual MDS assessment, which documents in part: R6 has a BIMS score of 5, which was previously a 4, remained on 15-minute checks for safety, continues to wander the unit, usually successful staff redirection and documents R6 continues to be satisfied with their living arrangements.On 8/25/2025, Director of Social Services-D completed an assessment/screen for post traumatic events and a trauma informed care plan for R6 was initiated. The Interventions are as follows: Assess/screen for post traumatic events and history of trauma, using nursing home appropriate screening tools, such as the LEC-5 (The Life Events Checklist for DSM-5 (LEC-5) is a self-report measure designed to screen for potentially traumatic events in a respondent's lifetime). Display warmth when answering questions, offer unconditional acceptance, being available and respecting the member's use of personal space. Maintain a calm, non-threatening manner, while working with the member. Member enjoys [NAME] wow or tribal-type music. This came [sic] help member feel grounded and calm, while connecting with their cultural background. Member used to enjoy hunting, fishing, being outside in nature, making things/fixing things with their hands. Per member's guardian, this was member's stress relief and a way to feel calm. Member should be offered a supervised walk inside or outside or something to do with their hands if s/s (signs/symptoms) of anxiety start to arise. Move the member to a quiet area with minimal stimuli and to maintain calmness in one's approach to the member. Provide reassurance and comfort if applicable. Provide activities and invite the member to participate. Praise member for their engagement and participation in social interactions. Visit the member to provide activity schedule and to encourage social interactions.On 8/25/25, at 6:46 PM, a progress note by RN-BB documented R6 exhibiting severe anxiety/restlessness, ignoring redirection, staff shut all doors on unit, R6 would just open the doors to enter resident rooms, another resident in the hallway due to not wanting to be alone in the room with R6. R6 requiring 1:1 interaction with staff but management continues to deem R6 only needing 15-minute checks. Staff finding it difficult to tend to other residents and prevent resident to resident altercations.On 8/25/25, at 8:07 PM, a progress note by RN-BB documented R6 continuing to open other resident's doors. Two other residents complained that R6 was either standing over them while they were in bed or opened their door. Residents expressing feeling unsafe.On 9/15/2025, 10:33 AM, Surveyor interviewed RN-BB. RN-BB explained to Surveyor, RN-BB has worked at the facility since 2017 and worked with R6 since admission Surveyor asked RN-BB about RN-BB‘s progress note on 8/25/25. RN-BB indicated R6 was exhibiting wandering behaviors that were disruptive to other residents and informed the charge nurse RN-EE. RN-BB explained that any charge nurse can initiate 1:1 supervision for a resident but usually only implement 1:1 supervision if an actual altercation occurs.2. R5 was admitted to the facility on [DATE] with diagnoses to include Post Traumatic Stress Disorder (PTSD) (a mental health condition that can develop after experiencing or witnessing a traumatic event, such as a natural disaster, war, physical or sexual assault, or a serious accident), Dementia (a general term for a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life,) and need for assistance with personal care.R5's Annual Minimum Data Set (MDS), dated [DATE], documents R5 has a Brief Interview for Mental Status (BIMS) score of 09 indicating R5 has moderate cognitive impairment and R5 has no limitations in upper or lower extremities.Surveyor reviewed the facility provided investigation regarding the altercation between R6 and R5 on 8/27/25. Surveyor noted the description of event documents the following: R6 entered R5's room. R5 was sitting in R5's room when R6 approached R5, R5 was startled and asked R6 what R6 wanted. R6 then began hitting R5 in the head and left eye with R6's cane. Staff witnessed R5 on R5's knees attempting to defend R5's self from R6. R5 and R6 were pulled apart and situation was diffused. R5 was cleaned up and assessed to have injuries to R5's head and left eye. R5 was sent to the hospital for further evaluation.Surveyor reviewed the facility provided document titled After Visit Summary for R5, dated 8/28/25. Surveyor noted R5 was discharged from the hospital with diagnoses that include Traumatic Brain Injury (TBI)-subdural hematoma measuring 5mm, Small Traumatic Subarachnoid hemorrhage, and Acute left frontal ischemia, likely traumatic.On 9/10/25, at 10:14 AM, Surveyor interviewed R5. Surveyor observed R5 to have a healing bruise under R5's left eye. R5 explained to Surveyor that R5 was working on bird houses in R5's room. R6 came into R5's room, catching R5 off guard and began hitting R5 over the head with R6's cane. R5 indicated that R5 has never experienced issues with R6 in the past, but explained other people have. During our discussion, R5 received a call for follow up regarding R5's injuries sustained during the assault. R5 indicated being ok with Surveyor listening to R5's phone call with Neurosurgery. Surveyor noted the Neurosurgery Nurse Practitioner explained to R5 the results of R5's most recent diagnostic imaging, indicating R5's brain bleed was getting smaller and no further follow up with neurosurgery was needed. R5 denied any pain or side effects of his injuries. R5 expressed feeling grateful and safe knowing R6 would not be returning to the facility. Surveyor noted that R6 remained at the hospital as of the time of the survey.On 9/15/25, at 1:06 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B indicated DON-B expects staff on evenings and nights to call the on-call nurse, who will then call DON-B, regarding any new/worsening behaviors or in the event of a member-to-member altercation. During daytime hours, the Intradisciplinary team (IDT) will meet to discuss resident triggers, behaviors and incident. DON-B indicated DON-B or NHA-A can initiate 1:1 supervision for residents. DON-B indicated DON-B should have been made aware of R6's escalating behaviors and found interventions to keep other residents safe. The facility's failure to keep R7 and R5 free from abuse created a finding of immediate jeopardy that began on 7/17/25. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 9/17/25 at 11:37 a.m. The immediate jeopardy was removed on 9/18/25 when the facility completed the following: - Staff development / Designee will educate licensed nurses and direct care staff on: Member to member altercation, abuse education, and educating on managing behaviors.- The social worker will review members for appropriate placement. All staff was educated member to member altercation policy, member behavior policy, care planning policy, mood assessment, and root cause analysis.- Social worker and clinical staff will review progress notes for resident's exhibiting aggressive behaviors or patterns of escalating behaviors and update care plans accordingly. IDT (interdisciplinary team) will review policy for member behaviors. Staff to review care plan for member's exhibiting behaviors for appropriate interventions. - SDC/Designee provided education to all staff regarding elopement on their very first shift in their work unit.- SDC/Designee provided education on managing aggressive behaviors and providing intervention before there is member to member contact. (early detection of escalating behavior) on their first shift in their work unit.- Administrator/Designee will provide education to social services on responding to resident's psychosocial needs, behaviors and wishes to be discharged , developing a plan and updating the care plans.- Administrator/Designee will provide education to mangers on completing a RCA (root cause analysis) for falls, elopements, and escalated behaviors. - SW (social worker) to audit 5 x per week x 6 weeks progress notes for any residents increase behaviors. Care plan & interventions to be updated based on Audit findings. Findings to be presented to QAPI (quality assurance and performance improvement) committee for review and suggestions. Findings discussed at IDT clinical daily stand-up meeting.No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 5 of 15 residents reviewed (R6, R14, R15, R12 and R11) received medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. * R6 has had 13 episodes of aggressive behaviors toward staff and other residents since 7/26/24, On 7/17/25, R6 punched another resident in the mouth. On 8/25/25, R6 hit R5 on the head with R6's cane, resulting in a traumatic brain injury for R5. The facility did not identify and seek ways to support R6's psychosocial and behavioral needs by reevaluating and assessing R6's behaviors. The facility did not identify and promote non-pharmacological approaches to care that met the mental and psychosocial needs of R6 and did not assess and identify possible transition of care services for R6 The facility's failure to provide R6 with necessary medically related social services, created a finding of immediate jeopardy that began on 7/17/25. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 9/17/25 at 11:37 a.m. The immediate jeopardy was removed on 10/7/25 when the facility implemented an immediate jeopardy removal plan. The deficient practice continues at a scope and severity of a E (pattern/potential for harm) for the following examples: *The facility did not reevaluate R14's behaviors in order to implement proper, person-centered interventions related to R14's psychosocial and behavioral needs. *The facility did not ensure R15's stop sign banner was in place to keep R14 from entering the room while R15 is in R15's room and did not follow up with R15's psychosocial needs following incident on 9/23/25. *Facility Social Worker did not follow up with R12 following R12's statement on 8/27/25 of feeling unsafe at the facility while R6 was at the facility. * Facility staff did not keep R11 from eloping from the facility. Facility staff did not update psychotherapy with R11's increased frustration or verbalizations of wanting to leave and feeling like a prisoner and did not address alternative placement or a less restrictive environment with R11 based on R11's continued verbalizations of wanting to leave the facility. Findings include: The facility's document titled “WISCONSIN VETERANS HOME Union Grove- Facility Assessment,” with a certification expiration date of November 25, 2025, documents in part, based on the resident assessment, the Facility accepts and provides for residents with Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder and behavior that need interventions. The decision to admit a resident is based on the following: does the Facility have sufficient staff to provide care for the resident, staff with the skill set to provide quality care, equipment and supplies need, additional staff training required and number of bed available. “Services and Care We Offer Based on our Resident's Needs.Mental Health and Behavior Manage the medical conditions and medication- related issues causing psychiatric symptoms and behavior identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities”. Under “Provide person-centered/directed care: Psycho/social/spiritual support ,“ the facility documents “Find out what resident's preferences are and routines are. what upsets him/her and incorporate this information into the care planning process. Record and discuss treatment and care preferences.” The facility documents “Caring for residents with mental and psychosocial disorders, and implementing nonpharmacological interventions is part of the Facility's competencies. 1.) R6 was admitted to the facility on [DATE] with diagnoses including Dementia (a general term for a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life) with mood disturbances and psychotic disturbances, Anxiety, Delirium, and Major Depressive Disorder Adjustment Disorder. R6's most recent MDS, dated [DATE], documents R6 has a BIMS score of 4 indicating severe cognitive impairment, had wandering behaviors 1 to 3 days, no impairment in upper or lower extremities, uses a cane for mobility and receives antipsychotic medications. Surveyor noted R6 has had 13 incidents of escalating aggressive behaviors since 7/26/24. a. On 6/9/25, R6 had a resident-to-resident altercation where R6 was the aggressor. No root cause analysis was completed. Surveyor noted a progress note dated 6/10/25, by Director of Social Services-D, which documents Director of Social Services-D met with R6 to discuss the incident, indicated R6 did not recall the incident, is in a good mood, does not have any concerns and remains on 1:1 supervision at that time. Surveyor noted Director of Social Services-D did not assess if current behavior interventions are effective for R6 or if any new interventions needed to be implemented. On 09/16/2025, at 12:24 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B indicated that upon DON-B's arrival to the facility, DON-B noted root cause analyses were not being done and DON-B began implementing them. DON-B indicated R6 was put on temporary 1:1 supervision as an immediate intervention and expects Director of Social Services-D to be completing the root cause analysis and following up, as well as the intradisciplinary team (IDT). b. A progress note, dated 6/14/25, documents R6 started swinging R6's cane at staff. A progress note, dated 6/16/25, documents, R6 was seen by Psych Nurse Practitioner-JJ who documents “patient has a history of physical altercations and is involved in numerous aggressive acts, indicating a high potential for aggressive behavior. Inappropriate behavior toward staff suggests poor impulse control and potential risk. The patient's difficulty with redirection further increases the risk of problematic behaviors. Close monitoring and intervention strategies are necessary to manage these risks.” Surveyor noted no documentation indicating clarification on what Psych Nurse Practitioner-JJ meant by “Close monitoring and intervention strategies are necessary to manage these risks” or what the facility is doing to manage R6's risks or mention of R6 swinging cane at staff on 6/14/25. A progress note, dated 6/17/25, documents the IDT met on 6/16/25 for “Mind over meds behavior management meeting” and discussed R6's medications and behaviors. c. Surveyor reviewed R6's progress notes from the facility's Electronic Health Record, and noted on 7/1/25, R6 used R6's cane to hit a staff member in the stomach when redirection of wandering was attempted. The facility's document titled “Care Plan Report” for R6 documents R6 has a potential for behaviors with an initiation date of 7/1/25 and documents the following interventions: - A stop sign banner will be placed across the other Member's doorway. Members will not sit together during activities, during mealtime and will be kept separated in hallways and/or elevators. All parties aware of interventions and in agreement with treatment plan. Surveyor noted that the above intervention was related to member-to-member interactions despite the 7/1/25 incident involved R6 striking a staff member with his cane and not a member. - PT to evaluate if Member is safe ambulating without cane - Members will not sit together during activities, during mealtime and will be kept separated in hallways and/or elevators. - Administer medications as ordered. Monitor/document for side effects and effectiveness. - Anticipate and meet the resident's needs. - Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. - Close supervision for increased behavior and safety - Explain all procedures to the resident before starting and allow the resident time to adjust to changes. - If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. - Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. - Member to be toileted Q2 hours - Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. - Pharmacy medication review - Provide a program of activities that is of interest and accommodates residents status. - Safety: 15-minute checks for Member whereabouts on unit. Surveyor noted no documented root cause analysis was completed. A progress note, dated 7/2/25, documents, Director of Social Services-D met with R6 for follow up regarding incident with staff member. Director of Social Services-D documented R6 did not recall the incident and expressed R6 does not feel R6 used R6's cane inappropriately. Director of Social Services-D documented R6 stated feeling calm and neutral in R6's mood and denied concerns. A progress note, dated 7/2/25, documents, the IDT met to discuss the incident, R6 on 30-minute safety checks, and implemented a new intervention of Physical Therapy assessing R6 for the need of a cane as a mobility device. On 9/11/25, at 9:13 AM, Surveyor interviewed Physical Therapy (PT) Director-J who indicated R6 was evaluated on 7/3/25 for the need of R6's cane. PT Director-J indicated it was determined R6 required R6's cane for mobility but was given a smaller, lighter cane on 8/27/25. On 7/7/25, R6 was evaluated by Psych Nurse Practitioner-JJ who documents “Risk Assessment Patient has a history of physical altercations and is involved in numerous aggressive acts, indicating a high potential for aggressive behavior. Inappropriate behavior towards staff suggests poor impulse control and potential risk. The patient's difficulty with redirection further increases the risk of problematic behaviors. Close monitoring and intervention strategies are necessary to manage these risks.” Surveyor noted no behavior interventions implemented or evaluated for effectiveness. d. A progress note, dated 7/13/25, documents, R6 attempted to take a box of tissues from a table where other residents were sitting. The residents became upset, telling R6 not to take their tissues. R6 became agitated and appeared to want to strike peers. Staff intervened and gave R6 a box of tissues. On 7/15/25, PhD (Doctor of Psychology)-DD documented “Staff reports that there have been no aggressive behaviors noted for the past few weeks.” R6 continues to minimize aggressive behaviors and is not able to identify triggers for actions. Positive reinforcement should be given for appropriate behaviors. Identifying triggers has been difficult at this time; however, attempts should be made to identify aggressive moods, comments, or physical changes that might signify potential acting out behaviors. Surveyor noted at least 2 incidents of aggressive behaviors documented for R6 from 7/1/25 to 7/15/25 which PhD-DD seems unaware of. e. A progress note, dated 7/17/25, documents R6 punched another resident in the head and mouth. A root cause analysis documents R6 is confused and went down the wrong hallway and went into the room in the same area as R6's room, R6 thought someone was in R6's room and punched them. Surveyor reviewed the Facility Reported Incident involving the resident-to-resident altercation that occurred on 7/17/2025. The facility's incident report documents R6 walked into R7's room and hit R7 in the mouth and head. Certified Nursing Assistant (CNA)-II was checking on residents in the dining room and noticed R6 was not in the recliner where R6 had previously been sitting. CNA-II walked toward R6's room to locate R6 and heard R7 yelling out for help. CNA-II observed R6 standing over R7. R7 was sitting in R7's recliner while R6 had ahold of R7's wrists. R7 was attempting to get R6 away from R7, using R7's legs. CNA-II was able to separate R6 and R7. CNA-II then walked R6 down the hall and informed the Nurse immediately, who then went and assessed R7. R6 was immediately placed on a 1:1 supervision. A progress note, dated 7/18/25, documents, The IDT met to discuss the incident. The IDT documents, R6 is confused, entered another resident's room and became aggressive when asked to leave. R6 became agitated and hit the other resident in the face. Interventions documents, R6 was placed on a temporary 1:1 supervision, R6 was not to sit with the other resident during meals, activities and will be kept separate in hallways/elevators and a stop sign would be placed across the other resident's doorway. On 9/15/25, at 1:06 PM, Surveyor interviewed DON-B. DON-B indicated that after R6 punched the other resident in the mouth family members and other residents expressed being fearful of R6 and uneasy around R6. DON-B indicated that this is when the facility began to realize R6 required more services then the facility could provide to keep other residents safe. DON-B informed Surveyor that the facility has sent R6 to the hospital for evaluations, but nothing is founded. DON-B believes the facility has been attempting to find alternative placement for R6 but would need to clarify with Director of Social Services-D. DON-B indicated they kept other residents safe by initiating a temporary 1:1 supervision for R6 and were monitoring R6's behaviors. On 9/15/2025, at 1:51 PM, Surveyor interviewed Director of Social Services-D regarding finding placement for R6. Director of Social Services-D indicated that R6's family member has expressed in the past about R6 going home to the reservation, but no other attempts to find alternative placement were looked into. Surveyor noted on 7/21/25, R6 was evaluated by Psych Nurse Practitioner-JJ. Psych Nurse Practitioner-JJ evaluation documents: R6 had recent physical altercation with peer. R6 entered peers' room, possibly mistaking it for R6's, and struck peer. R6 last seen 7/7/25 where it was noted R6 was improving since re-increase risperidone after failed gradual dose reduction. R6 with significant history of physical and verbal aggression, sexual inappropriateness, generalized anxiety disorder, dementia with anxiety, mood disorder, and insomnia. Staff reports R6 has had a history of both physical and verbal aggression towards staff and peers. Surveyor noted the assessment and plan documented the following:-recent physical aggression-Plan: increase vpa (valproic acid), continue duloxetine, emotional support -Insomnia-well controlled-Plan: continue emotional support - Recent physical aggression-Plan: increased vpa, consider change to SSRI in future; continue emotional support-increase vpa ER 500; taper and DC namenda; continue emotional support; follow up next rounds” A progress note, dated 7/21/25, documents: Director of Social Services-D attempted to meet with R6 to follow up regarding the incident on 7/17/25 but R6 was sleeping. A progress note, dated 7/22/25, documents: Director of Social Services-D met with R6 to discuss the resident-to-resident incident on 7/17/25 and documents the following: “This writer met with member to talk about a recent member to member where this member hit member (R7) in the face multiple times after entering their room. This member did not recall the situation. This member does not recall hitting anyone or entering anyone else's room. When asked what makes this member upset, they stated “kids.” This member talked about kids making him upset as they are not aware of who they are, and they are dummies and have no respect. This member went on to state that he does not like being instigated or being told what to do. This member shared he becomes agitated by this. This member then started to discuss a doll and stated, “She is not real.” This member shared that those kids are toys, and they like to argue a lot. This member mentioned that “She can't understand what we are talking about because she is just a doll.” Surveyor noted Director of Social Services-D did not evaluate R6's current interventions or assess effectiveness of current interventions. A progress note, dated 7/24/25, documents R6 was glaring at particular residents, writer became concerned enough to “briskly” walk toward R6 to intervene. f. A progress note dated 8/1/25, by RN-BB, documents R6 had multiple attempts to interact with a resident R6 had an altercation with, redirection was causing R6 to become “agitated/irritated” and began pushing staff. A progress note, dated 8/21/25, documents Director of Social Services-D met with R6 to conduct an Annual Minimum Data Set assessment. Director of Social Services-D indicated R6 is currently on 15-minute checks for safety, wanders off unit usually redirectable by staff, no traumatic events in the assessment period, an updated LEC-5 (The Life Events Checklist is a self-report measure designed to screen for potentially traumatic events in a respondent's lifetime). would be completed and R6 is satisfied with living arrangements. A Trauma informed Care plan was initiated on 8/25/25 for R6. g. A progress note dated 8/25/25, at 6:46 PM, by RN-BB, documents: R6 exhibiting severe anxiety/restlessness, ignoring staff redirection, all doors were shut on hallway but R6 kept opening other resident's doors, another resident stayed in the hallway due to not wanting to be alone in the room with R6, R6 requiring nearly 1:1 supervision but management deems R6 as 15 minute checks. A progress note dated 8/25/25, at 8:07 PM, by RN-BB documents: R6 continuing to display severe anxiety/restlessness, going into other resident rooms, unsuccessful redirection and making other residents feel unsafe. On 9/15/2025, at 1:51 PM, Surveyor interviewed Director of Social Services-D regarding R6's escalating behaviors and what was done for R6 to prevent further incidents. Director of Social Services-D indicated that Director of Social Services-D has met with R6's family member and went over trauma informed care interventions on 8/25/25 but indicated that was done due to needing a facility wide audit on trauma informed care, which every resident received. Director of Social Services-D indicated it was not a direct response to R6's behaviors. On 9/16/25, at 12:24 PM, Surveyor interviewed DON-B. DON-B indicated R6's behaviors were discussed in IDT meetings, DON-B began initiating root cause analyses and indicated Director of Social Services-D was not following up on the Social Services side. Surveyor expressed the concern regarding lack of Social Services involvement in R6's care. The facility's failure to provide R6 with necessary medically related social services, created a finding of immediate jeopardy that began on 7/17/25. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 9/17/25 at 11:37 a.m. The immediate jeopardy was removed on 10/7/25 when the facility implemented the following: NHA educated Social Worker on the following policies: - Definition of F745 Medically related social services from CMS - Members Behavior Policy - Member to Member altercation policy - Care planning policy - Trauma informed Care Policy - Root Cause Analysis process - Member mood assessment policy - Member discharge policy - Member at risk for elopement or unsafe wandering policy SDC/Designee educated Staff on - Member Behavior policy, Member to member altercation policy, care planning policy and member at risk for elopement or unsafe wandering policy. Education was started 9-18-2025 and completed on 10/7/25 - Social worker attended the Wisconsin Nursing Home Social Workers Association fall conference 10/2-10/3/2025. - Social Worker/Designee to follow up with members or POA-HC or Guardian in discharge planning per member discharge policy for members wishing to discharge from facility. - Nurse Managers/Designee to complete elopement assessment for members due for quarterly assessment or with current change of condition warranting updated elopement assessment. - Social worker will establish a mentorship relationship with a licensed clinical social worker at the Wisconsin Veterans Home at King with weekly mentorship meetings. Facility will also pursue professional services for social services consulting. - The facility implemented a system/procedure to review every behavior event, resident -to resident altercations, and elopements during morning clinical which included reviewing assessment and care plan interventions for appropriateness. - Social Worker/Designee will review progress notes 5 x per week in clinical meeting auditing for members with increased behaviors, exit seeking, wishes to discharge and trauma. Those members identified will be adequately assessed and interventions put in place. Findings will be reported to QA for further recommendations. - Social Service Director and Administrator to conduct weekly meeting to review Medically Related Social Services concerns and establish process for addressing concerns. The deficient practice continues at a scope and severity of a E (pattern/potential for harm) for the following examples: 2.) R14 was admitted to the facility on [DATE] with diagnoses that include Adjustment Disorder (a mental health condition characterized by emotional and behavioral symptoms that develop in response to a significant life stressor), Presbyopia (a common age-related condition that affects the eye's ability to focus on near objects), Dementia (a general term for a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life) and Post-Traumatic Stress Disorder (PTSD) (A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event.) R14's Quarterly Minimum Data Set (MDS), dated [DATE], documents in part, R6 has a Brief Interview for Mental Status (BIMS) score of 12 indicating R14 has moderate cognitive impairment, no behaviors, has no impairment in upper or lower extremities, uses a walker and wheelchair for mobility and receives antidepressant medication. R15 was admitted to the facility on [DATE], with diagnoses including depression. R15's admission MDS, dated [DATE], documents BIMS score of 15 indicating R15 is cognitively intact, has impairment in lower extremities on one side and uses a wheelchair for mobility. Surveyor noted R15 is care planned for Trauma Informed Care, initiated 9/9/25 and documents “. Depressive disorder, recurrent severe without psychotic features. Member was referred to in-house psychiatrist on 3/11/25 and inhouse psychologist on 4/14/25” On 9/30/25, during the extended survey at the facility, Surveyor reviewed the facility's grievance log and noted a grievance from R15 regarding R14 entering into R15's room on multiple occasions, with the most recent time resulting in R14 removing R14's clothing while in R15's room. Surveyor reviewed the facility provided document titled, “Member Grievance/Concern,” dated 9/23/25, by Social Worker (SW)-C, which documents R14 keeps going into R15's room and this has occurred 6 times in 12 days. This has been occurring after dinner and before bed, and on occasion R14 wanders into R15's room with pants and underwear down. R14 was placed on a temporary 1:1 overnight. Resolution of the complaint documents, R15 has a stop sign banner in front of R15's door to stop R14 from going into R15's room and indicated SW-C followed up with R15 with no concerns. On 9/30/25, at 9:54 AM, Surveyor observed R15's door open, the stop sign banner hanging next to the door and was not across the doorway. Surveyor interviewed R15. R15 informed Surveyor of the concerns regarding R14 coming into R15's room and R15 expressed those concerns to Director of Social Services-D. R14 has come into R15's room [ROOM NUMBER] times in 12 days. R15 indicated a stop sign banner is supposed to stop R14 from entering R15's room but it does not do any good when it's not put up and seems to only go up when R15 is not in R15's room. R15 explained being afraid to shut R15's eyes at night due to R14 coming into R15's room. R15 indicated wanting to buy a squirt gun to defend R15's self against R14 but does not want to get in trouble or hurt R14. R15 explained that R15 cannot defend R15's self, due to having a bum leg. R15 explained R14's behavior as strange and uncomfortable. R15 began to get choked up talking about the incident; R15 explained that R15 informed Director of Social Services-D, who came and spoke with R15, but has not spoken to R15 since. Surveyor noted no new interventions were implemented for R14 or R15 following this incident. On 9/30/25, at 11:10 AM, Surveyor interviewed Director of Social Services-D. Director of Social Services-D indicated Director of Social Services-D did not complete LEC-5s following the incident with R14 and R15 and care plans were not assessed or updated, interventions were not assessed for effectiveness and indicated that should have been done when the situation occurred and at follow up. Director of Social Services-D indicated that R14 was placed on a temporary overnight 1:1 supervision following the incident. No other interventions were implemented, and current interventions were not assessed. On 9/30/25, at 3:02 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A indicated that NHA-A was going to make a change to the plan of correction that LEC-5s were going to be done annually instead of quarterly, but should still be completed in between with any traumatic events, indicating R14 and R15 should have been reassessed following the incident. NHA-A indicated that R14 and R15 should have interventions evaluated. NHA-A indicated that the stop sign banner should be up while residents are in their rooms to prevent other residents from going into other resident rooms. 3.) On 8/27/25, R6 was involved in a resident-to-resident altercation resulting in R5 sustaining a traumatic brain injury after being hit over the head with R6's cane. During the resident-to-resident investigation, Surveyor noted a statement by R12 indicating R12 did not feel safe in the facility with R6. On 9/30/25, at 2:36 PM, Surveyor interviewed Director of Social Services-D regarding follow up with R12's statement following the resident-to-resident altercation. Director of Social Services-D informed Surveyor that Director of Social Services-D has not followed up with R12 regarding R12's statement of feeling unsafe with R6 around. Surveyor noted there were no immediate interventions implemented and no social services assessment following R6's increased behaviors on 8/25/25 prior to the assault on 8/27/25. 4.) R11 was admitted to the facility on [DATE] with diagnoses of Dementia Unspecified Severity (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), With Mood Disturbance, Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow and make it difficult to breathe), Essential (Primary) Hypertension (most common type of high blood pressure), Chronic Respiratory Failure With Hypoxia (long-term condition where the lungs are unable to adequately exchange oxygen and carbon dioxide), Insomnia (sleep disorder characterized by difficulty falling asleep), Unspecified, and Peripheral Vascular Disease (circulatory condition in which narrowed blood vessels reduce blood flow to limbs), Unspecified. R11's Quarterly Minimum Data Set (MDS) completed 6/26/25 documents R11's Brief Interview for Mental Status (BIMS) score is 12, indicating R11 demonstrates moderately impaired skills for daily decision making. R11's MDS documents no mood or behavior issues, including wandering. R11's main locomotion is by standard wheelchair. R11 is independent with dressing, mobility, and transfers. R11's Kardex (instructions to nursing staff) was updated 9/15/25. The Kardex documents: Safety -1/25/25 Encourage member to ask for help with computer -Alert on call nurse or DON or ADON for all incidents (escalated behaviors, attempts at elopement) -R11 has a wander guard on R11's wheelchair because R11 tries to tear it off R11's arm/leg -R11 now lives in memory care -R11 refused wander guard 4/25/25 -Redirect R11 when voicing need to leave facility to go to the bank. -Roam Alert wander band to R11's wheelchair R11's comprehensive care plan includes the following applicable problems: Safety Elopement: R11 at risk of elopement due to cognitive losses, Dementia high risk for elopement 7/10/25 R11 was waiting outside “for a ride to his bank”. 15-minute safety checks initiated for R11 whereabouts. R11 declines wearing roam alert device bracelet 8/4/25 15-minute checks discontinued 9/11/25 Roam alert device on R11's wheelchair Initiated 7/10/24 Interventions: -Monitor my behaviors to determine: duration, frequency, intensity, and patterns. Consider any changes that may have occurred such as: a room change, change in cognitive status, medication changes, new staff, or termination of treatment program. Initiated 7/10/25 -Alert on call nurse or DON or ADON for all incidents (escalated behaviors, attempts at elopement) Initiated 9/11/25 -R11 has a wander guard on R11's wheelchair because R11 tries to tear it off R11's arm/leg Initiated 9/11/25 -R11 now lives in memory care Initiated 9/11/25 2.Coping/Trauma Informed Care Plan: I am at risk for ineffective individual coping due to R11's diagnosis of Major Depressive Disorder, Recurrent Unspecified. Adjustment to nursing home. R11 referred to in-house psychologist on 6/10/25 Triggers: R11 breathing issues forced R11 to stop R11's construction in R11's 40s. When R11's breathing bothers R11, R11 can feel triggered. Initiated 9/9/25 Interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness. Initiated 9/9/25 -Arrange for psych consult, follow up as indicated. R11 referred to in-house psychologist 6/10/25. Initiated 9/9/25 -Assess/screen for post traumatic events and history of trauma, using nursing home appropriate screening tools, such as the LEC-5. Initiated 9/9/25 -R11 has deep breathing techniques to use when R11's breathing is bothering R11. R11 also enjoys socializing and being around family and friends. Initiated 9/9/25 -Discuss feelings around change and loss, facilitate R11's expression of these feelings. Initiated 9/9/25 -Encourage R11 to talk about how R11 is feeling to family, friends, or staff; remind R11 to utilize R11's support system if R11 is feeling down. Initiated 9/9/25 -Please watch R11 for the signs and symptoms which may indicate R11 feeling sad or depressed such as somnolence, social isolation, increased sadness, frequent weeping, anger, refusal of cares, decreased appetite, weight loss/gain. Initiated 9/9/25 Starting 3/26/25, the facility completed an [NAME]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility did not provide 5 residents (R4, R7, R11, R12 and R15) of 11 residents reviewed with the necessary cares and services to promote quality of life and assist residents to maintain their highest practicable level of physical, mental, and psychosocial well-being. *The facility did not provide R7 with the sense of safety within the Facility from R6. R7 indicated being in fear of R6, a resident who displayed escalating aggressive behaviors. R7 was assaulted by R6 and was assessed as experiencing Post-Traumatic Stress Syndrome (PTSD) as a result. R6 went on to assault R5 a few weeks later. The facility did not have a plan to effectively monitor R6. * The facility failed to provide R4 a sense of satisfaction with oneself, the environment, and the care received. R4 has continually expressed dissatisfaction with the living at the facility. R4's dissatisfaction with the facility has caused R4's behavior of planning unsafe ways of leaving the facility. R4's loss of a friend was not addressed in R4's plan of care potentially triggering unsafe behaviors by R4. *The facility was aware of R11's previous attempts and continued expressions of wanting to leave the facility and did not implement interventions to keep R11 safe while residing at the facility as evidenced by R11's [DATE] elopement from the facility. The facility did not identify R11's signs of distress exhibited by R11's expressions of wanting to leave the facility and attempting to elope. R11's care plan does not document person-centered interventions. Medically related social services has not been provided to R11 resulting in a deterioration in R11's psychosocial well-being. *R12 documents during a statement following a resident-to-resident altercation, that R12 did not feel safe at the Facility with R6 wandering “in here.” *R15 expressed being fearful of closing R15's eyes at night due to R14 wandering into R15's room. R15 expressed not being able to defend R15's self from R14 and wanting to purchase a water gun to deter R14 from entering R15's room. This pervasive disregard for residents' quality of life created a finding of immediate jeopardy that began on [DATE]. The Facility was notified of the immediate jeopardy on [DATE] at 11:37 AM. The immediate jeopardy was removed on [DATE] when the facility implemented an immediate jeopardy removal plan. Findings include: 1.) On [DATE], R6 was the aggressor in a resident-to-resident altercation with R7. On [DATE], R6 had another resident -to-resident altercation where R6 is the aggressor. A statement from R7, dated [DATE], documents R7 does not feel safe at the Facility with R6 around. R12's statement, dated [DATE], documents the resident feels unsafe when R6 wanders in “here.” On [DATE], at 6:46 PM, a progress note, by Registered Nurse (RN)-BB, documents R6 exhibiting severe anxiety/restlessness, ignoring redirection, staff shut all doors on unit, R6 would just open the doors to enter resident rooms, another resident in the hallway due to not wanting to be alone in the room with R6. R6 requiring 1:1 interaction with staff but management continues to deem R6 only needing 15-minute checks. Staff finding it difficult to tend to other residents and prevent resident to resident altercations Surveyor noted a progress note by PhD (Doctor of Psychiatry)-DD, dated [DATE], documents R7 is experiencing acute PTSD symptoms following recent assault by R6. R7 reports being “frightened and surprised” by the assault with fears R6 will return and hurt R7 again. PhD-DD documents R7's anxiety symptoms are currently heightened due to the recent assault and expressing fear in R6's return. 2.) R4 was admitted to the facility on [DATE] with diagnoses that include COPD, Dementia with Mood Disturbance, Dementia with Moderate Anxiety, PTSD, Multiple Sclerosis- and MVI (motor vehicle incident) with quadriplegia. R4 was placed under protective placement via a court order on [DATE]. R4's Determination and Order on Petition for Guardianship Due to Incompetency document dated [DATE] documents, This individual is found to be incompetent because other like incapacities .The court transfers to the guardian of the person the power to exercise in full the ability to receive medical or treatment records of the individual; make decisions related to mobility and transfer- Partial Transfer. The individual retains the power with Guardian consent. Protectively placed: indicating the ward is totally incapable of providing the wards own care or custody as to create a substantial risk of serious harm to the ward or others. Serious acts may be acts of overt acts or acts of omission.” R4 has an elopement history with multiple planned elopements from appointments. The most recent prior to [DATE] was dated [DATE] when R4 eloped from the hospital and was found at a hotel approximately seven hours later. A later investigation found R4 planned the elopement and had saved money to go to a different location and to live independently R4's Last Brief Interview for Mental Status (BIMS) was completed in June of 2024 with R4 scoring 15 indicating intact memory. R4 refuses to participate in the BIMS process. R4's minimum data set (MDS) with an assessment reference date of [DATE] documents under section GG that R4 uses a manual wheelchair and once seated can wheel independently at least 150 feet. R4's Discharge Care Plan initiated on [DATE] documents, DISCHARGE PLANS: Long-term stay anticipated at this SNF r/t (related to) I'm no longer able to reside at home d/t (due to) eviction from apartment, my history of falling at home. I voice wanting to leave the facility to go and live independently but I am unrealistic about my abilities. I refuse to have [NAME] County come out and do discharge options counseling. The VA (Veterans Affairs) spinal cord unit has encouraged me to talk to the county as the VA does not have a discharge option. R4's medications include Sertraline 50 mg daily started [DATE]. R4's Psychiatry progress note dated [DATE], at 2:42 PM, documents: “Pt is [AGE] year-old male seen today for follow up psychiatric evaluation. Pt seen for yelling, restiveness with cares and medications, anxiety and agitation. Pt will refuse cares/meds at times from certain staff, then report that he was not offered/given the cares/meds. Pt dismissive of exam today. Pt will discuss with staff and practitioners when he wants per staff report. Overall behaviors improved since rx (medication) sertraline….” R4's nursing note dated [DATE], at 12:54 PM, documents: “Writer attempted to recheck members blood pressure due to reading this morning. Member stated Get the fuck out! Get the fuck out! writer will notify physician. Supervisor aware. Member is on blood pressure medications as well. Plan of care continues.” R4's Incident Report dated [DATE], at 2:30 PM documents: “Incident description” Member was seen returning from the gazebo outside onto the unit. Member had 4 fluid filled blisters on his face. Immediate action taken, Description: member was monitored. Member did not report pain or discomfort from the Sunburn. The physician was called. Nurse notified physician and received orders Aloe. Aloe received. Member offered aloe. Member agreed and was applied. Mental Status oriented to Person. Oriented to situation. Oriented to place. Oriented to time. Predisposing factors: other. Predisposing Physiological factors: none. Predisposing Situation factors: Active exit seeker. Other info: Member prefers to be non-compliant. Member enjoys being outside in the sun. member does not like to wear sunscreen. (Historical Temperature was 84 degrees). R4's nursing note dated [DATE], at 1:00 PM, documents: “Register Nurse (RN) and Assistant Director of Nursing (ADON) went outside to assess member's forehead. Member refused. Was using abusive language and left the area where he was outside. RN and ADON notified member we were going back inside. Member's face is normal color, and he has a hat down over his forehead”. R4's elopement nursing note dated [DATE], at 2:48 PM, documents: Member left out the unit at 12:30 with water in hand. Declined sunscreen, had hat on. At approximately 1:30 member was not seen at the gazebo. Staff immediately went to look at {….Hall} and outside. Staff coming in for second shift alerted writer member was rolling towards Highway C. Writer and aid jumped in personal vehicle and drove towards member to check on safety. Member seen close to Wisconsin Southern Center State sign, Writer and aid got out and spoke with member. Member stated, “I don't want to be here, I want to go to [NAME]”. Writer called 911 when member appeared not to stop. Member agreed to come back to facility. Staff rolled member to safe location and called transport to pick him up to drive back to {….Hall}. New intervention implemented and added to TPOC (care plan). Provider notified this shift: [DATE] 2:45 PM. Family/Guardian notified [DATE] 2:45 PM. Supervisor notified via phone [DATE] 2:00 PM. (Historical Temperature was 86 degrees). R4's Psychiatric note dated [DATE], at 9:53 PM, documents: Reason: Adjustment disorder with Depression and Anxiety. R4, [AGE] years old male seen today for follow up psyche visit. Start time 10 AM end time 10:30 AM record review/consultation with staff 10 minutes, face- to -face with patient 20 minutes. This clinician was asked to see R4 by his Family Member. Attempts have been made over the past several months; however, he has refused services. Records indicate that last weekend he eloped twice, when found, he stated that he wanted to go to [NAME] as they have in his opinion, better physical therapy. He cooperated with staff and got in their car and returned to the facility. If R4 does not have a wander guard at this time, that should be considered. R4 was angry and frustrated. He did not wish to engage in individual therapy despite wanting to leave the facility and knowing that talking to the staff and cooperation could assist him in being accepted in another facility. He was verbally aggressive during the session and stated that no one could help him. He is oriented x 3. Due to his self-isolation and verbal aggressiveness, therapy will be attempted within the coming 2 weeks…. On [DATE], at 12:00 PM, Surveyor interviewed R4 about R4's elopement and [DATE] sunburn incident. Surveyor asked if R4 membered leaving the building in July. R4 informed Surveyor that R4 remembered leaving. R4 informed Surveyor “I was going to [NAME]”. Surveyor asked R4 why R4 wanted to leave. R4 informed Surveyor that “I don't like it here, I keep escaping” and that R4 has always planned on leaving. R4 informed Surveyor that R4 didn't believe the facility was trying to help him. R4 informed Surveyor that R4 was finally going to an assisted living next week Tuesday and that they won't treat him like a baby like they do here. Surveyor asked R4 why R4 had been out so long on [DATE] causing R4 to get a bad sunburn. R4 informed Surveyor the R4 was sad that day. R4 didn't seem like R4 wanted to continue. Surveyor asked if the Surveyor could come back later. R4 agreed. On [DATE], at 9:58 AM, Surveyor continued the interview with R4. Surveyor asked R4 if R4 could tell Surveyor about why R4 felt he needed to leave the facility. R4 informed Surveyor that R4 was going to [NAME] to the hospital because the Social Workers here won't help him. R4 informed Surveyor that R4 could have been in [NAME] but they didn't evaluate him because the Social Worker didn't help set it up. R4 informed Surveyor the Social Worker at [NAME] Hospital would help him. Surveyor asked R4 what route R4 took. R4 informed Surveyor that R4 wheel himself down the road from the Gazebo then down the main road towards the highway. R4 informed Surveyor they must have finally noticed I wasn't there, and they came after me. R4 informed Surveyor “I escaped in Milwaukee before; I had to do something”. R4 informed Surveyor that the family member was stealing from him and that they were not helping him get out here. R4 informed Surveyor They treat me like a baby here Surveyor asked R4 if R4 was being monitored by staff. R4 informed Surveyor the staff was not monitoring him but that after he left, they sure are now. Surveyor asked R4 if R4 had any provisions like water for the trip. R4 informed Surveyor that R4 was in Vietnam and knew how to pack a [NAME] sack. R4 informed Surveyor he had cloths and water with him. Surveyor asked R4 if he was planning to leave now. R4 informed Surveyor he was being transferred to an assisted living next week Tuesday and was happy about that. Surveyor asked R4 how long R4 was out on [DATE] when R4 received the Sunburn of R4's forehead. R4 informed Surveyor that R4 like to be in the Sun and often is outside tanning. R4 informed Surveyor the R4 was outside from about noon to after 3:00 PM maybe 3:20 PM. Surveyor asked why R4 was outside long enough to get burned. R4 informed Surveyor the R4 was thinking about R4's friend who died and R4 was very sad and didn't want to come inside. R4 informed Surveyor that R4 wanted to sit by himself outside for as long as possible. R4 informed Surveyor that R4 has a new friend now like R4 who wants to escape from here. R4 informed Surveyor my friend has escaped 3 times already. Surveyor asked R4 if the facility or social services had spoken to R4 about why he was sad and why he was outside for so long. R4 informed Surveyor that no one has spoken to me about anything about that day. R4 informed Surveyor that the social worker wouldn't help him anyway. On [DATE], at 2:12 PM Surveyor interviewed RN-V, Surveyor asked RN-V about R4's behaviors when R4 goes outside. RN-V informed Surveyor R4 refuses to sign out and refuses Sunscreen and other measures to protect R4 from injury. Surveyor asked RN-V about R4's friend that passed away and that R4 told the Surveyor that R4 stayed outside to long because R4 was sad on [DATE] over the death of R4's friend. RN-V informed Surveyor that R4 and the resident who passed away last February 2025 were close and went outside together. They often took their shirts off and had tanning contests despite warnings of Sun exposure by staff. RN-V informed Surveyor that R4 was impacted by the other member's death and that RN-V had informed Administration this was one of the concerns RN-V had for R4's behaviors. On [DATE], at 12:42 PM, Surveyor interviewed Director of Social Service (DSS)-D about R4. Surveyor asked DSS-D about R4's statement to Surveyor about a friend who passed away this year. DSS-D informed Surveyor that R4's friend at the facility passed away in February or 2025. Surveyor informed DSS-D that R4 informed the Surveyor that is why R4 had sat outside so long on [DATE] and that it still seems to trouble R4, and no one has spoken to R4 about it. DSS-D informed Surveyor they have spoken. Surveyor asked if DSS-D documented that conversation as Surveyor could not locate it and there is nothing in the care plan addressing it. DSS-D informed Surveyor it would be in the social service progress notes. Surveyor asked DSS-D how interventions and member care plans were assessed for the most meaningful and effective actions, especially triggers for behaviors that are implemented for each member. DSS-D informed Surveyor that the Interdisciplinary Team (IDT) reviewed the members care plan and implemented the interventions needed. Surveyor asked DSS-D if DSS-D could explain how that process works in the IDT meetings. DSS-D informed Surveyor the members charts were reviewed and the departments had input from their staff. Surveyor informed DSS-D that during an interview with R4 informed Surveyor the R4 has never stopped wanting to leave. Surveyor asked if DSS-D was aware R4 has never stopped wanting to leave. DSS-D acknowledged that R4 wanted to leave. Surveyor acknowledged to DSS-D that now the R4 is leaving R4 seems to be satisfied with the move to an assisted living. Surveyor asked DSS-D back before R4's elopement R4 had an elevation in behaviors of being resistive to cares and medications as noted by the psychiatry note on [DATE], and with R4's elopement history, was it safe or a good idea for R4 to have no meaningful psychosocial or proactive elopement/safety interventions in place except a 2-hour safety check placed on [DATE]. DSS-D informed Surveyor “no, probably not.” Surveyor asked NHA-A and DON-B for the process the IDT team used to develop, evaluate and implement safety and elopement interventions. Surveyor informed NHA-A that most of what the Surveyor noticed were safety checks, and motion lights. Surveyor requested any system the IDT team used to implement interventions and evaluate triggers for behaviors and the success of the interventions. DON-B informed Surveyor that ADON-S charted under the IDT notes in the point click care system. Surveyor informed DON-B these notes were sparse and basic and did not show the thought process behind the reason for the interventions or any analysis of the interventions being discontinued. NHA-A informed Surveyor she would look to see what the process involved and get back to the Surveyor. (Note: Surveyor noted there was no IDT meeting on R4 from [DATE] until after R4's [DATE] Sunburn incident.) Surveyor did not note any interventions documented in R4's safety plan of care for potential behavior triggers related to R4's sadness over R4's friend or the possibility R4 was not leaving on the anticipated day of Tuesday [DATE]. On [DATE], at 8:52 AM, Surveyor interviewed DON-B about members who are elopement risks. Surveyor asked DON-B if there was any more information about the processes for implementing interventions for members especially with risk factors such as dealing with psychosocial issues, elopement concerns or behaviors that might lead to injury like R4 staying outside too long and developing blistering sunburns. Surveyor informed DON-B that R4 was seen for behavior increases on [DATE] by psychiatric services and Surveyor did not note any care plan changes. DON-B informed Surveyor that DON-B did not find a policy or procedure for IDT care plan intervention implementation and evaluation. On [DATE]. At 3:24 PM, Surveyor gave serious concerns to NHA-A and DON-B from Surveyor's investigation as of [DATE]. Surveyor informed NHA-A that the facility did not evaluate the root causes of R4's [DATE] elopement and [DATE] blistering sunburn injury. The facility failed to implement meaningful and effective care interventions for R4 to keep R4 safe. R4's incident on [DATE] had no investigation on when or why R4 left the building and never asked R4 why R4 was outside for so long. R4 informed Surveyor that R4 was sad, and R4 went outside around 12:00 PM and did not come back into the building until around 3:20 PM. R4 informed Surveyor that he was sad thinking about his friend who had passed away. R4 informed Surveyor that no one has asked R4 anything about the [DATE] sunburn incident. R4 had a psychiatric consult on [DATE] asked for by R4's family because of increasing behaviors of refusing cares. Staff informed Surveyor that R4 had a history of refusing sunscreen and protective measures when in the sun before the [DATE] incident where R4 received a blistering sunburn. No psychosocial or proactive interventions were documented or discussed by the IDT team responsible for care plan interventions, and no proactive interventions to keep R4 safe from these behaviors were placed in R4's care plan until after R4 ended up with a blistering sunburn on R4's forehead. No root cause analysis except comments: “member prefers to be non-compliant” “Member enjoys being in the sun” and “Member refuses sunscreen” Nothing about R4's sadness over the loss of R4's friend or interventions related to R4's feelings of loss that may have triggered the behavior. Surveyor asked NHA-A if NHA-A would agree that R4 had nothing proactive in R4's plan of care for elopement and safety until after R4 almost made it almost a mile away to a highway in a wheelchair. NHA-A and DON-B agreed that the Surveyor was correct there was nothing proactive in place for R4's elopement concerns prior to R4's [DATE] elopement. NHA-A informed surveyor that a WanderGuard and closer monitoring of R4 are in place now. NHA-A informed Surveyor that the NHA-A had initiated training of the staff and NHA-A found that the staff believed R4 was R4's own person and could make all his own decisions. NHA-A informed surveyor the staff were not aware of R4's cognitive impairment. R4's Physicians order dated [DATE], at 06:30 AM documents, “Member cannot sign himself out (even to the grounds of the facility). He has recently left the property after signing himself out to the gazebo. Member must be always accompanied outside (by a staff member of a volunteer). All behaviors, including attempted elopements need to be documented and interventions immediately put into place. Member may use the courtyard for 1W (Memory Care) if he prefers. If member is in courtyard, must be placed on 15-minute checks.” No new psychosocial interventions in R4's safety care plans implemented to address R4's feelings of loss or potential disappointment with R4's transfer timeline. 3.) R11 was admitted to the facility on [DATE] with diagnoses that inclide Dementia Unspecified Severity (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), With Mood Disturbance, and Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities). R11 has an activated Health Care Power of Attorney (HCPOA) as of [DATE], however, there is a guardianship hearing on [DATE] because family no longer wants to be the HCPOA. R11's Quarterly Minimum Data Set (MDS) completed [DATE] documents R11's Brief Interview for Mental Status (BIMS) score is 12, indicating R11 demonstrates moderately impaired skills for daily decision making. R11's MDS documents no mood or behavior issues, including wandering. R11's main locomotion is by standard wheelchair. R11's Kardex, instructions to nursing staff was updated [DATE]. The Kardex documents: Safety -[DATE] Encourage member to ask for help with computer -Alert on call nurse or DON or ADON for all incidents (escalated behaviors, attempts at elopement) -R11 has a wander guard on R11's wheelchair because R11 tries to tear it off R11's arm/leg -R11 now lives in memory care R11 refused wander guard [DATE] -Redirect R11m when voicing need to leave facility to go to the bank. -Roam Alert wander band to R11's wheelchair R11's comprehensive includes the following applicable problems: 1.Safety Elopement: R11 at risk of elopement due to cognitive losses, Dementia high risk for elopement [DATE] R11 was waiting outside “for a ride to his bank”. 15-minute safety checks initiated for R11 whereabouts. R11 declines wearing roam alert device bracelet [DATE] 15-minute checks discontinued [DATE] Roam alert device on R11's wheelchair Initiated [DATE] Interventions: -Monitor my behaviors to determine: duration, frequency, intensity, and patterns. Consider any changes that may have occurred such as: a room change, change in cognitive status, medication changes, new staff, or termination of treatment program. Initiated [DATE] -Alert on call nurse or DON or ADON for all incidents (escalated behaviors, attempts at elopement) Initiated [DATE] -R11 has a wander guard on R11's wheelchair because R11 tries to tear it off R11's arm/leg Initiated [DATE] -R11 now lives in memory care Initiated [DATE] 2.Coping/Trauma Informed Care Plan: I am at risk for ineffective individual coping due to R11's diagnosis of Major Depressive Disorder, Recurrent Unspecified. Adjustment to nursing home. R11 referred to in-house psychologist on [DATE] Triggers: R11 breathing issues forced R11 to stop R11's construction in R11's 40s. When R11's breathing bothers R11, R11 can feel triggered. Initiated [DATE] Interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness. Initiated [DATE] -Arrange for psych consult, follow up as indicated. R11 referred to in-house psychologist [NAME] [DATE]. Initiated [DATE] -Assess/screen for post traumatic events and history of trauma, using nursing home appropriate screening tools, such as the LEC-5. Initiated [DATE] -R11 has deep breathing techniques to use when R11's breathing is bothering R11. R11 also enjoys socializing and being around family and friends. Initiated [DATE] -Discuss feelings around change and loss, facilitate R11's expression of these feelings. Initiated [DATE] -Encourage R11 to talk about how R11 is feeling to family, friends, or staff; remind R11 to utilize R11's support system if R11 is feeling down. Initiated [DATE] -Please watch R11 for the signs and symptoms which may indicate R11 feeling sad or depressed such somnolence, social isolation, increased sadness, frequent weeping, anger, refusal of cares, decreased appetite, weight loss/gain. Initiated [DATE] Starting [DATE], the facility completed an elopement assessment every day, sometimes multiple times a day until [DATE] triggering multiple times of a score of 10 or more indicating R11 must have a safety plan put into place. Surveyor notes a safety plan was not put into place at this time for R11. R11's current physician orders document R11 is on Duloxetine 20 mg 1 capsule at bedtime for pain in left foot. Surveyor notes that Duloxetine can be used to treat Major Depressive Disorder, Generalized Anxiety, and chronic pain. Surveyor notes there is no documentation how R11's Duloxetine has impacted R11's diagnosis of Major Depressive Disorder. The facility has not been monitoring for signs of symptoms of depression and/or behaviors related to the Duloxetine because the facility is stating the facility is treating R11 with Duloxetine for pain. The facility has no current accurate documentation of signs and symptoms related to R11's diagnosis of Major Depressive Disorder because the facility has not monitored R11's behaviors. Surveyor reviewed R11's electronic medical record (EMR) and notes the following progress notes: On [DATE], Director of Social Services (DSS)-D documented R11 had coat on stating R11 wanted to leave the building, order a cab, go to their bank and get a debit card. R11 stated that R11 wanted to complete an online purchase from a store of potato chips and other snacks. Placed on 15 checks. On [DATE], Registered Nurse (RN)-BB documented R11 voicing R11 wanted to leave and was hard to redirect. Making multiple statements about leaving on Monday and will have to be shot to be stopped. Stating is waiting for debit card so R11 can work R11's way to California and cross the border to Mexico for some new lungs. Stated the lungs would be from drug dealers that the Mexicans kill. R11 stated that R11 is too old to get new lungs in the US and that is why R11 has to go to Mexico for them. Surveyor notes there is root cause analysis by DSS-D or any interventions put in place for R11. On [DATE], Registered Nurse (RN)-CC documented R11 voicing the want to leave. R11 stating “you can't keep me here. I'm not a prisoner.” R11 wanting to go outside. R11 attempting to go to 2nd floor elevators and not easy to redirect. Surveyor notes there is no follow-up by DSS-D on how R11 is feeling and what psychosocial concerns R11 has. On [DATE], Registered Nurse (RN)-G documented R11 making multiple statements about leaving on Monday and R11 will have to be shot to be stopped. Surveyor notes there is no documentation DSS-D met with and provided support to R11 in regard to the intense feelings R11 was expressing. On [DATE], it is documented that 30-minute checks were discontinued for R11. On [DATE], it is documented that a referral to psychology was initiated. On [DATE], R11 was evaluated by Psychology (PhD)-DD with the goal for psychotherapy to address cognitive distortions, improve reality orientation, and enhance coping skills. R11 was to be seen for six individual psychotherapy sessions, each 30 minutes in duration, over the coming three months. R11 has not been seen since [DATE] by PhD-DD. On [DATE], Registered Nurse (RN)-EE documented R11 voiced to a staff member he had intentions of escaping during the planned facility shopping trip tomorrow [DATE]. R11 stated “I am going to escape and go to the bank, get a debit card, buy a plane ticket and I am going to buy a house in Hawaii and a plane ticket.” …”Called and reported to Interim commandant, DON, and ADON were notified.”… No documentation after this was voiced by R11 of any interventions put into place. Surveyor notes there is no documentation that DSS-D completed a root/cause analysis of R11's expressions. On [DATE], Activity Aide (AA)-FF documented R11 was waiting outside “for a ride to his bank”. Nursing aware. 15-minute checks initiated. On [DATE], another elopement assessment was completed with a score of 16, indicating R11 is high risk for eloping. Surveyor notes that an elopement care plan with a safety plan was not implemented until [DATE]. R11 had multiple previous verbalizations of wanting to leave the facility. On [DATE], 15-minute checks were implemented. The only intervention on R11's care plan added on [DATE] was to monitor behaviors to determine: duration, frequency, intensity, and patterns. Consider any changes that may have occurred such as: a room change, change in cognitive status, medication changes, new staff, or treatment of treatment program. On [DATE], Nursing Supervisor (NS)-HH documentation states 15-minute checks discontinued, however, Surveyor notes that staff continued to document 15 minute checks were in place. On [DATE], 15-minute checks were discontinued as documented by NS-HH. On [DATE], RN-BB documents R11 is expressing that R11's kids are taking R11 to court and trying to take all R11's money and that R11's children were handing over their HCPOA to a guardian. R11 is upset and unreceptive to redirection. Surveyor notes on [DATE] the coping trauma informed care plan was initiated. On [DATE], at 7:45 AM, R11 initiated conversation with Surveyor who was observing two other Residents on the unit. Surveyor notes R11 was very focused on leaving, the upcoming court hearing, and wanting to get to the bank so R11 can pay a lawyer for the upcoming court hearing. On [DATE], at about 9:55 AM. R11 was found out of the facility, down at the 3 way stop sign. Staff were alerted by a family membe

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure 6 (R2, R11, R4, R3, R8, and R10) of 7 residents received adequate supervision to prevent accidents from falls and elopements * R2 has had 15 falls since 1/9/25. On 1/17/25 R2 fell. A fall risk assessment on 1/17/25 indicates R2 is at low risk for falls. On 3/5/25 the facility completed another fall risk assessment and was assessed to be high risk for falls. R2 fell on 4/1/25, 4/3/25, & 4/7/25. R2's fall risk assessment dated [DATE] assesses R2 as low risk for falls. R2's fall risk assessment dated [DATE] and subsequent fall risk assessments assess R2 as high risk for falls. On 4/3/25 R2 was transferred to the hospital and diagnosed with a traumatic hematoma of the forehead. The facility did not thoroughly investigate R2's falls on 4/1/25, 4/3/25, & 4/7/25, did not determine if prior interventions were in place and did not determine a root cause of these falls to prevent further falls. On 4/9/25 R2 fell. R2 was transferred to the hospital on 4/9/25 and admitted on this date with diagnoses of Subdural Hematoma, Hematoma, Subarachnoid hemorrhage, T12 fracture and UTI. R2's hospital Discharge summary dated [DATE] documents She will need Keppra for 4 weeks for seizure prophylaxis. Following hospitalization R2 sustained falls on 4/16/25, twice on 4/29/25, 5/8/25, 5/10/25, 5/26/25, 6/24/25, 7/19/25, 7/25/25, & 8/18/25. With the exception of R2's fall on 7/19/25 the facility did not thoroughly investigate R2's falls, did not consistently obtain staff statements, and did not determine the root cause of R2's falls to help prevent further falls. *R11 was assessed as being high risk for elopement. On 3/26/25 R11 had a coat on stating wanted to leave the building, order a cab, and go to the bank for a debit card. On 4/12/25 R11 voiced he wanted to leave. On 7/8/25 R11 voiced to a staff member he had intentions of escaping during a planned facility shopping trip. R11 stated he was going to escape, go to the bank, get a debit card, buy a plane ticket and was going to buy a house in Hawaii. On 9/11/25 R11 was found out of the facility, down the road at the three way stop sign. Facility staff was unaware R11 had left the facility and was made aware by another resident's family member. The facility was aware of R11's previous attempts and continued expression of wanting to leave but did not implement interventions to keep R11 safe. *The facility failed to put a system in place to monitor R4's safety when R4 left the building unattended. On 6/28/25 R4 came in from the outdoors with 4 blisters from sunburn on R4's forehead. R4 was found outside by staff arriving to the facility for their assigned second shift. On 7/27/25 R4 had traveled in R4's wheelchair .9 miles on the road almost making it to a highway C a well-traveled local class A highway. The facility's failure to provide adequate supervision, to thoroughly investigate R2's falls and determine a root cause and its failure to prevent R11 and R4 from eloping from the facility led to a finding of immediate jeopardy (IJ) that began on 4/9/25. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were informed of the immediate jeopardy on 9/16/25 at 3:31 p.m. The immediate jeopardy was removed on 10/7/25 when the facility implemented and IJ removal plan. The deficient practice continues at a scope and severity of a D (potential for harm/isolated) based on the following examples of additional noncompliance not at the level of immediate jeopardy: *On 5/25/25 R3 had an unwitnessed fall from R3's bed. The facility did not thoroughly investigate R3's fall and did not determine a root cause to help prevent further falls. On 8/18/25 R3 had an unwitnessed fall and was discovered on the floor next to R3's bed. R3 was transferred to the emergency room and on 8/19/25 R3 underwent surgery for a closed right hip fracture. The facility did not conduct a thorough investigation of R3's fall on 8/18/25. *R8 rolled out of bed on 2/28/25 and 4/11/25 both related to trying to reposition in bed as documented. The intervention to have a body pillow in place was to be implemented after the 2/28/25 incident. There is no documentation this was implemented. R8 rolled out of bed on 4/11/25 and the fall checklist documents that R8 has expressed a refusal of the body pillow. The facility did not implement an alternative intervention after refusing the body pillow in relation to the 2/28/25 incident resulting in R8 rolling out of bed again on 4/11/25. *R10 fell on 1/17/25 on the way to the bathroom. No intervention was put into place. R10 fell on 1/28/25 trying to get into wheelchair. No root/cause analysis as to why R10 was trying to get into the wheelchair. R10 fell on 2/16/25 attempting to get to the bathroom again. No interventions was put into place. On 8/10/25, R10 fell out of the recliner. There is no root/cause analysis and no intervention was put into place. Findings include: The facility's policy, titled “Member Falls” and last revised January 2025 under Policy documents: All members shall have a care plan addressing their fall risk and predisposing factors… Interventions implemented to prevent falls shall be individualized for the member and relevant to the root cause of a recent fall. Interventions that are generalized and are not relevant to the reason the member fell are not appropriate…. Under Procedure for Fall Care and Follow Up documents ….5. The Registered Nurse (RN) initiates fall documentation in the electronic record through risk management. 5.1 If the member has multiple falls, each fall is a new entry. A repeat unwitnessed fall or fall with head injury, restarts the neurological assessment schedule. 6. Additional information related to the member's fall is required to be documented as an incident assessment note in the member's chart. 7. The RN attempts to determine root cause of fall through member and staff interview, all known information is documented in the electronic record. 7.1 Review the members care plan, Kardex, and orders to determine if the plan was provided as written and if total plan of care addresses the root cause. 8. Implement a relevant intervention to prevent recurrence, considering the root cause of the incident…. 1.) R2 is [AGE] years old with diagnoses which includes Alzheimer's Disease (progressive brain disorder that causes gradual cognitive decline), dementia, anxiety disorder (group of mental health conditions characterized by excessive & persistent worry, fear, and nervousness that can interfere with daily life) depressive disorders, delusional disorders (a belief or altered reality that is persistently held despite evidence or agreement to the contrary), hypertension (high blood pressure), and diabetes mellitus (high blood sugar). R2 has had 15 falls since 1/9/25. R2's at risk for falls care plan initiated 4/14/25 & revised 9/10/25 documents the current following interventions: *High Risk: I am at an increased risk for falls based on my screening evaluation; this means that I have several predisposing factors which increase my risk for falls. Remind me to be safe and to call for assistance. Initiated 2/15/23. *Be Aware: I take medications that may cause e to have low blood pressures, remind me to change positions slowly. Initiated 2/15/23. *Arrange my environment to minimize my risk for falls; ensure my space is free of clutter and my furniture is securely against the walls. Initiated 2/15/23. *Orient me to the facility and my surroundings often as I can become confused, and this increases my risk for falls. Initiated 2/15/23. *Make sure I have everything I need and the call light close by. Initiated 2/16/23. *Member not to open brake away doors to assist with helping members to the unit. Initiated 11/5/24. *Keep door open when in room. Initiated 4/4/25. *Provide additional assistance with cares. Initiated 4/6/25. *Staff to assist member with AM cares. Initiated 4/16/25 & revised 6/25/25. *Utilizing a body pillow while member is in bed for safety and fall prevention. Initiated 4/20/25 and revised 5/5/25. *Utilize scoop mattress. Initiated 4/29/25 & revised 5/2/25. *Monitor and redirect member when in peers' personal space. Make sure non-slip material is placed in w/c or recliner before I sit down to prevent me from sliding. Initiated 4/29/25 & revised 6/25/25. *Encourage member to stay in common area. Include member in activities taking place on unit. Initiated & revised 5/8/25. *When member appears agitated or restless, toilet member. Initiated 5/9/25. * NOC (night) get up prior to leaving shift & bring to day room for supervision. Initiated 5/10/25 & revised 8/12/25. *Body pillow in place while member is in bed. Initiated 5/19/25 & revised 5/20/25. *PT (physical therapy) Eval (evaluation) and treat. Follow up with Ortho 6 weeks. Initiated 6/15/25 & revised 7/28/25. *Staff to monitor and supervise member when she is awake and sitting reclined in the recliner in dayroom. Initiated 5/26/25 & revised 6/25/25. *Member has individualized wheelchair set up by therapy. Chair to be in slight reclined position when not eating meals. Upright for meals. Initiated 6/25/25. *Member to have shoes on properly, heels to be in shoes correctly, not waking on back of shoes Initiated & revised on 6/25/25. *Motion sensor in room on at all times. Initiated & revised 6/25/25. *Leave sensor alarm on at all times. Initiated 6/25/25. *Member to wear shoes or grippy socks when standing up or transferring with staff. Initiated & revised 6/25/25. *Member to wear gripper socks while in bed every shift. Initiated 6/25/25. *Member to wear hip protectors during day on in AM with cares upon rising and off at HS (hour sleep) for prevention, size medium. Initiated 6/25/25. *To make sure member has items within reach when sitting in dining room table to avoid injury. Initiated 7/8/25. *Another motion sensor in members room near the door in front of bathroom entrance. Her current motion sensor is positioned above her bed and does not activate until there is motion just past the foot board of her bed, need detection for door and bathroom entrance. Initiated 7/21/25 and revised 9/10/25. *Maintenance to install another motion sensor in members room near door in front of bathroom entrance. Initiated 7/21/25. *Second motion sensor placed in room to cover bathroom entrance. Sensor to be on at all times and verified every shift for functionality. Initiated & revised 7/23/25. *Tels in for anti-roll backs for W/C. Initiated 7/28/25. *Member is not to be left alone when in the restroom. Initiated 8/12/25. *Member wants blinds to be closed when she goes to bed for sleeping. Initiated 8/19/25. The following are fall Interventions initiated and resolved/cancelled: *PT/OT (physical therapy/occupational therapy) eval and treat. Initiated 2/15/23 and revised & cancelled 4/11/25. *NP (Nurse Practitioner) ordered CBC (complete blood count), BMP (basic metabolic panel), UA (urinalysis). Initiated 12/4/23 and revised & cancelled 8/23/24. *Member to be 15-minute checks. If member sustains fall while on 15 min checks member will become 1:1. Initiated 4/9/25 & revised and cancelled 4/13/25. *Encourage me to take rest periods often as I may tire when I am ambulating with staff. Initiated 4/14/25 and revised & cancelled 6/25/25. *Member on 15 min (minute) check staff monitoring for safety due to high fall risk. Initiated & resolved on 4/16/25. *Motion sensor placed in member's room to alert staff when Member is attempting to transfer, toilet or ambulate independently. Initiated 4/16/25 & resolved on 6/25/25. *Member on 1:1 for safety and fall prevention. Initiated 4/17/25 & resolved 4/28/25. *Member to have untucked body pillow on the outer edge of the bed for protection against falls. Initiated 4/16/25 & revised and resolved 5/5/25. *Toileting program; at risking around mealtimes, and before bed. Staff to assist Member to toilet before 5AM if awake. Initiated 4/28/25 & resolved 6/25/25. *Member is 1:1. Initiated 4/29/25 & resolved 5/9/25. *Place Dycem in my w/c or recliner to prevent me from sliding out of chair. Initiated 4/29/25 and revised & cancelled 6/25/25. *Member to wear hip protector for safety. Initiated 4/30/25 & resolved 6/17/25. *Order pommel cushion for wheelchair to allow proper alignment for member when sitting in wheelchair. Initiated 5/2/25 and revised & cancelled 6/25/25 *Ordering small W/C (wheelchair) for Member. Initiated & resolved on 5/21/25. *Member is on 15 minute checks on night shit for fall prevention. Initiated 5/21/25 and revised & resolved 6/13/25. *Walking: 2ww (wheeled walker), gait belt, 2nd person to follow with wheelchair, ambulate 100-300 ft (feet) to and from meals and as needed when member has extra energy to prevent falls Initiated 5/25/25 & revised and cancelled 7/28/25. *When member is awake sitting in the recliner, don't put recliner in the reclined position. Initiated 5/25/25 and revised & cancelled 6/25/25. *Fall Prevention: 30-minute checks. Initiated 6/13/25 & revised and resolved 8/21/25. *Encourage member to wear gripper socks while in bed every shift. Initiated 6/18/25 and revised & resolved on 6/25/25. *Staff to make sure that member has gripper socks on at bedtime. Initiated 6/25/25 and revised & cancelled 6/25/25. *The resident requires limited assist of two staff members and gait belt for transfers. Initiated 6/25/25 & resolved 7/28/25. *Tels request for maintenance to install another motion sensor in members room near the door in front of bathroom entrance. Initiated 7/19/25 & revised and resolved 7/23/25. *Pt (patient) will receive frequent cues/reminders to ask for help if needing assistance. Initiated 7/25/25 and revised & cancelled 7/28/25. *Pt will receive frequent cues/reminders to ask staff for assistance before trying to self-ambulate. Initiated 7/25/25 and revised & cancelled 7/28/25. R2's fall CAA (care area assessment) dated 12/30/24 under analysis of findings for nature of problem/condition documents Member has a dx (diagnosis) of Alzheimer's Disease, dementia, anxiety, wandering, cognition is severely impaired. Receives scheduled antidepressant medication. Has had 5 falls in last year. Hx (history of) falls d/t (due to) UTI (urinary tract infection) is up ad lip/ambulatory. Should have proper footwear on, currently being treated by psych due to behaviors/increase in packing while looking for labor and delivery. R2's fall risk assessment dated [DATE] has a score of 8 which indicates low risk for falls. FALL R2's nurses note dated 1/17/25 at 07:15 (7:15 a.m.) written by Registered Nurse (RN)Supervisor-W documents Member was found sitting with legs out on the floor. Member was towards the foot of the bed. Member was fully dressed with nothing on the feet. Lamp was on in the room. Member stated they had a fall and bumped their head. Denied any other pains. Assessed member. Minimal help back into bed after placing shoes on feet. Member states bump to back of head. Assessment no abrasion, no bump, no indication of pain when touching, denied PRN (as need) pain relief medication. Neuro check was negative. BP (blood pressure) was elevated at 188/84. Check and hour and half later 170/82. All other vitals WNL (within normal limits). Lungs clear, BS (bowel sounds) all quads. (quadrants). Mentation at baseline. Updated supervisor and provider. Vitals BP 170/82, 1/17/25 05:17 (5:17 a.m.), Position: sitting l (left) arm, P (pulse) 68 – 1/17/25 0325 (3:25 a.m.), pulse type regular. T (temperature) 97.7 1/17/25 0325 Route: forehead (non-contact), R (respirations), O2 (oxygen) 95% -1/17/25 0325 Method: room air. Pnl (pain level) 1- 1/17/25 0235. Pain scale Pain ad. Follow up new intervention implemented and added to TPOC (temporary plan of care) wear shoes or gripper socks while ambulating/walking. Surveyor reviewed R2's fall investigation which includes an incident audit report for date of incident 1/17/25 03:10 (3:10 a.m.) and two fall/incident witness statements. Surveyor noted the facility's fall investigation was not thoroughly investigated as the investigation does not include when R2 was last toileted, how was R2 positioned in bed etc, if previous interventions were in place at the time of the fall and does not include a root cause. R2 ‘s care plan was not revised with the new intervention to wear shoes or gripper socks while ambulating. R2's fall risk assessment dated [DATE] has a score of 18 which indicates high risk for falls. R2's quarterly MDS (minimum data set) with an assessment reference date of 3/11/25 has a BIMS (brief interview mental status) score of 4 which indicates severe cognitive impairment. R2 is assessed as requiring set up or clean up assistance for eating, toileting hygiene, rolling left & right, and chair/bed to chair transfer. R2 is assessed as being independent for toilet transfer. R2 is occasionally incontinent of urine and frequently incontinent of bowel. R2 has fallen since prior assessment, one fall with no injury. FALL R2's nurses note dated 4/1/25 at 10:15 a.m. and written by Licensed Practical Nurse (LPN)-N documents CNA was giving member a shower. Member was standing in the shower, went to step out of the shower on a towel on the floor, fell and struck her head. CNA assisted member onto the shower chair and placed the call light on. See progress note for entire fall assessment. R2's nurses note dated 4/1/25 at 10:49 a.m. and written by LPN-N documents Certified Nursing Assistant (CNA) placed call light to shower room on to report that member fell on the floor. Writer entered tub room at 1015 member was sitting on the shower chair. CNA states member was stepping out on the shower, a towel was on the floor for member to step onto. Member fell and struck the back of her head on the shower wall. CNA informed writer that CNA assisted member back onto the shower chair. No redness or bruising noted to buttock or back. Writer did assess members head, no redness or injury at this time. Member unable to state what happened, was asking for under ware (sic)/clothing. Writer sent e mail to Assistant Director of Nursing (ADON) and charge nurses per fall check off sheet. ADON not in office. Writer obtained V.S. (vital signs) and did neuro check. Neuro check is negative bilateral pupils are large, round and reactive to light. Hand grasps are strong and equal. Call placed to [Name of medical group]. Writer spoke to [Name] NP and informed of fall wand that member struck her head, no visible injury. Informed that member has an order for prn (as needed) Voltaren gel no other blood thinners. New order received to send member to ER (emergency room) for eval due to her age. Call placed to members son [Name] and let a voice message requesting a return call. R2's nurses late entry nurses note dated 4/1/25 at 1700 (5:00 p.m.) documents Member returned from ER. ER called to get [Name] Pharmacy information to send antibiotic prescription for Member. Information was given to [Name] ER and prescription was sent to [Name] Pharmacy from [Name] ER. R2's fall risk assessment dated [DATE] has a score of 8 which indicates low risk for falls. R2's IDT (interdisciplinary team) note dated 4/2/25 at 9:53 a.m. & created on 4/3/25 at 17:56 (5:56 p.m.) written by ADON-S documents Met to discuss fall in shower. Intervention to provide shower stool/chair of appropriate size for member. Surveyor reviewed the facility's fall investigation for R2's fall on 4/1/25 which included an incident report, neuro assessments on 4/1/25 at 10:15 a.m. & 17:15 (5:15 p.m.) and 4/2/25 at 9:43 a.m., an incident audit report for incident date 4/1/25 10:15 a.m. and CNA-VV's fall/incident witness statement. Surveyor noted the facility did not conduct a thorough investigation as the facility did not investigate why CNA-VV placed a bath blanket on the floor, why did CNA-VV get R2 off the floor without being assessed by a Registered Nurse (RN) and did not determine the root cause. R2's care plan was not revised with an appropriate size shower stool/chair. FALL R2's nurses note dated 4/3/25 at 10:30 a.m. and written by LPN-N documents Writer was called to members room at 1030 per CNA. CNA states “Member is on the floor.” Writer went to room, member sitting a few feet away from door to her room. Member dressed with shoes on sitting on buttocks. Member noted with a large, raised bruise to the middle to her forehead. Member stated to writer “It happened so quick.” Member stated she fell in the bathroom. Member did have a BM (bowel movement) in the bathroom in her room. Writer informed ADON [initials] that member was on the floor. ADON did see member in her room. [Name] NP was on the unit NP did see member, noted bump to forehead and gave order to send to ER for an evaluation. Members ROM (range of motion) per usual. Member continuing to deny pain and discomfort. Body check was done, no other apparent injuries. Member was assisted to toilet to change clothing that was soiled. Writer placed call to members son [Name] who is members HC POA (healthcare power of attorney). Son is aware of fall, head injury and order to send to ER for an evaluation per NP who was in building and assessed member. [Name] Ambulance was called and cannot transport. [Name] Ambulance will transport member to [Hospital Name] for an evaluation due to head injury. R2's nurses note dated 4/3/25 at 18:49 (6:49 p.m.) written by RN Supervisor-W documents Member returned from [Name] ED (emergency department) at 1700 (5:00 p.m.). Member was diagnosed with acute cystitis without hematuria, traumatic hematoma of forehead, and fall. Member was started on ciprofloxacin 500mg (milligrams) tab (tablet) for acute cystitis. Member baseline mentation. R2's fall risk assessment dated [DATE] has a score of 12 which indicates high risk. R2's IDT note dated 4/4/25 at 10:41 a.m., created on 4/6/25 at 1447 (2:47 p.m.) and written by ADON-S, documents: Met to discuss fall. Intervention: Encourage member to stay in common area. Provide additional assistance with cares. Keep door open when in room. POA and physician notified of fall. Surveyor reviewed the facility's fall investigation for R2's fall on 4/3/25 which consisted of an incident report dated 4/3/25, neuro assessments dated 4/3/25 at 9:51 a.m., 10:35 a.m., 21:44 (9:44 p.m.), 4/4/25 at 05:15 (5:15 a.m.), 17:37 (5:37 p.m.), and 4/6/25 at 04:06 (4:06 a.m.) & 17:12 (5:12 p.m.). An incident audit report dated 4/3/25 10:30 a.m. and CNA-VV's fall/incident witness statement. Surveyor noted the facility did not thoroughly investigate R2's fall as there is no evidence the facility investigated whether prior interventions were in place. The facility did not clarify CNA-VV's statement regarding the last time staff interacted with R2 which was 10:22 a.m. when walking R2 to her bed & the last time R2 was toileted is documented as 10:25. The facility did not determine a root cause to help prevent further falls. Surveyor noted R2's fall care plan was revised on 4/4/25 & 4/6/25. R2's nurses note dated 4/4/25 at 14:44 (2:44 p.m.) written by RN-O documents Bruise to forehead remains, purple/red in color. Writer noted 2 new bruises developing to members right eye moving up into eyebrow and bridge of nose. Nose bruise 1.5 x .3 and eye bruise measures 2.5 x 1 cm (centimeter). Member had fall with head injury on 4/3. Bruises purple/red in color. Member denies pain/discomfort to area. FALL R2's nurses note dated 4/7/25 at 22:35 (10:35 p.m.) written by RN-QQ documents Staff found member sitting on the floor near her bed. Member said that she hit her head. Noted a small bump and redness on the occipital area, measures 2.5 x 1.5cm. No c/o (complaint of) pain. Neuro check and ROM per baseline. VSS (vital signs stable). No loss of consciousness. R2's fall risk assessment dated [DATE] has a score of 12 which indicates high risk. R2's nurses note dated 4/8/25 at 01:40 (1:40 a.m.) written by RN-QQ documents [Name] ambulance brought the member back to floor from [Hospital Name] ER. No new orders received. R2'S IDT note dated 4/8/25 at 10:05 a.m. documents Met to discuss 4/7/25 fall. Floor was reported to be dry when the member fell despite commenting she slipped. Med review completed by pharmacy – members fall do not appear to be associated with orthostatic hypotension as BP (blood pressure) is not abnormally low upon incident. BS (blood sugar) do not appear to be low. Possible transient torsades with cipro and quetiapine but unlikely. Unsteadiness could be attributed to active UTI (urinary tract infection). Culture from hospital shows susceptible to current antibiotic. Also discussed possible Vitamin D deficient or related to GDR (gradual dose reduction). Surveyor reviewed the facility's fall investigation for R2's fall on 4/7/25 which consists of an incident report dated 4/7/25, neuro assessment dated [DATE] at 22:35 (10:35 p.m.), 4/8/25 at 11:00 a.m., & 20:28 (8:28 p.m.), an incident audit report dated 4/7/25 at 22:35 (10:35 p.m.) and five fall/incident witness statements. Surveyor noted the facility did not thoroughly investigate R2's fall as there is no evidence the facility investigated whether prior interventions were in place, how R2 was in bed prior to the fall, and did not address R2's footwear when R2 indicated the floor was slippery. The facility did not determine a root cause to help prevent further falls. R2's falls care plan was not revised until after R2 sustained another fall on 4/9/25. FALL R2's nurses note dated 4/9/25 at 07:45 (7:45 a.m.) written by RN/Education-KK documents Member had transferred herself to the bathroom to toilet. It appears she had a bowel movement and possible stood up to pull her brief and pants up and lost her balance. Neuro check seems to be baseline, and no new injuries found on body check. Member was cleaned up transferred to toilet and clean close sic (clothes) put on. No signs or expression of pain. Member to be 15 min (minute) checks per IDT team. R2's fall risk assessment dated [DATE] has a score of 15 which indicates high risk. R2's IDT note dated 4/9/25 at 09:57 (9:57 a.m.) written by ADON-S documents IDT met to discuss 4/9 fall. Interventions: 15 minute checks and motion sensor put in room. POA, DON and NP notified. Concerns about multiple falls discussed. Call placed to physician for orders included concerns of possible sepsis given multiple recent diagnosis of infection and BP reported below baseline. New orders received from NP. Results will be reviewed and member will be seen tomorrow by NP. Surveyor noted the new orders are for Stat CBC (complete blood count) and BMP (basic metabolic panel). R2's nurses note dated 4/9/25 at 16:13 (4:13 p.m.) written by RN-BBB documents Writer spoke with [Name of Medical Group] and spoke with [Name] NP about member's STAT CBC and received no new orders with instructions to continue pushing fluids. R2's nurses note dated 4/9/25 at 18:04 (6:04 p.m.) written by RN-BBB Writer spoke with on-call [Name] NP to report STAT BMP results, writer received order to send member to emergency room for treatment of acute kidney injury based on elevated BUN (blood, urea, nitrogen) (39), elevated creatinine (1.46) and reduced eGFR (estimated glomerular filtration rate) (33). R2's nurses note dated 4/9/25 at 23:30 (11:30 p.m.) written by RN-QQ documents Member is admitted to [Hospital Name] with diagnoses of Subdural Hematoma, Hematoma, Subarachnoid hemorrhage, T12 fracture and UTI. Surveyor reviewed the facility's fall investigation for R2's fall on 4/9/25 which consists of an incident report dated 4/9/25. Under other info (information) documents Member lives on memory care unit and is (sic) severe dementia. She has recently had and tx (treatment) for Pneumonia and now UTI. Due to her age and deconditioning, confusion and lack of safety awareness she is high risk for falls. Neuro assessments dated 4/9/25 at, 05:45 (5:45 a.m.), 08:13 (8:13 a.m.) and 17:37 (5:37 p.m.), an incident audit report dated 4/9/25 at 07:45 (7:45 a.m.) and one staff statement by CNA-VV which documents As I went to do morning cares on [R2's initials] I walked in to her sitting on her bathroom floor with her brief and pants down to her knees. She had toilet paper in her hand and turned to her left side almost in a seated fetal position trying to wipe her bottom. Surveyor noted the facility did not conduct a thorough investigation as there is no evidence as to who last saw R2, when was she toileted, were prior interventions in place and did not determine a root cause to help prevent further falls. Surveyor noted the facility did not conduct a thorough investigation and did not determine the root cause of R2's four falls prior to R2's fall on 4/9/25. R2 transfer to the hospital and R2 was diagnosed with a Subdural Hematoma, Hematoma, Subarachnoid hemorrhage, & T12 fracture. R2's hospital Discharge summary dated [DATE] under diagnosis documents Traumatic subdural with intracranial bleed. Dementia with behavioral disturbance with some delirium. Essential hypertension. Urinary tract infection present on admission. Frequent falls. Under Hospital Course documents Patient is a [AGE] year-old female with dementia with power of attorney activation with frequent falls who comes in with a fall consequence of subdural hematoma and intracranial bleed. patient was monitored CT did not show worsening bleeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility did not ensure that 1 out of 4 residents (R2) reviewed remained free from sexual abuse. R2, a female resident with a significant history of PTSD (post-traumatic stress disorder) and a history of sexual assault was inappropriately sexually touched by R1. The facility's failure to keep R2 safe from and free from sexual abuse created a finding of immediate jeopardy that began on 5/6/25. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 5/29/25 at 3:50 p.m. The immediate jeopardy was removed on 5/30/25, however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's policy last revised on July 2, 2024 and titled, Prohibition and Prevention of Member (Resident) Abuse, Neglect, and Exploitation documents: *All staff shall be expected to immediately report any, and all, observed or alleged abuse and other reportable incidents. *Immediate intervention shall be initiated to maintain member safety with all observed or suspected allegations. Reporting: (includes) 1.) On observation of actual or suspected abuse, or other reportable incident, staff immediately reports the event to the RN (Registered Nurse), nursing supervisor, or facility NHA. 2.) The RN and unit staff immediately develop a plan to maintain member safety, removing any potentially harmful agents/situations and conducts an initial evaluation of the circumstances. 5.1) If the incident resulted in serious bodily injury, notification to local law enforcement is required within 2 hours of forming suspicion. Incidents not resulting in serious bodily injury must be reported to law enforcement no later than 24 hours after forming the suspicion. 8.) A list of possible witnesses is given to the nursing supervisor as soon as possible. 10.) The Social Worker will be involved in taking statements from the members involved in the situation and those who also could have been affected by this or similar incident. 1.) R1 was originally admitted to the facility on [DATE] with diagnoses that include PTSD (Post-Traumatic Stress Disorder) (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), dementia, and Cognitive Communication Deficit. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 has a BIMS (Brief Interview for Mental Status) score of 8, indicating that R1 has moderate cognitive impairment. The MDS documents that R1 is ambulatory and can walk at least 150 feet and turn twice with supervision of staff. The MDS documents that R1 uses a 4 wheeled walker and exhibits no behaviors. Surveyor conducted a review of R1's individual plan of care and noted: R1 has a potential for wandering with walker, R1 attempted to visit his old room, found outside in parking lot looking for a ride. This care plan was initiated 9/29/21 and last revised 6/8/24. The resident has impaired cognitive function due to dementia. R1's behavior care plan was written on 2/14/23 and documents that R1 has potential for aggressive or threatening behavior due to dementia. Interventions include that R1 likes personal space and encourage staff and other residents to respect R1's space. Targeted behavior is striking out at staff or peers. R2 was admitted to the facility on [DATE] with diagnoses that included Post-Traumatic Stress Disorder (PTSD), Personal History of Physical and Sexual Abuse, Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), Recurrent, Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities), Personal History of Other Mental and Behavioral Disorders, dementia, Severe, with Mood Disturbance (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), and Early Onset Alzheimer's Disease (progressive disease that destroys memory and other important mental functions.) R2's care plan includes an intervention initiated on 2/11/25 that documents R2 is to have only female caregivers due to history of trauma. R2's Quarterly MDS dated [DATE] documents that R2's short- and long-term memory is impaired and R2 demonstrates severely impaired skills for daily decision making. The MDS documents that R2 has no depressive or behavioral symptoms. The MDS also documents: R2 has clear speech, is understood, and understands; R2 requires set-up for eating, supervision for mobility, and substantial/maximum assist for transfers; R2 is dependent for showers; R2 has no range of motion impairment and R2 is independent with ambulation. On 5/6/25, the facility submitted the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report (F-62617) to the state survey agency. The form indicated that on 5/6/25, Resident (R1) reached out and grabbed another resident (R2). The date and time this occurred is documented as 5/6/25 at 11:00 a.m. The report documents that the time the facility discovered the alleged abuse/mistreatment was at 3:00 p.m. on 5/6/25. This form was submitted by NHA-A. On 5/12/25, the facility submitted the Misconduct Incident Report (F-62447) which documented the facility became aware of a resident to resident altercation. The report documents that the date/time the incident occurred is 5/6/25 at 1:30 p.m. The report asks the facility to explain the steps taken, upon learning of the incident, to protect the affected person(s) and others from further potential misconduct. The facility report documents: residents placed in safe location and investigation ensued. The affected person is listed as R2, and the accused is listed as R1. The facility documented that law enforcement was not contacted or involved. Persons with knowledge of the incident are listed as Laundry Aide-C, CNA (Certified Nursing Assistant)-D and RN (Registered Nurse)-F. The report also contained a typed summary from NHA-A about the incident. Surveyor noted the following: On Tuesday, May 6, 2025, this writer (NHA-A) was informed by laundry staff member of a resident-to-resident altercation whereby a male resident (R1) placed his hand on female resident (R2) crotch as she was walking near him. At the time of the incident, the nurse on the unit was made aware and both residents were immediately separated and maintained in a safe situation. This writer (NHA-A), DON-B and ADON (Assistant Director of Nursing)-E were also informed of the situation. Both residents (R1 and R2) live in the Memory Care area of our community, and both have activated Power of Attorneys (POA). R1 has a BIMS score of 9 (moderate cognitive impairment) on 3/12/25 and R2 has a BIMS score of 1 (severely impaired cognition) as of 2/24/25. Due to the cognition deficit and dementia diagnosis, it was determined that we were not able to immediately determine the psychological or emotional harm on the female resident (R2), so a self-report was submitted to Department of Health Services of Caregiver Quality. Activated POAs for both residents were communicated with as to what the situation was and how we are going to move forward to keep our residents safe. Male resident (R1) was moved to a different unit where no female residents reside and continues on 30-minute checks to assure safe distance from female residents. We will continue to monitor his adjustment to the new room/wing for any adverse effects. Female resident's (R2) mood and behavior indicated no immediate adverse effect from this altercation. We will continue to monitor. Care plans were reviewed by nursing and updated and consent for psych services for male resident (R1) was received from POA. Female resident (R2) involved in the altercation will be monitored for psycho-social/mood and/or behavior changes because of this situation and care plan updated as needed to assure safety and well-being. No other residents were identified as being at risk because of this altercation, but again, we will continue to monitor and provide a safe and secure environment for all. Surveyor conducted a review of the written statements that were included with the misconduct report. On 5/6/25, a member grievance/concern form was filled out by Laundry Aide-C. The form documented that R1 and R2 were involved and that Laundry Aide-C was delivering linens, R1 had grabbed R2 in the crotch. And then R2 walked back over and R1 grabbed her in the butt. The aide stated that it has been going on for a while. On 5/28/25 at 11:20 a.m., Surveyor interviewed Laundry Aide (LA)-C regarding what she witnessed between R1 and R2 on 5/6/25. LA-C stated that it was early in the afternoon on 5/6/25 and she was delivering resident laundry on the unit. R2 had come over to LA-C and gave her a hug, something she would do often, and continued to walk about the hallway. R1 was seated in a chair at the table near the nursing desk. LA-C stated that when R2 walked past R1, he scooted in the chair towards R2 and grabbed her in the crotch. LA-C said to R1 you can't do that, that is not nice. R2 appeared shocked and walked away. R2 continued to walk up and down the hallway and again past LA-C. LA-C stated that when she walked past R1 again, approximately 5 minutes later, R1 grabbed R2 in the butt. LA-C said she told R1 again, that is not nice. LA-C stated that R2 was then guided over by the dining room table and R1 stayed where he was originally seated. LA-C stated she is not sure what they (unit staff) did after that. LA-C stated that she then reported what she witnessed to her boss. LA-C stated that the nurse was aware what happened as she was in the area. LA-C stated that her boss brought her down to report what she saw to DON-B and ADON-E, who then alerted NHA-A. LA-C said she gave her statement, and someone had typed it out and she signed it that day. Surveyor asked LA-C how did R2 respond to the incidents. LA-C stated that R2 appeared shocked that it happened. LA-C stated she had never seen this happen between R1 and R2 before. A written witness statement from CNA-D was reviewed by Surveyor. The statement, dated 5/6/25 at 4:25 p.m., documented that the incident involved R1 and R2 on 5/6/25 at approximately 7:30 a.m. CNA-D documents that on 5/6/25 at approximately 1:30 p.m., not too long after lunch, R2 was walking the hallway per usual as she does. R1 was sitting in his chair. As R2 walked by R1, R1 reached out and grabbed R2 touching her butt area. R2 exchanged words with R1. Nurse instructed R1 to not touch R2 again. To my knowledge, R1 heard her and nodded. Shortly after, then R2 continued to pace the floor and R1 touched R2 front area which caused R2 to be upset. Floor nurse then intervened and instructed R1 to move from his original sitting area to a new table out of the way of R2. Also, the behavior from R1 is not new. He has tried this before. On 5/28/25 at 12:07 p.m., Surveyor interviewed CNA-D regarding the incident on 5/6/25 with R1 and R2. CNA-D stated that R2 paces the hallways all day long, this is her usual thing that she does. CNA-D recalls that it was in the afternoon, after lunch, on 5/6/25 when R1 was seated in his specific spot at a table near the nurse's desk and hallway. CNA-D stated she was seated in the dining area and watched R2 walk past R1, and he tried to grab her. R2 tried to say the f-word several times and kept walking. The 2nd pass through the common area, R1 grabbed R2 in the butt. I yelled for R1 to stop and let her go. CNA-D reported to the nurse right away. The nurse got up from the desk and intervened. R2 continued to walk the hallway and a little bit later (unknown how long) R2 walked by R1 again and this time he grabbed her front area (crotch). CNA-D stated that R2 said stop aggressively. She asked R2 if she was alright and R2 just kept walking away from the area. The nurse heard the commotion and intervened again by having R1 move to the dining room table so R2 could walk freely in the common areas. CNA-D stated that the staff were told to keep R1 and R2 separated by having R1 move tables. CNA-D stated that she has seen R1 try to grab for R2 previously and R2 will yell out stop. CNA-D stated that she does not know why R1 wasn't moved after the first time he was able to grab and touch R2. CNA-D stated that the nurse was aware of the situation because she heard all of the yelling and commotion. On 5/12/25, a written statement was submitted from RN-F regarding the incident between R1 and R2. The statement indicates that RN-F, on May 6, 2025, was notified by Laundry Aide that R1 was attempting to touch another member (resident) inappropriately. Writer did not see incident however got up and approached both members and Laundry Aide. Writer made sure both members were separate and safe. R1 remained in his seat and the other member (R2) was on the other side of the Laundry Aide. Writer was not aware of any physical contact so writer spoke to R1 and reminded him we cannot touch others. A little while later, R2 was walking down the halls on the unit and R1 attempted to touch R2 again. Writer removed R1 to another table out of the hallway view. Again, R1 did not make contact from writers acknowledgement however due to members dementia writer was unsure if member (R1) would continue to attempt to touch other members. Member (R1) was ok with moving to a different table. On 5/29/25 at 10:45 a.m., Surveyor interviewed RN-F regarding the incident that happened between R1 and R2. RN-F confirmed that she was working on day shift 5/6/25. RN-F stated that she did not observe anything happen between R1 and R2. RN-F stated that she also was not told that R1 touched R2, only that he had attempted to touch her. RN-F stated that when she first heard that R1 had tried to touch R2 she stated that the two residents need to be separated, and staff should be on high alert. RN-F stated that she had been busy doing charting and passing medications at the time. RN-F stated that the first report came from the laundry aide that R1 was trying to touch R2. RN-F stated that she then asked where was R2. R2 was walking in the hallway as she always does. RN-F stated that she told staff to just monitor the 2 residents. RN-F stated that awhile later, she heard the aide say to R1 NO so she got up from the nurse's desk and R1 was sitting in the same spot he was previously and R2 had already walked away down the hallway. RN-F stated that she was again told that R1 tried to touch R2, so she said we must move R1. RN-F said that they moved R1 to a table near the window facing the TV and out of the walkway. RN-F stated that nothing happened after that. RN-F stated that she emailed her statement to the NHA, as she works part time and was not back at the facility for a few days. RN-F stated that she had never witnessed R1 try to touch R2 like that before. On 5/29/25 at 1:50 p.m., Surveyor interviewed RN-H regarding the incident between R1 and R2 on 5/6/25. RN-H stated that the incident happened on his shift as he worked 2nd shift on 5/6/25. RN-H stated that when he was getting report at the beginning of his shift from the 1st shift nurse, he received a rough description of what happened between R1 and R2. Then ADON-E came up to the unit and stated that he was not happy about the whole situation. Surveyor asked what that meant. RN-H stated it was maybe because it took too long to report it. RN-H stated he was instructed to document the incident in the electronic record. RN-H stated that he felt this incident was kind of building up between R1 and R2. He has witnessed R1, on a number of occasions, try to reach out and grab R2's hands. R1 would want to look at R2's tattoos closer. RN-H stated that R1 has Parkinson's and R2 walks very quickly so he was surprised that R1 was able to make contact with R2. RN-H stated that R2 would walk by R1 500 times a day because that is all she did was pace the unit. RN-H stated R1 would watch R2 walk by and sometimes would yell out Hey to get her attention. It didn't seem to bother R2 at all. R1 does not talk much and R2 has a lot of difficulty making her needs verbally known. RN-H stated he was instructed to put R1 in 1 to 1 supervision until he could get the incident documented in the medical chart. DON called the families and notified them of the situation. RN-H stated that after the reports were written, he believed R1 was then on 30-minute checks. Surveyor noted discrepancies within the facility's investigation regarding the incident that occurred on 5/6/25 between R1 and R2. The written summary provided by NHA-A documents that there was only 1 time where R1 touched R2 inappropriately on 5/6/25. Both witness statements from Laundry Aide-C and CNA-D state that R2 was touched 2 different times, 1 time in the crotch area and 1 time in the butt by R1. Both witness statements state different times that these incidents occurred. The summary indicates that nurse was aware of the incident and separated R1 and R2 to maintain a safe situation, although R1 was able to grab and touch R2 a second time. The time between these 2 incidents is not reflected in any of the witness statements, only that R2 had walked away after the 1st incident and sometime later walked by R1 again and he grabbed her. NHA-A first identified the incident as happening at 11:00 a.m. on 5/6/25 and not discovered by the facility staff until 3:00 p.m. on 5/6/25. The 2nd submitted report to the state agency indicates the incident occurred at 1:30 p.m. on 5/6/25. The written statement from Laundry Aide-C does not indicate a time of occurrence, although the statement from CNA-D states the time of the occurrence was 7:30 a.m. on 5/6/25. The written statement from RN-F does not indicate what time she was notified or what time she took corrective action to keep the residents safe. Surveyor also noted that the facility did not thoroughly investigate this incident by interviewing all staff who may have had knowledge of this incident. A review of the schedule for 5/6/25 shows that 5 staff members were working on the unit for the morning shift (6:30 am-3:00 PM) in addition to Laundry Aide-C being on the unit returning resident clothing. Surveyor conducted further review of R1's medical record for further clarification of the incidents between R1 and R2. The following was noted: R1's nursing note dated 5/6/25 at 4:27 p.m. documents: Writer called POA to give update on member behavior of reaching out to touch female members. Left message to call back. This note was written by DON-B. R1's nursing note dated 5/6/25 at 5:15 p.m. documents: Member (R1) noted to reach out and grab fellow member R2 in a purposeful and inappropriate physical contact with member's genital/buttock area. Member (R1) has attempted to reach out and grab R2 in the past but has not targeted such areas and been successful. This note was written by RN-H who worked the 2nd shift on 5/6/25. R1's Incident note dated 5/6/25 at 5:19 p.m. documents: Follow-up: new intervention implemented and added to Treatment Plan of Care. Seating situation permanently changed. This note was written by RN-H. Surveyor reviewed R1's plan of care and noted it was updated with the following: On 5/6/25, the care plan was updated stating that R1 has actual problem of reaching out for inappropriate touching of other members. Interventions added on this date included: During non-meal hours R1 should be encouraged to be in the area over by the other male residents due to repeated reaching out in inappropriate manners to other residents. Encourage R1 to sit in the common area and not in hallway to prevent reaching out to females. 5/7/25 30-minute checks to ensure that when member is seated in common area that he is with other male members and not in common walkway areas utilized by pacing members. 5/8/25 targeted behavior is inappropriate touching of female staff or members. R1's IDT (interdisciplinary team) note dated 5/7/25 documents: Summary of discussion (late entry): met to discuss incident. All proper parties notified. Interventions: 30-minute checks to ensure that when member (R1) is seated in common area that he is with other male members and not in common walkway areas utilized by pacing members. During non-meal hours, R1 should be encouraged to be in area over by the other male members. Encourage member (R1) to sit in the common area and not in hallway to prevent reaching out to females. Monitor member (R1) behavior around female members. This note was written by ADON- E. R1's nursing note dated 5/7/25 at 1:38 p.m. documents: Per ADON-E, Member (R1) is on 30-minute checks. ADON-E updated members (R1) care plan. Member (R1) currently off the unit and out of the building with activity staff. Surveyor did request to see evidence that the 30-minute checks were being completed. The facility provided documentation with 30-minute checks starting at 1:40 p.m. on 5/7/25 until R1 moved to a different unit on the afternoon of 5/8/25. R1's communication note dated 5/7/25 at 4:30 p.m. documents: This writer met with member's (R1) POA and discussed a psychiatry referral for member. This POA was agreeable to transition R1 to see the in-house psychiatrist for a more integrated care approach instead of R1 going out to see a psychiatrist outside of this facility. This POA signed off on this consent. This writer and POA discussed R1's recent behavior towards female on the unit and inappropriately touching the female. This writer and POA discussed moving this member to a new unit, without females, as an intervention. This POA was agreeable to this idea, should the facility feel that it was in everyone's best interest. This note was written by SW (Social Worker)-G. Surveyor noted that although SW-G obtained consent for R1 to see the in-house psychiatrist for a more integrated approach, R1 did not actually have the initial Psychiatry evaluation until 5/19/25. R1's behavior note dated 5/7/25 at 10:29 p.m. documents: Member (R1) did not make contact; member emerged from his room with his walker and attempted to grab R2's arm however R2 walked away too quickly for R1 to make contact with her. Member noted to have 1 attempt to reach to and grab member (R2). This member (R1) did express great remorse to the writer and volunteered a promise to never do it again. Note written by RN-H. On 5/29/25 at 1:50 p.m., Surveyor interviewed RN-H. RN-H confirmed that on 5/7/25, he observed R1 come out of his room with his walker and try to grab R2 as she was walking by. R1 didn't really make contact, just grazed R2's arm. There is a speed difference in R1 and R2, she is fast to move. RN- H stated that he believed R1 was definitely interested in R2, although he doesn't show much interest in anything else. R1's communication note dated 5/8/25 at 12:00 p.m. documents: This writer called members (R1) POA and left a voice mail message. This writer informed POA of members (R1) room move to a new unit as an intervention to member's inappropriate touching towards a female peer on current unit. Note written by SW-G. On 5/29/25 at 11:46 a.m., Surveyor interviewed SW (Social Worker)-G regarding the incident between R1 and R2. SW-G stated that she does not recall how she found out about the inappropriate touching between R1 and R2. SW-G stated that she did not conduct any interviews with R1 or R2 immediately following the incident. SW-G sated that she did speak with R1's POA regarding having a psych evaluation and this was over the phone on 5/7/25. R1's POA did give consent to the evaluation and a room change. Surveyor asked SW-G why R1 did not have his initial psych evaluation until 5/19/25. SW-G stated she wasn't exactly sure but believes the in-house Psychiatrist was out on vacation and only comes to the facility every Monday. Surveyor asked SW-G when R1 moved rooms to a different unit on a different floor. SW-G stated that R1 moved in the afternoon of 5/8/25. Surveyor asked SW-G why R1 wasn't moved on 5/7/25 after the POA gave permission. SW-G stated she doesn't know why there was a delay in moving R1, maybe they didn't have a room ready or the manpower to move his belongings. Surveyor asked SW-G if she was aware that R1 attempted to grab R2 again after coming out of his room on 5/7/25. SW-G stated she was not aware of this. SW-G stated that interventions were put in place for 30-minute checks for R1 but not for R2. Staff were to be looking for any reactions to the incident from R2 and chart them in the electronic medical record. The delay in moving R1 created a very vulnerable situation and did not protect R2 from further sexually inappropriate touching. Given R2's extensive history of multiple trauma, especially sexual assault, this left R2 to be very vulnerable and any reasonable person would have the potential to respond to the actions of R1 in a negative way. On 5/28/25 at 10:49 a.m., Surveyor interviewed NHA-A in regard to the incident between R1 and R2 on 5/6/25. Surveyor stated to NHA-A that upon reviewing the written summary, it only identifies that R1 touched R2 inappropriately one time. The written witness statements document that R1 touched R2 twice. NHA-A stated that she thought it all happened at the same time. Surveyor asked NHA-A if she was aware what time the incidents happened because the facility's report documents 11:00 a.m., 1:30 p.m., witness statement says 7:30 am, and another states after lunch. NHA-A stated she does not recall what time she was notified and did not know the times of the incidents. NHA-A confirmed that the police were not called per the policy within 24 hours. NHA-A was asked what was done to protect the residents. NHA-A stated that R1 and R2 were separated. Surveyor asked if R1 and R2 were separated for safety, why was R1 able to touch R2 inappropriately a second time. NHA-A stated that NHA-A thought it all happened at the same time. On 5/28/25 at 2:28 p.m., Surveyor interviewed DON-B regarding the incident between R1 and R2 on 5/6/25. DON-B stated that she was made aware initially by ADON-E that the laundry aide had witnessed R1 touch R2 inappropriately. DON-B stated that she instructed ADON-E to gather interviews with any witnesses and find out where the incident happened. DON-B stated that she was not involved in the investigation because she was out of the facility for the next week immediately following the incident. DON-B stated that she was very concerned about R2 given her traumatic history with abuse and having flashbacks. DON-B stated that immediately following the incident, R1 was put on 15-minute checks and staff were to keep an eye on both R1 and R2 for any changes in behaviors. When R1 is out of his room, he is to sit in a more supervised area. DON-B is not aware of any other times where R1 inappropriately touched R2 or the other female residents on the unit. On 5/28/25 at 2:52 p.m., Surveyor interviewed ADON-E regarding the incident that occurred with R1 and R2 on 5/6/25. ADON-E stated he could not give a time of when he was notified but remembers the girl from laundry came into the conference room and told us she witnessed R1 touch R2 inappropriately. ADON-E stated that R1 had grabbed R2 in the crotch and then also grabbed her in the butt. ADON-E stated he immediately notified NHA-A because the issue needed to be addressed right away. ADON-E stated that an investigation began immediately and put R1 and R2 on 15-minute checks, if he remembers correctly. ADON-E stated that there were no behavioral changes to R2, and staff was keeping the 2 residents separated. Surveyor asked ADON-E what type of behaviors that the staff was monitoring for R2 to determine if she had been affected by this situation. ADON-E said they are watching all behaviors but could not give specifics for either resident. Surveyor noted that facility staff were aware that R1 had made several attempts to touch R2 as she would walk past him, although many thought it was harmless in intent. On 5/6/25, R1 was seated in a stationary chair at a table near the nurse's desk when R2 walked by. R1 grabbed R2 in the crotch, making R2 yell out stop and quickly walking away from the area. Staff told R1 that this was not nice of him and not to do it again. R1 remained seated in the same chair at the same table when R2 walked by again sometime later. R1 then grabbed R2 in the butt. R2 tried to swear at R1 and quickly walked away again. Staff determined that an immediate intervention was to move R1 to an area away from the walking path of R2. After NHA-A, DON-B, and ADON-E became aware of the situation, an investigation began and R1 was placed on 30 minute checks. DON-B thought it was 15 minute checks, but there was no evidence of this. R1's plan of care was updated with the interventions of having his seat moved when in the common area and staff are to observe him every 30 minutes. In the meantime, the afternoon of 5/7/25, R1 was able to walk out of his room and attempt to grab at R2 as she walked by in the hallway. R1 was moved to another unit on a different floor 2 days after the incident. The facility's failure to keep a resident free from sexual abuse created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on 5/30/25, however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan: - Identified RN was suspended pending completion of investigation. - All staff have been in-serviced by their next scheduled shift on prohibition and prevention of member abuse, neglect, and exploitation with reporting expectations. - IDT team was educated on the process of trauma assessments, identification of the need for a trauma care plan and the necessitation of ongoing monitoring and auditing of interventions success. - All staff will be in-serviced by next scheduled shift assigned training regarding identifying trauma triggers and mitigation strategies. - Abuse screening was completed by a sampling of members. - All new admissions will be assessed and anyone who triggers for trauma needs will have those needs care planned by the IDT team, interventions will be evaluated and adjusted if needed monthly for 3 months and then quarterly results of assessments and interventions of new admissions will be reviewed in QAPI. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility's policy and procedure titled, Member Rounds, with a last revision date of January 7, 2025, documents: Rounding shall be defined as nursing staff accounting for all members assigned to their unit frequently using the 4 Ps of rounding and purpose. It should be understood rounding is not every 2 hours as that is merely an absolute minimum: rounding is a continual event. One round should flow into the next round, this is how rounding reduces fall, skin breakdown, and other accidents and injuries.- Walking rounds shall occur at AM (morning) into PM (afternoon) and PM into NOC (night) shift change with CNA (Certified Nursing Assistant) staff from oncoming and outgoing shifts.- A walking round shall be considered when staff physically walk the unit to observe each member and their status, any noted change of the member shall be promptly reported to the on-duty nurse.2.) R1 was admitted on [DATE] with diagnoses that include repeated falls, dependence on other enabling machines and devices, unspecified Cranial Injury, Cognitive Communication Deficit, Post Traumatic Stress Disorder, and Encephalopathy.R1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 04/26/2024, documents a BIMS (Brief Interview for Mental Status) score of 10, indicating moderately impaired cognition for R1. Section GG (Functional Abilities and Goals) documents R1's self-care as needing maximal assist with toileting, dressing, bathing, indicating that facility staff provides more than half the effort for R1's self-care. Section GG also documents R1's mobility as dependent on staff for transfers, requires substantial/maximal assist using a manual wheelchair, indicating that facility staff provides more than half the effort for R1's wheelchair mobility.R1's Care Area Assessment (CAA) dated 05/10/24 documents under the analysis of findings section: R1 requires assistance with toilet use, has had a decline in condition and now requires use of a full body lift for transfers.Surveyor noted R1's care plan titled Potential Wandering was implemented for R1 on 7/12/24 after R1's 7/12/24's incident resulting in R1 being hospitalized for dehydration, heat exposure, and heat exhaustion. Under the interventions section it documents: Roam Alert. Under the goals section it documents: R1 will use the sign in/out form when leaving the unit. R1's nursing noted dated 7/12/24, at 03:30 PM, documents: Writer Licensed Practical Nurse (LPN)-D was called from receptionist that member (R1) was found stuck outside in the parking lot by staff coming into work. Writer LPN-D went to reception area and member (R1) was sitting in his w/c not responding, body very warm, very red in the face. Charge nurse went and gotten cold water for member (R1) to drink cool cloths to applied on member. Member brought up to 2nd floor 2 west and vital signs taken. Charge nurse continue to cool member (R1) down with cold water to drink and changing clothes for new cool cloths. Members (R1) not opening eyes, member (R1) is shaking his head yes and no. C/O nausea. Member (R1) continues to be non-verbal. Member (R1) was outside for about 1 hour and 15min.R1's nursing note dated 07/12/24, at 10:00 PM, documents: At 1530 (3:30 PM), writer Registered Nurse (RN)-C was walking into the building and noticed R1 sitting in his wheelchair near the outer corner of the car circle in front of [facility]. Writer RN-C called out R1's name a few times with no response, writer RN-C then walked up to member (R1) and noted that his face, neck, and arms were red, skin very warm to touch and member (R1) did not reply. Writer RN-C brought member (R1) inside the front entrance and receptionist called the unit LPN (Licensed Practical Nurse) to come down to also assess member (R1). Writer then went to grab member ice water and cold wet cloths. Member (R1) brought up to the unit and ADON (Assistant Director of Nursing) also present, placed fan facing member (R1) and ice-cold wet cloths to his forehead, back of neck, arms and armpits to help cool him down. Unit LPN took member vitals and continued to try to arouse him, facial grimacing noted with sternal rub, after a few minutes member then nodding his head when asked if he felt nauseated, not opening his eyes and no verbal response, member able to drink 2 cups of ice water with encouragement, member did say soda, skin slowly less red but still warm, unit LPN called NP (Nurse Practitioner) at 1545 (3:45 PM) and NP stated to continue to monitor him and if no improvement in mentation in 30 minutes send to ER (Emergency Room) for Evaluation. At 1605 (4:05 PM) Power of Attorney called and then 911 to send R1 to hospital. 911 paramedics here and IV (Intravenous) inserted and normal saline IV started, blood sugar 120, R1 transferred to stretcher with Hoyer lift and R1 out to Hospital at 1630 (4:30 PM). R1 returned to the facility on 2010 (8:10 PM) with Dx (diagnosis) of dehydration, heat exposure/exhaustion and renal insufficiency and was given IV fluids, labs and imaging done- ECG (Electrocardiogram) and CXR (chest x-ray)- no new orders received. Member in bed watching TV and ate noodles and drank the broth, requested orange soda. Roam Alert bracelet and device applied to members rt wrist (#F0341C) per ADON instruction for safety, POA (Power of Attorney) is aware and agreeable. Writer questioned R1 and asked what he was doing outside on the opposite side of the drive circle, and R1 stated I went out there to find a good spot to get some sun and a tan, but I got stuck and then I fell asleep. Next thing I know I was at the hospital with the paramedics shaking me up, I won't be doing that anymore .Roam Alert Device with bracelet applied to R1's right wrist for safety precautions due to R1 being found outside in sun and heat. Tag #F0341C exp 8/2027. R1 must have escort when going outside.Surveyor noted that the outside temparature according to the National Weather Service on 7/12/24 was 82 degrees Farenheit. R1's hospital after visit summary documents: Today's visit you were seen by (Doctor) Diagnoses: Dehydration; Heat exposure; Renal insufficiency.On 3/12/25, at 02:05 PM, Surveyor interviewed Receptionist-H regarding R1's 7/12/24 incident resulting in R1's hospitalization for dehydration, heat exposure, and renal insufficiency. Surveyor asked if Receptionist-H was working 7/12/24 the day when R1 was found outside by RN-C. Receptionist-H informed Surveyor that Receptionist-H was working on 7/12/24. Surveyor asked Receptionist-H if Receptionist-H remembered when R1 went outside. Receptionist-H informed Surveyor that Receptionist-H had no recollection of when and how R1 got outside.Surveyor asked Receptionist-H if R1 typically received help getting off the unit. Receptionist-H informed Surveyor R1 typically went off the unit and out of the building and came back independently. Surveyor asked Receptionist-H how the facility monitored the safety of R1 and other unsupervised residents after they exit the building to head outdoors. Receptionist-H informed Surveyor a sign in and out book that was started after R1's elopement incident on 7/12/24. Receptionist-H informed Surveyor that all residents must now sign in and out of the building. Surveyor asked Receptionist-H if Receptionist-H knew of any staff checking on R1 after R1 went outside on 7/12/24. Receptionist-H informed Surveyor that Receptionist-H did not remember seeing anyone check on R1. Surveyor asked Receptionist-H what the current protocol for resident's leaving the building unsupervised. Receptionist-H informed Surveyor the facility uses a sign in and out book. Surveyor asked Receptionist-H what the protocol prior to R1's 7/12/24 incident was. Receptionist-H informed Surveyor the facility always kept track of appointments and outings, and that after R1's 7/12/24 incident all unsupervised and supervised resident's leaving the building for any reason must sign in and out On 3/13/25, at 8:21 AM, Surveyor interviewed Receptionist-H regarding the facility monitoring protocol of unsupervised residents exiting the building to head outdoors. Surveyor asked Receptionist-H to explain the protocol put in to monitor unsupervised residents exiting the building to head outdoors. Receptionist-H informed Surveyor the residents sign into and out of the book. Any receptionist working will track all the times a resident exits the building and when a resident returns. The receptionist will write it in the book if the resident does not write it in themselves. Surveyor asked Receptionist-H who keeps an eye on the unsupervised residents outside on the facility grounds. Receptionist-H informed Surveyor the people working the reception desk will visualize where the residents are outside. Receptionist-H informed Surveyor the front desk will check on a resident frequently to make sure while the resident is outside is okay. Receptionist-H informed Surveyor all the receptionists keep a close eye out throughout the day to make sure the receptionist can see the resident through the windows. Receptionist-H informed Surveyor if a resident starts to move out of view, they will call the unit or go out and redirect the resident back into a visible location.Surveyor asked Receptionist-H if the facility had any safety monitoring protocols for unsupervised residents exiting the building to head outdoors prior to 7/12/24. Receptionist-H informed Surveyor the facility did not have a protocol to monitor unsupervised residents exiting the building to head outdoors prior to 7/12/24. Receptionist-H informed Surveyor the facility did keep track of resident's leaving and coming back from all appointments and family outings prior to 7/12/24. On 3/12/25, at 01:10 PM, Surveyor conducted a phone interview with CNA-E regarding R1's 7/12/24 incident resulting in R1's hospitalization for dehydration, heat exposure, and renal insufficiency. Surveyor asked CNA-E if CNA-E remembered the incident with R1 on 7/12/24. CNA-E informed Surveyor that CNA-E did not remember R1 or the incident. CNA-E informed Surveyor that CNA-E was working the other second floor unit most of the time. Surveyor asked CNA-E what the facility's expectation was for staff to monitor the safety of residents leaving the unit or building unsupervised. CNA-E informed Surveyor that staff is supposed to round every 2 hours, but most residents do not stay out that long. Surveyor asked CNA-E how CNA-E would know what length of time a resident was gone. CNA-E informed Surveyor that if a resident hadn't come back for some time staff would notice and go look for them. CNA-E informed Surveyor that CNA-E was not familiar with R1 and had no further information for the Surveyor.On 3/12/25 at 01:12 PM Surveyor conducted a phone interview with CNA-F regarding R1's 7/12/24 incident resulting in R1's hospitalization for dehydration, heat exposure, and renal insufficiency. CNA-F informed Surveyor CNA-F's shift started at 2:30 PM. CNA-F informed Surveyor CNA-F didn't see R1 in the parking lot when coming in for the shift. CNA-F informed Surveyor CNA-F remembered R1 coming back into the facility. CNA-F remembered R1 was lethargic and redden in the face. Surveyor asked CNA-F if R1 routinely went outside without supervision. CNA-F informed Surveyor that R1 went outside without supervision. Surveyor asked CNA-F what the facility's expectation of staff was to monitor the safety of residents like R1 going outside unsupervised. CNA-F informed Surveyor the expectation is to do rounds on all residents, there is no expectation to check on the independent residents like R1 who go off the unit, as those residents will come back to the unit on their own. CNA-F informed Surveyor that staff will check on residents that are fall risks or a wander risks. CNA-F informed Surveyor that staff wouldn't let a resident go out independently if that resident was at risk for injury. CNA-F informed Surveyor the staff will go with a resident if the resident is a fall risk or wander concern. CNA-F informed Surveyor R1 wasn't a fall risk or a wander risk and could be independent going outside. CNA-F informed Surveyor R1 was not the type of resident that needed to be supervised. CNA-F informed Surveyor that R1 would normally sit in the front lobby or go downstairs to the vending machines to get a soda. CNA-F informed Surveyor that R1wasn't at risk and R1 went outside frequently. CNA-F informed Surveyor R1 always came back in the facility on R1's own, so staff would not have checked on R1.Surveyor asked CNA-F if there is no policy or procedure for unit staff to check on unsupervised residents considered independent, then who would be responsible to check to make sure there are no medical or safety concerns when a resident is off the unit or outside CNA-F informed Surveyor the front desk will check on the residents and often the activities staff will check on the residents outside. Surveyor asked CNA-F if CNA-F was informing the Surveyor that R1 didn't need to be monitored off the unit or outside. CNA-F informed Surveyor that R1 went outside frequently and safely and didn't need to be monitored by the unit staff.On 3/12/25, at 02:49 PM, Surveyor interviewed LPN-D regarding R1's 7/12/24 incident resulting in R1's hospitalization for dehydration, heat exposure, and renal insufficiency. Surveyor asked LPN-D to provide details on the 7/12/24 incident with R1. LPN-D informed Surveyor that the day R1 was found in in the parking lot, LPN-D arrived that day to work a scheduled PM shift. Surveyor asked LPN-D what time LPN-D started work on 7/12/24. LPN-D informed Surveyor that LPN-D came in a little before the 2:30 PM shift start time. Surveyor asked LPN-D when the last time LPN-D saw R1 prior to R1 being found in the parking lot on 7/12/24. LPN-D informed Surveyor LPN-D saw R1 when coming in for LPN-D's shift just before 2:30 PM. Surveyor asked LPN-D what R1 was doing at the time LPN-D observed R1. LPN-D informed Surveyor R1 was in the front lobby talking about wheeling outside. Surveyor asked LPN-D how they determined the time frame of 1 hour and 15 minutes R1 was outside. LPN-D informed Surveyor the time 2:15 PM when LPN-D saw R1 in the lobby and the time 3:30 PM when RN-C found R1 was a 1 hour and 15 minutes. Surveyor asked LPN-D if R1 could wheel himself outside. LPN-D informed Surveyor that R1 does wheel down to lobby and outside for short distances. Surveyor asked LPN-D how often staff are expected to check on unattended residents that leave the unit or go outside of the building. LPN-D informed Surveyor that the Certified Nursing Assistants (CNAs) are good at letting LPN-D know when a resident has left the unit. Surveyor asked LPN-D if the protocol was the CNAs just know when a resident has left the unit and been gone too long. LPN-D informed Surveyor the staff will notice if a resident has been gone too long. Surveyor asked LPN-D how staff knew what time a resident left the unit. LPN-D informed Surveyor the staff will notice if a resident is leaving the unit. LPN-D informed Surveyor if a resident doesn't come back for some time, staff would let LPN-D know or go and look for them. Surveyor asked LPN-D how would staff know what time an unsupervised resident left the building once the resident was downstairs. LPN-D informed Surveyor the staff know the residents and when the residents are gone for too long a period, and the front desk staff would inform the units if a resident went outside to long. Surveyor asked LPN-D if there were any protocols for resident safety checks in the facility. LPN-D informed Surveyor the facility staff will do rounding every 2 hours for all residents in the building. Surveyor asked LPN-D if that is the basic policy for the building and not specifically for unsupervised residents that exit the building to head outdoors. LPN-D informed Surveyor that it was a policy for staff to round every 2 hours on all residents in the facility. On 3/13/25, at 12:25 PM, Surveyor conducted a phone interview with RN-C regarding R1's 7/12/24 incident resulting in R1's hospitalization for dehydration, heat exposure, and renal insufficiency. Surveyor asked RN-C if RN-C recalled the 7/12/24 incident with R1 in the parking lot. RN-C informed Surveyor that RN-C found R1 in the parking lot when coming in to work a scheduled 3:30 PM shift. Surveyor asked RN-C how it was determined that R1 was outside as documented by LPN-D for 1 hour and 15 minutes. RN-C informed Surveyor it was about an hour based on when R1 was last seen by staff at the front desk. RN-C informed Surveyor LPN-D always comes in 15 minutes before LPN-D's start time of 2:30 PM. RN-C informed Surveyor the facility staggered their shifts by an hour and RN-C came in at 3:30 PM. Surveyor asked RN-C how the facility keeps track of unsupervised residents leaving the unit and the building. RN-C informed Surveyor there is a sign out sheet that is inconsistently used. RN-C informed Surveyor that residents will often leave the unit and not tell staff. RN-C informed Surveyor that R1 usually didn't go outside, R1 mainly went down to the lobby to get a soda. RN-C informed Surveyor that RN-C asked R1why R1 went outside that day. RN-C informed Surveyor R1 told RN-C it was to get some sun. Surveyor asked RN-C what the staff did for resident safety checks before the unit sign-out was put in place after R1's 7/12/24 incident. RN-C informed Surveyor the staff relied on the staff seeing the resident leave but really had no specific monitoring system. RN-C informed the Surveyor the staff were good about realizing when someone was off the unit. RN-C informed Surveyor that the nursing station is in the front of the unit by the elevators and the front desk is by the front door and someone should notice if a resident was leaving. RN-C informed the Surveyor the facility will encourage residents use the sign out sheets, but the residents don't always comply. RN-C informed Surveyor there now is a sign out protocol for residents leaving the building by front desk. On 3/13/25, at 10:23 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R1's 7/12/24 incident resulting in R1's hospitalization for dehydration, heat exposure, and renal insufficiency. Surveyor asked DON-B if an investigation was completed on R1's 7/12/24 resulting in R1's hospitalization for dehydration, heat exposure, and heat exhaustion. DON-B informed Surveyor that no investigation was done on R1's 7/12/24 incident. Surveyor asked DON-B what the expectations of staff were to monitor a resident's safety that leave the building unsupervised. DON-B informed Surveyor the expectations when DON-B started in late July of 2024 was a resident sign out sheet on the unit. DON-B informed Surveyor the unit sign out form was already in place when DOB-B started in the position. DON-B informed Surveyor that DON-B started after the 7/12/24 incident involving R1. Surveyor asked DON-B when the sign in and out protocol for monitoring Residents leaving the building and visualization of the residents by the receptionists at the front desk was started. DON-B informed Surveyor the front desk protocol to monitor unsupervised residents leaving the building was started by DON-B sometime late July 2024.Surveyor asked DON-B what the facilities previous process to monitor unsupervised residents leaving the building prior to the 7/12/24 incident involving R1. DON-B informed Surveyor that DON-B did not know what the process was to monitor unsupervised residents leaving the building prior to the date of 7/12/24. DON-B informed Surveyor that DON-B was not at the facility until late July 2024.No additional information was provided as to why the facility did not ensure that R1 was not provided with supervision to prevent accidents. Based on interview and record review, the facility did not ensure that 2 (R2 & R1) of 2 residents reviewed received adequate supervision to prevent accidents. * R2 had expressed his desire to live independently and not stay at the facility. R2 also has a history of elopements as well as leaving medical appointments early. R2 was sent to a hospital appointment with a transportation company and not accompanied by staff or provided with supervision. R2 eloped from the hospital and was found at a hotel approximately seven hours later. A later investigation found R2 planned the elopement and had saved money to go to a different location and to live independently. The failure to provide adequate supervision to prevent R2 from eloping created a finding of Immediate Jeopardy that began on 03/06/2025. The Nursing Home Administrator (Administrator-A) and Director of Nursing (DON-B) were notified of the immediate jeopardy on 3/13/2025 at 1:22 PM. The immediate jeopardy was removed and corrected on 3/14/2025.The deficient practice continues at a scope and severity of a G (Actual Harm/Isolated) due to the following example:The facility failed to put a system in place to monitor R1's safety when R1 left the building unattended. R1 was found outside by staff arriving to the facility for their assigned second shift. R1 was transferred to the hospital for evaluation and was diagnosed with dehydration, heat exposure, and renal insufficiency.Findings include:1.) R2 was admitted to the facility on [DATE] with diagnoses that include COPD, Dementia with Mood Disturbance, Dementia with Moderate Anxiety, PTSD, and mild cognitive impairment. R2 was placed under protective placement via a court order on 11/17/23.R2's Discharge Care Plan initiated on 5/6/22 documents, DISCHARGE PLANS: Long-term stay anticipated at this SNF r/t (related to) I'm no longer able to reside at home d/t (due to) eviction from apartment, my history of falling at home. I voice wanting to leave the facility to go and live independently but I am unrealistic about my abilities. I refuse to have [NAME] County come out and do discharge options counseling. The VA (Veterans Affairs) spinal cord unit has encouraged me to talk to the county as the VA does not have a discharge option.R2's Safety Care Plan initiated on 2/17/23 documents, SAFETY: I am at risk for becoming a danger to myself by trying to leave the facility unsafely. Under the Interventions is documented: If resident leaves the facility and cannot be redirected to stay, and he has no safe plan for returning home: 1. Contact the Supervisor to update what is happening. 2. Call 911, report we need assistance with resident who is trying to leave the facility without a plan and his safety is a concern. 3. A staff person should follow resident and reapproach him to return to the facility.The safety care plan does not address proactive measure to prevent R2 from eloping even though the 5/6/22 discharge plan indicates R2 speaks about wanting to leave the facility. There was no evidence that an elopement care plan was put into place prior to 3/6/25.Surveyor reviewed nursing/progress notes for R2 and noted the following: R2's psychiatric progress notes dated 4/5/23 document, We also discussed the recommendation for activation of his DPOAHC (Durable Power of Attorney for Health Care) and continued placement in a supervised living environment that can assist with medication administration, meal preparation and transportation. The veteran again disagreed with these recommendations, stating, This is bullshit! He discontinued the appointment and left the examiner's office . R2's nursing note dated 6/13/23 documents, Social Services Progress Note Text: Member was scheduled for an appointment at [name of hospital] Urology around 824am with Transtar transport. Hospital called at 2pm that member did not make it to the appointment. Member has not returned to the facility. Writer attempted to call member-phone disconnected. Writer and HUC called Transtar- confirmed patient was dropped off at [name of hospital] around 930am and they have not picked him up. Facility conducted campus and building search for member. Facility notified Zablock campus security. Writer called local law enforcement and APS per member safety plan.Surveyor noted that after the above event in June 2023, R2 was referred for protective placement.R2's evaluation for protective placement dated 10/24/23 documents, On June 13, 2023, the [NAME] County Human Services Department received a referral on behalf of R2 requesting Emergency Chapter 54/55 Guardianship and Protective Placement .The referral also stated that on June 13, 2023, R2 had a urology and spinal cord injury appointment at [hospital] name in Milwaukee, Wisconsin. While at the [hospital name], R2 reportedly eloped from the hospital. It was reported that R2 was picked up at the facility by Transtar. R2 was then dropped off around 9:30 AM at [hospital name]. It was reported that R2 had an appointment at 10:00 AM but did not attend the appointment. At 2:00 PM that afternoon, [hospital name] alerted the facility that R2 had missed his appointment. R2 was eventually located at the hospital hiding from staff.R2's Determination and Order on Petition for Guardianship Due to Incompetency document dated 11/17/23 documents, This individual is found to be incompetent because other like incapacities .The court transfers to the guardian of the person the power to exercise in full the ability to receive medical or treatment records of the individual; make decisions related to mobility and transfer- Partial Transfer. The individual retains the power with Guardian consent.On 3/7/24, R2 has an appointment at the VA. R2's appointment visit notes dated 3/7/24 that documents: Pick up at 930 AM. Resident returned from VA lab, Va x-ray .well after 6:00 PM. On 3/13/25 at 8:50 AM, Health Unit Coordinator (HUC) -W informed Surveyor that when she spoke to the hospital via telephone, she was informed that R2 did not attend the 3/7/24 appointment. Surveyor asked HUC-W if there was any information as to where R2 went on 3/7/24 as R2 did not attend the appointment. HUC-W informed Surveyor that there was no information as to where R2 went on 3/7/24 when R2 did not attend the appointment. R2's psychiatric note dated 4/16/24 documents, Resident has been isolating in his room. He frequently refuses cares. Resident repeatedly stated, I hate it here, I don't care anymore. His sister is attempting to relocate him closer to where she lives in La Crosse; however, that has been problematic.R2's Annual MDS dated [DATE] documents that R2 has short and long term memory problems. The MDS documents a PHQ-9 mood assessment score of 6, indicating that R2 has mild depression. Section GG documents that R2 has no impairment to R2's upper or lower extremities, uses a wheelchair for mobility purposes, is able to self-propel, and is independent wheeling himself at least 150 feet. R2's Psychosocial Well-being CAA (Care Area Assessment) dated 2/4/25 documents under the care plan considerations section, Member self-isolates in their room. Member does not often participate in activities. Member often refuses to participate in assessments with staff and daily cares. Staff assessments were completed, which rated member to be a 06 on the PHQ9 scaled, indicating mild depression.Despite R2's care planned interventions and R2's failure to show for appointments on 6/13/23 and 3/7/24, R2 was assessed for elopement risk on 2/4/25 and deemed to not be at risk for elopement with a score of 6. The elopement risk assessment documents that a score over 10 requires an elopement care plan. R2's nursing note dated 3/6/25 documents, Member was transported out of facility at [Name of hospital] Milwaukee for his ultrasound appointment by TranStar around 1300 (1:00 p.m.). Facility received call from Transtar Driver that when driver went back to pick member up from [name of hospital] Hospital after appointment, he was unable to locate member. Call placed to [name of hospital] hospital; staff confirmed that member never attended his appointment. Police was alerted by Hospital staff. [NAME] County Sheriff's office was informed by DON. Guardian [name] informed @ 1810 (6:10 p.m.). Police informed that silver alert was issued for member. Member was safely located by Milwaukee police approximately around 2130 (9:30 p.m.). Member was brought back to facility by unknown transportation service around 2330 (11:30 p.m.). Member wheeled his wheelchair to his unit with smiling face. Member refused body check and vitals and helped to go to bed by staff.The facility's self-report and investigation dated 3/6/25 documents, Trans star transportation picked up resident at 1:30 PM for a 2:30 PM ultrasound appointment at [hospital]. At 5:30 PM ADON (assistant director of nursing) was informed that resident was not at the designated spot at [hospital] for post appointment pickup. Call was placed to doctor's office, and it was made known that resident did not check in for his 2:30 PM ultrasound appointment.Timeline as follows:5:30 PM- 9:52 PM1. ADON informed DON. 2. DON called hospital and doctors office to inquire about resident. 3. Guardian, Regional Administrator and Administrator were notified. 4. DON called resident's cell phone (no answer).5. DON called County Sheriffs office, County informed local sheriff.6. Silver Alert issued. R1 was dropped off at hospital in Milwaukee at approximately 2:00 PM for appointment. Resident however did not go to said appointment. Resident left hospital on his own and was found at 9:13 PM at [NAME] Milwaukee Fairfield (hotel) Inn. On 3/7/25R2 was interviewed by Charge nurse. Resident stated that he planned the events yesterday. He stated that he had slowly been saving cash. He also stated that he was hoping to pay cash for a cab to the [NAME] VA because he likes that hospital better than the one in Milwaukee. When asked about why he tried what he did he stated that he was unhappy and feels like he lives in a prison. He also stated that he doesn't like the PT department here because they tell him that he can't walk and that they treat him like a kid.R2 was asked about how he felt while he was out last night and he stated that he wasn't cold nor scared. Charge nurse stated that he was in good spirits and laughing about the events of last night.R2's statement documented that the elopement was planned, R2 saved $900 prior to the elopement, and that R2 wanted to pay for a cab with cash and wanted to go to [NAME] as R2 likes that hospital.R2's nursing note dated 3/7/25 and completed by RN (Registered Nurse)-V documents, Resident frequently non-compliant with care plan for safety, has history of leaving scheduled medical appointments.R2's elopement care plan documents, I am at risk of elopement r/t Dementia with mood disturbance. 3/06 Member eloped from [Name of Hospital] hospital from his appointment, silver alert was issued, member was located safe by Police. Interventions: Member is to have a companion ride along for all appointments to the VA. Q (every) checks 30 minutes.On 3/12/25 at 1:51 PM, Surveyor interviewed RN-V regarding R2's nursing note dated 3/7/25. Surveyor asked RN-V if R2 had eloped previously. RN-V informed Surveyor that R2 had eloped previously and/or had left appointments early, and that Surveyor should review R2's nursing notes. Surveyor asked RN-V why R2 was allowed to go appointments alone if he had eloped previously. RN-V informed Surveyor that RN-V did not know why R2 went to appointments alone as he had previously eloped. On 3/12/25 at 1:53 PM, Surveyor spoke with R2 about R2's elopement attempt. Surveyor asked R2 why R2 eloped from the facility. R2 informed Surveyor that R2 planned to go to the hospital in [NAME] as R2 hated living at the facility and that SW (Social Worker)-K did not help him get placement to live near [NAME]. R2 informed Surveyor that R2 planned to elope during his appointment as R2 had done it previously and R2 was aware that the facility did not send him with an escort. R2 informed Surveyor that R2 still wanted to leave the facility and had saved money to leave at R2's last appointment. R2 informed Surveyor that R2 felt extremely frustrated as SW-K did not speak with R2 and did not help R2 in any way to obtain another place to live. Resident believes that his sister gets his hopes up and it doesn't happen. Resident spends his days alone, playing chess on his computer.On 3/13/25 at 9:07 AM, Surveyor interviewed SW -K regarding R2's elopement and placement services. SW-K informed Surveyor that R2 had been offered placement services approximately 6 months prior to R2's elopement a[TRUNCATED]