Sandstone Of Tucson Rehab Centre

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to protect the rights of on resident to be free from abuse (#2) by another resident (#4). The deficient practice could result in residents being physically and emotionally injured.

Based on interviews, record reviews, and observations, the facility failed to implement its policies for preventing and prohibiting abuse were implemented consistently by staff, resulting in a delay in reporting resident to resident abuse to the state agencies, physician, abuse coordinator and family.

Based on observation, interviews, review of documentation, and review of facility policies, the facility failed to ensure that all allegations of abuse were reported to the state agency and other mandated entities within the required timeframe for two residents (#2) and (#4). The deficient practice could lead to a failure of the facility to report allegations of abuse timely, and could lead to continued abuse for a resident.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an allegation of abuse was reported to the State Agency for one resident (#69). The deficient practice could result in abuse allegations not being reported.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to protect the rights of two residents (#69, #77) to be free from abuse by another resident (#81, #76). The deficient practice could result in other residents being abused.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an allegation of abuse was reported to the State Agency for one resident (#69). The deficient practice could result in abuse allegations not being reported.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to protect the rights of two residents (#69, #77) to be free from abuse by another resident (#81, #76). The deficient practice could result in other residents being abused.

Based on clinical review, staff interviews, and facility policy and procedures, the facility failed to ensure that behaviors were monitored and documented prior to medication administration for 2 out of 3 residents sampled (#1, #2).

Findings include:

-Resident #1 was admitted on August 2, 2024 with diagnosis including unspecified atrial fibrillation, chronic kidney disease, cerebral infarction without residual effects, major depressive disorder-recurrent, unspecified psychosis, hallucinations, cognitive communication deficit.

A review of the MDS (minimum data set) dated August 8, 2024 revealed a BIMS (brief interview of mental status) score of 06 indicating severe cognitive impairment.

A review of the physician orders revealed the following orders: Paroxetine HCI 10mg , 1.5 tablets by mouth once a day for antidepressant; Risperidone 0.5mg 1 tablet two times a day for psychotic disorder-delusions, paranoia, hallucinations.

A review of the care plan revealed no evidence of monitoring of medication side effects and or behaviors either depression or psychotic disorder.

A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for December 2024 revealed no evidence that behaviors or side effects were being monitored for this resident.

-Resident #2 was admitted on December 2, 2024 and discharged from the facility on December 9, 2024 with diagnosis including a wedge compression fracture of the first lumbar vertebra, type 2 diabetes mellitus with hyperglycemia, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.

A review of the MDS dated December 5, 2024 revealed a BIMS score of 06, indicating severe cognitive impairment.

A review of the physician orders revealed the following orders: Escitalopram Oxalate 20mg, 1 tablet once a day for depression; Olanzapine 5mg, 0.5 tablet two times a day for mood stabilizer, agitation.

A review of the MAR for December 2024 revealed no evidence that behaviors or side effects were being tracked.

An interview was conducted on December 16, 2024 at 11:15 A.M. with a Certified Nursing Assistant (CNA/staff #181). Staff #181 stated that certain residents are on behavior tracking and that this is documented in the electronic health record. She stated that this helps to identify if behaviors are still occurring, escalating and potentially for when a nurse may need to follow-up with a doctor.

An interview was conducted on December 16, 2024 at 11:30 A.M. with a Registered Nurse (RN/staff #151). Staff #151 stated that when someone is on a medication for a specific behavior, that these are tracked in the TAR. She stated that the risk for not tracking the behaviors could include medication administered when they are not needed.

An interview was conducted on December 16, 2024 at 12:02 P.M. with the Assistant Director of Nursing (ADON#199). Staff #199 stated that with certain medications behaviors need to be tracked. Staff #199 reviewed the MAR/ TAR for resident #1 and #2 and stated that behaviors should have been tracked, but were not. She stated that the risk for not monitoring the behaviors could include over medication.

An interview was conducted on December 16, 2024 at 12:23 P.M. with the Director of Nursing (DON/staff #16). Staff #16 reviewed the medical record for resident #1 and resident #2 and stated that behaviors were not being monitored for either resident. She stated that behaviors should be tracked but were not. She stated that the expectation is to track the behavior to ensure that the medication administered is the correct one for the behavior. Staff #16 stated that the risk for not monitoring the behaviors could include over medication.

A review of the facility policy entitled Medication Administration adopted May 1, 2024 revealed that medications should be administered in accordance to meet the needs of the resident. Furthermore, the policy entitled Documentation adopted May 1, 2024 revealed that any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the resident's medical record.

Based on clinical record review, interviews, and policy review, the facility failed to ensure that one residents (#2) received treatment and care in accordance with professional standards of practice.

Findings include:

Resident #2 was admitted on December 2, 2024 and discharged from the facility on December 9, 2024 with diagnosis including a wedge compression fracture of the first lumbar vertebra, unspecified fall, type 2 diabetes mellitus with hyperglycemia, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.

A review of the MDS dated December 5, 2024 revealed a BIMS score of 06, indicating severe cognitive impairment.

A review of the care plan revealed that the resident was at risk for falls and interventions included: administer medications as ordered, monitor for potential side effects, ensure call light is within reach and respond promptly, and ensure resident is wearing appropriate footwear while mobile.

A review of the fall assessment dated December 2, 2024 revealed a score of 65, indicating that the resident was at a high risk of falling. The assessment further noted a history of falling. The assessment noted that the resident over-estimates or forgets limits.

A review of the progress notes revealed that on December 9, 2024 the resident slid out of his wheelchair and sustained an abrasion to the back of the head. It was noted that resident was picked up by the ambulance team and left the facility at 8:30 P.M.

A review of the unwitnessed fall documentation noted a date of December 9, 2024 and time of 6:30 P.M. for the fall.

A review of the neurochecks revealed only one entry on December 9, 2024 at 6:45 P.M. However, no evidence that additional neuro checks were documented in the medical record.

An interview was conducted on December 16, 2024 at 11:15 A.M. with a Certified Nursing Assistant (CNA/staff #181). Staff #181 stated that if an unwitnessed fall occurred then neurochecks are conducted every 15 minutes for the first hour and then every 30 minutes for an hour and stated she wasn't sure but thought it was every hour for the next 4 hours and then every hours for the next 24 hours, but stated either way, they have the guidelines posted that staff can refer back to. She stated if there were further concerns during the neurochecks she would immediately inform the nurse.

An interview was conducted on December 16, 2024 at 11:30 A.M. with a Registered Nurse (RN/#151). Staff #151 stated that nuerochecks are always conducted for an unwitnessed fall and a fall with a head injury to help identify any issues with the brain or spine. The risk for not conducting neurochecks could include missing something like a brain bleed.

An interview was conducted on December 16, 2024 at 12:02 P.M. with The Assistant Director of Nursing (ADON/#199). Staff #199 stated that that the expectation for neurochecks is that they are conducted and documented as required and outlined in the policy. Staff #199 stated that there is a specific form that the CNA's utilize to document the neurochecks. Staff #199 reviewed the resident's neurochecks and stated that there should have been at least 4 more entries. She stated that the risk for not conducting them as specified could include missing a change of condition.

An interview was conducted on December 16, 2024 at 12:23 P.M. with the Director of Nursing (DON/staff #16). Staff #16 stated that the expectation is that neurochecks should be conducted in their entirety as indicated and clearly documented. She stated that the risk for not conducting the neurochecks as scheduled could include missing something that could prove detrimental to the resident.

A review of the facility policy entitled Neurological evaluation adopted May 1, 2024 revealed that a comprehensive neurological assessment is to be done every 15 minutes for the first hour, then every 30 minutes for 2 hours, then every hour for 4 hours and then every shift for 72 hours.

Based on staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure residents were free from abuse.

Findings include:

Resident #114 was admitted on September 17, 2024 with diagnoses of dementia and Bipolar Disorder.

A 5 day MDS dated September 21, 2024 included that this resident was moderately cognitively impaired with fluctuations of altered level of conscious, disorganized thinking and inattention. This resident requires partial/moderate assistance with lower body dressing and was independent with mobility.

A care plan dated September 18, 2024 included that the resident had behavior concerns wandering into other resident rooms, and hoarding other resident's items/food related to dementia with an intervention to anticipate and meet the residents needs.

A care plan included that the resident is on frequent checks for safety/wandering and includes an intervention on October 11, 2024 of safety checks every 15 minutes. This careplan also included that the resident was placed on every 30 minute checks for safety on November 21, 2024, which is less frequently. Another intervention dated October 11, 2024 included to redirect this resident from wandering into other resident's rooms as needed. However, this resident was not redirected from entering other residents rooms.

A progress note dated September 23, 2024 included that this resident took all her clothes off and made her way to her neighbors' room which is a male's room and that this resident was redirected her back to her room to change her and get her back into bed.

A provider note dated September 23, 2024 included that this resident required daily supervision for safety risks and includes that the resident's judgement is poor and that her cognition is confused/impaired.

A progress note dated October 2, 2024 included "The patient continues to present with wandering into other residents rooms regardless of the patient, publicly attempting to disrobe, verbal and physical aggression towards staff, rummaging through other residents belongings."

A progress note dated November 26, 2024 included that "Resident is alert, difficulty making needs known related to cognitive impairment. She is wandering into rooms, hallways, needs cueing and redirecting most of the time. She is compliant with medications and care, incontinent of bowel and bladder at times. Ambulates with an unsteady gait .NO behaviors noted at this time"

A progress note dated November 27, 2024 included "CNA went to assist male patient up to w/c to eat in dining room. Viewed male's hand in females groin. Female laying back on bed with pants off. CNA Immediately removed female from male room taken back to her own room. Then notified nurse of occurrence. Patient skin checked no redness, no c/o pain. Patient unaware of occurrence only complained of sock on left foot and removed it folding it and holding on to it. When asked if she was okay patient responded i'm alright. Patient body relaxed when sitting in a chair calm mood ..."

-Resident #129 was admitted on May 17, 2024 with diagnoses of Major Depressive Disorder, encephalopathy and cerebral infarction.

A quarterly Minimum Data Set (MDS) dated August 20, 2024 included that this resident was moderately cognitively impaired and required supervision or touching assistance with toileting hygiene, showering/bathing himself, lower body dressing, putting on/taking off footwear and personal hygiene.

A care plan dated November 5, 2024 included this resident is on frequent checks for safety-aggression towards others.

A progress note dated November 27, 2024 included "At 1705 CNA entered resident room to assist up to w/c to eat in dining room. Viewed resident hand in females groin. Female laying down on bed without pants. Female removed from room back to her own room. When asked patient what he was doing he stated that female and him have known each other for awhile. Stated he didn't know her name but they where going to get married. Asked patient if he was hurt stated my feelings are hurt. Became agitated with nurse and stated again we are gonna get married ..."

An interview was conducted on December 2, 2024 at 12:33 p.m. with a Certified Nursing Assistant (CNA/staff #27) who said that resident #114 does not like to put closes on and that she will put on a gown but that she likes to take her clothes off. This staff said that they were a float on the day of the incident and that she recalled that it happened when they were trying to get the residents into the cafeteria and that resident #114 was wearing pants that day but was found with her pants off and that she was told that resident #129 had his hand in her brief. This CNA stated that afterwards she watched #114 for the rest of the day. She said that resident #114 was not capable of consent and that she had to keep telling her "lets go to the kitchen" because otherwise she would be confused and stop. She said that there were enough people to watch the residents when there were 3 staff but if there were 2 and a "float" which worked on several halls on the same shift, it was not enough. This staff said that she could not really watch the residents when she was going between halls.

An interview was conducted on December 2, 2024 at 12:45 p.m. with a CNA (CNA/staff #81) who said that this was her regular hall. This staff said that the patients need to be looked after more than the other halls. This staff said that usually they have 3 CNA on the hall per shift but that day one went out to escort a resident. This staff said that she was the one who found the residents. She said that she went to go get resident #129 and that resident #114 was in his room and her legs were open and she was laying back, and I walk in and he's touching her privates. This staff said that resident #129 had his hand inside resident #114's brief. This staff said that she asked the residents "What are you doing?" and resident #129 said "nothing" This staff said that resident #114 sat up and doesn't say anything and she grabbed resident #114's arm and her pants and that she escorted her out. This staff said that resident #129 is not capable of consent and that his cognition varied. This staff said that when there were 3 staff on the hall that it was enough but that that there was a new staff that day who was floating.

An interview conducted on December 2, 2024 with a Licensed Practical Nurse (LPN/staff #14) who said that the hall that residents' #129 and #114 were on was a locked unit for exit seeking behavior and dementia. This nurse said that resident #114 was a very heavy wanderer, an exit seeker and that she had bad dementia and bad cognition and that resident #129 was occasionally delusional and that he was not able to distinguish dreams from reality. She said that resident #114 was not able to consent at all because she was very disoriented but that it was possible that resident #129 might be. This staff stated that she was unaware that residents' #129 and #114 had a sexual incident and said that she would separate them immediately because resident #114 is not her own person, and contact the unit manager and contact the resident's representative and ask the representative what they wanted us to do. This nurse said that she believed that this was not abuse but that if it was not addressed that it would be.

An interview conducted on December 2, 2024 at 2:04 p.m. with a Registered Nurse (RN/staff #30) who said that she would separate them, then call the nurse manager and delegate a CNA to stay with them while deciding what to do next and informing management and the resident's guardian. She said that she thinks somebody else updates the care plan and that she believed it was the Director of Nursing or the Assistant Director of Nursing.

An interview was conduc

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#1) and (#2) were free from physical abuse.

Findings include:

-Regarding resident #1

Resident #1 was admitted on June 21, 2023 with diagnosis including alcohol-induced persisting amnestic disorder, Wernicke's encephalopathy, chronic obstructive pulmonary disease, epilepsy, cognitive communication deficit osteomyelitis and major depressive disorder-recurrent.

A review of the care plan revealed a focus area indicating that the resident has a potential risk for alteration in mood state and psychological well-being with interventions including encouraging alternative communication, admission to a secure unit, documentation of all behaviors and monitoring of interactions and the presence of negative thoughts and feelings. The care plan further revealed a focus area of resident knowledge deficit and confusion due to Wernicke's disease.

A review of the progress notes for resident #1 revealed an entry dated October 20, 2024 indicating that staff heard the resident yelling out and that he appeared shaky and agitated. It was noted that resident #1 stated that resident #2 came to his room and hit him multiple times in the head and face with his television remote control. It was noted that the resident had an injury (abrasion) to the back of his right ear. The progress notes further indicated that the resident was placed on 15-minute safety checks and that appropriate notifications took place.

-Regarding resident #2

Resident #2 was admitted on September 27, 2024 with diagnosis including unspecified dementia, psychotic disturbance, mood disturbance, anxiety disorder, major depressive disorder-recurrent, chronic systolic heart failure and Alzheimer's disease.

A review of the MDS dated October 4, 2024 revealed a BIMS score of 3, indicating severe cognitive impairment.

A review of the care plan revealed a focus area of wandering with interventions including distracting the resident by offering pleasant diversions, identification of any patterns or purpose of wandering and providing structured activities. The care plan further notes that that the resident is required to have a 2 person assist at all times during care. The care plan also indicated that the resident requires frequent safety checks and requires one to one supervision at all times.

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A review of the facility's documentation revealed a counseling/ disciplinary notice indicating that on October 19, 2024 at 3:00 A.M. staff #46 CNA (certified nursing assistant) was assigned as a one on one staff for resident #2 and failed to watch the resident, which allowed a resident to resident altercation to occur. The disciplinary notice was signed and dated October 21, 2024.

An interview was conducted on October 29, 2024 at 4:26 P.M. with staff #10 CNA. Staff #10 stated that she did not observe the incident but was aware that resident #2 had hit resident #1. She further stated that she knew that resident #2 was noted to require 2 staff to assist when providing care and that he required a one to one at all times, meaning that the resident has to be at arm's length from the staff member assigned to them.

An interview was conducted on October 29, 2024 at 4:35 P.M. with resident #1. The resident stated that he recalled the incident and stated that someone came into his room and was speaking Spanish and then hit him on the head and gave him a bloody ear. He stated that he did not recall the resident's name but stated that he knew the resident resided on the same hall. Resident #1 stated that he feels safe at this time but wants to leave to go to a half-way house.

An interview was conducted on October 29, 2024 at 4:39 P.M. with staff #30 RN (registered nurse). Staff #30 stated that she was not present the day of the incident but had heard that about the incident. She stated that a one on one should always be in arm's length of the assigned resident, even when the resident is in the bathroom. She heard that the resident #2 was in the bathroom, but that the one on one was not within arm's length and resident #2 left the bathroom through the other door and subsequently injured resident #1. She explained that the bathroom was a "jack and jill" bathroom facilitating entry to 2 separate resident rooms. She stated that resident #2 is no longer at the facility and had been moved to another facility on October 25, 2024. She stated that although the risk to resident #1 no longer exists, since the resident #2 is no longer there, the risk to residents in general when not supervised according to the care plan, could include injury to others. She further stated that she felt that resident #1 was initially reliving the incident and that she and other staff try to reassure the resident that he is safe. She stated that she felt he was more at baseline now.

A telephonic interview was conducted on October 29, 2024 at 5:15 P.M. with staff #46 CNA. Staff #46 stated that he was the assigned CNA for resident #2. He stated on the date of the incident, he was sitting outside of resident #2's bathroom as the resident had requested privacy. He stated that he was not aware that anything had happened until he heard resident #1 yell out. He stated that he did not actually witness the interaction between the residents. Staff #46 further stated that he kept trying to peek into the bathroom but resident #2 kept closing the door and locked it. He stated that resident #2 ultimately had slipped out of the other door and into the other room where he must have made his way to resident #1's room. Staff #46 reported that another staff member had come to assist and separate the residents, post incident. He further stated that knew resident #2 to wander but not that he could be violent. Staff #46 stated that in hind sight, he could have gone to the other door, as that one did not lock to ensure that the resident did not wander through the other room. He stated that when a CNA is assigned as a one on one that the resident has to be within arm's length and viewable. He stated that the risk for not ensuring that eyes are kept on a resident and that staff are at arm's length could include potential trauma or physical injury to another resident.

An interview was conducted October 29, 2024 with the staff #118 DON (Director of Nursing). Staff #118 stated that the expectation is that residents are free from abuse. Staff #118 further stated that if residents are not supervised, as assigned, the risk could include injury to that resident or others.


A review of the facility entitled Abuse and Neglect adopted May 1, 2024 revealed that it is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse.

Based on clinical record review, interviews, and review of facility policies the facility failed to ensure an avoidable elopement was prevented. The deficient practice could result in residents finding themselves in unsafe situations in the community, unsupervised.

Findings include:

Resident #1 was admitted to the facility on July 9, 2024 with diagnoses of mild cognitive impairment, nontraumatic intracerebral hemorrhage, schizoaffective disorder and aphasia.

A review of the facility's assessment called "Wander Risk Scale", completed on July 10, 2024, indicated resident #1 was a low risk for wandering/elopement. A review of the resident's electronic health record (EHR) revealed no other "Wander Risk Scale" assessment being completed during resident #1's stay.

A review of the admission Minimum Data Set (MDS) assessment dated July 16, 2024 revealed resident #1 was unable to complete a Brief Interview for Mental Status (BIMS) assessment. As a result, staff assessed his cognitive skills for daily decision making as modified independence.

A review of resident #1's care plan, revised on July 17, 2024, to include a focus around resident #1's elopement risk and attempts to exit seek. Interventions included providing encouragement with socialization, reminding the resident why he was placed in the unit, and allowing the resident to share his feelings and frustrations each shift.

A review of resident #1's progress notes revealed that a care conference was held on July 26, 2024 and the resident's cousin was in attendance. The note indicates the interdisciplinary team agreed the resident going to be discouraged from smoking and having leave of absences due to the resident talking about escaping the facility.

Progress notes from July 26, 2024 through September 20, 2024 revealed multiple occasions where resident #1 have attempted or talked about leaving the facility, however, during each attempt resident #1 was able to be redirected by staff.

A progress note from September 19, 2024 indicated resident #1 was exit seeking and a high elopement risk. The note also indicated resident #1 was able to exit the secured unit by following staff out the unit. The note also stated "staff was educated on the importance of closing exit doors and ensuring no residents go beyond the exit doors".

A progress note from September 20, 2024 indicated that at 6:55 PM resident #1 left the secured unit with his belongings. The note continued to indicate that staff attempted to redirect resident #1 to return to the facility but was unsuccessful. Police and the resident's cousin were contacted and arrived to assist with the resident. The resident agreed to go to a crisis facility instead of returning back to the facility.

An interview was conducted on September 25, 2024 at 10:18 AM with staff #3 (Certified Nursing Assistant). She confirmed that she was working on the Behavioral Health Unit (BHU) on Friday, September 20, 2024. She indicated that she observed a kitchen staff member let resident #1 out of the secured BHU unit as he was bringing meal trays in. Staff #3 indicated they then followed resident #3 out of the unit and caught up with him outside. She indicated that her and several staff members attempted to convince resident #1 back into the building onto the BHU but the resident refused.

An interview was conducted on September 25, 2024 at 11:10 AM with staff #9 (Licensed Practical Nurse). She confirmed that she was working on the BHU on Friday, September 20, 2024 and she was familiar with resident #1. Staff #9 explained the process of entering and exiting the BHU as follows: staff have a badge they use to leave and exit the unit and must make sure the doors are closed. Staff will open the door for family members. When asked what happened on September 20, 2024, staff #9 indicated that an employee was delivering the evening meals and let the resident walk out. Staff #9 indicated that she was alerted to the situation by another resident and then immediately met with the other Certified Nursing Assistants to locate resident #1.

An interview was conducted with staff #5 (Cook) on September 26, 2024 at 9:33 AM. Staff #5 confirmed that he worked on September 20, 2024 and sometimes he goes to the BHU to deliver meals or to replace a plate if something is wrong with the order. Staff #5 indicated that residents that live in the BHU are not permitted to leave their unit and individuals with badges or visitor stickers are permitted in and out of the unit. Staff #5 explained that he went onto the BHU on September 20, 2024 and at the time he thought resident #1 was a visitor because he had a backpack on. Staff #5 indicated that resident #1 told him he was visiting and staff #5 proceeded to let him out of the unit via the three security doors. When asked if resident #1 had a badge or a visitor's sticker, staff #5 indicated that he did not look. When asked what the risks would be when residents in the BHU elope from the facility, staff #5 indicated that they could relapse in the community, get lost and not know where to go.

An interview was conducted with staff #8 (Director of Nursing) on September 26, 2024 at 9:06 AM. Staff #8 indicated that upon admission, resident #1 was considered a low risk of elopement. She explained that resident #1 tended to pace the hallways in the BHU with his belongings but was easily redirected by staff. When asked what her expectation was for staff when entering and exiting the BHU, staff #8 indicated that she expected them to use their badge to get in and out and to always look around them to see if there is anyone around. She also indicated that she expected staff to make sure the door closes before they walk away. Staff #8 also indicated that visitors get a badge at the front desk and are escorted to and from the BHU with a staff member. Staff #8 indicated the risks associated with letting a resident out of the BHU were "all kinds of stuff". She went on to explain that residents might not be willing to come back onto the unit, they might be exposed to unsafe weather conditions, and might not be able to be safe in the community due to the cognitive functioning.

A request for the facility's policy and procedures for security doors was made on September 25, 2024 however, the facility did not have this document.

Based on clinical record review, interviews, and review of facility policies the facility failed to ensure an avoidable elopement was prevented. The deficient practice could result in residents finding themselves in unsafe situations in the community, unsupervised.

Findings include:

Resident #1 was admitted to the facility on July 9, 2024 with diagnoses of mild cognitive impairment, nontraumatic intracerebral hemorrhage, schizoaffective disorder and aphasia.

A review of the facility's assessment called "Wander Risk Scale", completed on July 10, 2024, indicated resident #1 was a low risk for wandering/elopement. A review of the resident's electronic health record (EHR) revealed no other "Wander Risk Scale" assessment being completed during resident #1's stay.

A review of the admission Minimum Data Set (MDS) assessment dated July 16, 2024 revealed resident #1 was unable to complete a Brief Interview for Mental Status (BIMS) assessment. As a result, staff assessed his cognitive skills for daily decision making as modified independence.

A review of resident #1's care plan, revised on July 17, 2024, to include a focus around resident #1's elopement risk and attempts to exit seek. Interventions included providing encouragement with socialization, reminding the resident why he was placed in the unit, and allowing the resident to share his feelings and frustrations each shift.

A review of resident #1's progress notes revealed that a care conference was held on July 26, 2024 and the resident's cousin was in attendance. The note indicates the interdisciplinary team agreed the resident going to be discouraged from smoking and having leave of absences due to the resident talking about escaping the facility.

Progress notes from July 26, 2024 through September 20, 2024 revealed multiple occasions where resident #1 have attempted or talked about leaving the facility, however, during each attempt resident #1 was able to be redirected by staff.

A progress note from September 19, 2024 indicated resident #1 was exit seeking and a high elopement risk. The note also indicated resident #1 was able to exit the secured unit by following staff out the unit. The note also stated "staff was educated on the importance of closing exit doors and ensuring no residents go beyond the exit doors".

A progress note from September 20, 2024 indicated that at 6:55 PM resident #1 left the secured unit with his belongings. The note continued to indicate that staff attempted to redirect resident #1 to return to the facility but was unsuccessful. Police and the resident's cousin were contacted and arrived to assist with the resident. The resident agreed to go to a crisis facility instead of returning back to the facility.

An interview was conducted on September 25, 2024 at 10:18 AM with staff #3 (Certified Nursing Assistant). She confirmed that she was working on the Behavioral Health Unit (BHU) on Friday, September 20, 2024. She indicated that she observed a kitchen staff member let resident #1 out of the secured BHU unit as he was bringing meal trays in. Staff #3 indicated they then followed resident #3 out of the unit and caught up with him outside. She indicated that her and several staff members attempted to convince resident #1 back into the building onto the BHU but the resident refused.

An interview was conducted on September 25, 2024 at 11:10 AM with staff #9 (Licensed Practical Nurse). She confirmed that she was working on the BHU on Friday, September 20, 2024 and she was familiar with resident #1. Staff #9 explained the process of entering and exiting the BHU as follows: staff have a badge they use to leave and exit the unit and must make sure the doors are closed. Staff will open the door for family members. When asked what happened on September 20, 2024, staff #9 indicated that an employee was delivering the evening meals and let the resident walk out. Staff #9 indicated that she was alerted to the situation by another resident and then immediately met with the other Certified Nursing Assistants to locate resident #1.

An interview was conducted with staff #5 (Cook) on September 26, 2024 at 9:33 AM. Staff #5 confirmed that he worked on September 20, 2024 and sometimes he goes to the BHU to deliver meals or to replace a plate if something is wrong with the order. Staff #5 indicated that residents that live in the BHU are not permitted to leave their unit and individuals with badges or visitor stickers are permitted in and out of the unit. Staff #5 explained that he went onto the BHU on September 20, 2024 and at the time he thought resident #1 was a visitor because he had a backpack on. Staff #5 indicated that resident #1 told him he was visiting and staff #5 proceeded to let him out of the unit via the three security doors. When asked if resident #1 had a badge or a visitor's sticker, staff #5 indicated that he did not look. When asked what the risks would be when residents in the BHU elope from the facility, staff #5 indicated that they could relapse in the community, get lost and not know where to go.

An interview was conducted with staff #8 (Director of Nursing) on September 26, 2024 at 9:06 AM. Staff #8 indicated that upon admission, resident #1 was considered a low risk of elopement. She explained that resident #1 tended to pace the hallways in the BHU with his belongings but was easily redirected by staff. When asked what her expectation was for staff when entering and exiting the BHU, staff #8 indicated that she expected them to use their badge to get in and out and to always look around them to see if there is anyone around. She also indicated that she expected staff to make sure the door closes before they walk away. Staff #8 also indicated that visitors get a badge at the front desk and are escorted to and from the BHU with a staff member. Staff #8 indicated the risks associated with letting a resident out of the BHU were "all kinds of stuff". She went on to explain that residents might not be willing to come back onto the unit, they might be exposed to unsafe weather conditions, and might not be able to be safe in the community due to the cognitive functioning.

A request for the facility's policy and procedures for security doors was made on September 25, 2024 however, the facility did not have this document.