Ridgecrest Post Acute

Based on observations it was determined the facility failed to provide a clear means of egress to exit to a public way. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency. NFPA 101, Life Safety Code, 2012, Chapter 3, Section 3.3.169 * Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge. Section 3.3.169.1 Accessible Means of Egress. A means of egress that provides an accessible route to an area of refuge, a horizontal exit, or a public way. Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.2.1.5.10. Findings Include: The emergency exit across from the beauty shop has no hard surface to the public way. There is no cement pad directly outside the door. The landscape in this area consists of area consists of rock, dirt and grass. The management team confirmed during the facility tour and exit conference on December 11, 2024, that the exit did not have a clear hard packed surface to the public way.

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff. NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction." NFPA 80 2010 edition, Chapter 5 Section 5.2.14 Maintenance of Closing Mechanisms. 5.2.14.1 Self-closing devices shall be kept in working condition at all times. Findings include: REPEAT FINDING Observations made while on tour on December 11, 2024, revealed the following; Field modifications, missing closures, or other closure hardware 1. Room 101 is missing door closure hardware 2. Room 102 is missing door closure hardware 3. Room 103 is missing door closure hardware Tagged 3/16/2023 4. Room 105 is missing door closure hardware 5. Room 106 is missing door closure hardware Tagged 3/13/2023 6. Room 107 is missing door closure hardware 7. Room 109 is missing door closure hardware Tagged 3/16/2023 8. Room 111 is missing door closure hardware Tagged 3/16/2023 9. Room 113 is missing door closure hardware Tagged 3/16/2023 10. Room 116 is missing door closure hardware and not latching 11. Room 119 is missing door closure hardware 12. Room 120 is missing door closure hardware 13. Room 122 is missing door closure hardware Tagged 3/16/2023 14. Room 123 is missing door closure hardware 15. Room 125 is missing door closure hardware Tagged 3/16/2023 16. Room 126 is missing door closure hardware Tagged 3/16/2023 17. Room 127 is missing door closure hardware Tagged 3/16/2023 18. Room 201 is missing door closure hardware Tagged 3/16/2023 19. Room 202 is missing door closure hardware Tagged 3/16/2023 20. Room 205 is missing door closure hardware 21. Room 207 is missing door closure hardware Tagged 3/16/2023 22. Room 208 is missing door closure hardware 23. Room 209 is missing door closure hardware Tagged 3/16/2023 24. Room 210 is missing door closure hardware 25. Room 211 is missing door closure hardware Tagged 3/16/2023 26. Room 213 is missing door closure hardware 27. Room 301 is missing door closure hardware 28. Room 303 is missing door closure hardware Tagged 3/16/2023 29. Room 304 is missing door closure hardware 30. Room 305 is missing door closure hardware 31. Room 307 is missing door closure hardware Tagged 3/16/2023 32. Room 309 is missing door closure hardware 33. Room 311 is missing door closure hardware 34. Room 312 is missing door closure hardware 35. Room 316 is missing door closure hardware 36. Room 324 is missing door closure hardware 37. Room 326 is missing door closure hardware 38. Room 401 is missing door closure hardware 39. Room 403 is missing door closure hardware Tagged 3/16/2023 40. Room 405 is missing door closure hardware Tagged 3/16/2023 41. Room 410 is missing door closure hardware 42. Room 411 is missing door closure hardware

Based on observation the facility allowed the use of power strips but did not use the wall outlet receptacles for appliances. Failure to properly use power strips and outlets could lead to electrical overload or fire, which could harm the patients and staff. NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters. S&C: 14-46-LSC- Life Safety Code surveyors assess the use of power strips in healthcare facilities. However, the following guidance is provided as reference for healthcare surveyors as they survey physical environment along with other CoP requirements. Any observed power strip deficiencies should be conveyed to the LSC surveyors for citation. Findings include: Observations made during the tour from December 11, 2024, revealed that the following locations had power strips plugged into equipment with heavy load-drawing appliances (refrigerators, microwaves, and large printers). 1. Human Resource office- the refrigerator was plugged into a power strip. 2. Physical Therapy office- the refrigerator was plugged into a power strip. 3. Nurses Station 100- the refrigerator was plugged into a power strip. The management team confirmed during the facility tour and exit conference conducted on December 11, 2024, that power strips were being used in the above-listed location.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was accurate for one of three sampled residents (#139). Findings include: Resident #139 was admitted on October 4 2024 with diagnoses that included altered mental status, catatonic disorder condition, anxiety disorder, and auditory hallucinations. A baseline care plan dated October 7, 2024 revealed that the resident's goal was to discharge to home. An order summary dated October 11, 2024, revealed that the resident's tentative discharge plan was to return home with family. A social services progress note dated October 16, 2024, revealed that the resident was discharged to home with her daughter and husband. The note further revealed that the home health was also arranged. A nursing progress note dated October 16, 2024, revealed that the resident was discharged home with home health. Despite this, a review of a discharge MDS assessment dated October 18, 2024, revealed that the resident had been discharged to a short-term general hospital on October 16,2024. An interview was conducted on December 4, 2024 at 10:26 AM with a Registered Nurse (RN-Staff #218), who stated that a transfer form/e-interact transform form is completed when a resident is transferred to the hospital, along with Physician discharge notes. The RN reviewed the clinical record and stated that the resident had been discharged home. She further stated that a social worker's note revealed that the resident left by car with home health arrangements. An interview was conducted on December 4, 2024 at 10:41 AM with the MDS Coordinator (Staff #55), who stated that MDS data should be accurate as per the standard of care. He reviewed the resident's clinical record and stated that there was a discrepancy between progress notes, which indicated a discharge home, and the MDS discharge assessment, which indicated the resident was discharged to the hospital. He stated that the potential risk could result in inaccurate MDS data. An interview was conducted on December 4, 2024 at 10:57 AM with the Director of Nursing (DON/Staff #141), who stated that she expected MDS assessments to accurately reflect a resident's status. The DON reviewed Resident #139's progress notes, and stated that the resident was discharged home. She then reviewed the discharge MDS assessment dated October 16, 2024 and stated that the assessment indicated that the resident had been discharged to a hospital. She further stated that the MDS was inaccurate and would need to be corrected. The DON stated uncertainty regarding the resident's final destination (Home or Hospital) and stated that she would have to look into it. The DON also stated that an inaccurate MDS assessment could result in incorrect MDS data. Further interview was conducted on December 4, 2024 at 12:20 PM with the DON (Staff #141) who stated that the clinical record contained a physician order to discharge the

Based on record review, staff interviews and observations, the facility failed to ensure that electronic records for one of twenty-eight sampled residents (#64) were accurately documented. Findings include: Resident #64 was admitted on April 17, 2023 with diagnoses of dementia, type 2 diabetes mellitus, major depressive disorder and anxiety disorder. Review of Resident #64's medical record revealed a New Admission Medication Review dated June 12, 2023 that was for another resident, regarding Prednisone 20 mg. Further review of the form revealed another resident ' s name, date of birth, and medications, and was no longer a resident at the facility. An additional New Admission Medication Review dated June 12, 2023 was also in Resident #64 ' s medical record with the same resident ' s name that included: Evaluate: Bupropion 150 mg Modify: Prednisone 20 mg Evaluate: Rosuvastatin 20 mg Evaluate: Leader Nicotine gum 2 mg An interview was conducted with the Health Information Director (HID/Staff #33) on December 4, 2024 at 1:44 p.m., who stated documents are checked before and after they are uploaded into the medical records system. She stated that if incorrect records are found, the issue would be immediately corrected. She reviewed Resident #64 ' s clinical records and stated that New Admission Medication Reviews dated June 12, 2023 were that of another resident. She also indicated that the records were inaccurately placed in Resident #64 ' s records. An interview was conducted with the Director of Nursing (DON/Staff #141) on December 4, 2024 at 2:00 p.m., who stated that all resident records should be held privately in the online system. She reviewed Resident #64 ' s clinical record and stated that another resident ' s New Admission Medication Reviews were incorrectly placed in Resident #64 ' s clinical record. She also stated that this did not meet her expectations and should be corrected immediately, as this was private resident information. Review of a policy titled, Confidentiality of Information and Personal Privacy, document revealed that the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. Review of a policy titled, Resident Rights, revealed that Federal and State laws guarantee basic rights to all residents that include privacy and confidentiality. The policy further revealed that the unauthorized release and access to resident information is prohibited.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure one resident (#113) is assessed for self-administration of medication. Findings include: Resident #113 was admitted on August 1, 2024 with diagnoses that included chronic obstructive pulmonary disease, anxiety disorder, obstructive sleep apnea, and arthritis. Review of the admission MDS (Minimum Data Set) assessment dated August 5, 2024, revealed the resident has a Brief Interview for Mental Status (BIMS) score of 15.0 indicating cognitively intact. The MDS also indicated that the resident uses a walker and wheelchair. The MDS assessment also revealed that the resident needs setup or clean up assistance with eating, partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, and personal hygiene. During a medication administration observation with licensed practical nurse (LPN/Staff #176) on December 4, 2024 at 08:02 am, the following medications were observed prepared by Staff #176: - aspirin 81 mg (milligram), one tablet - duloxetine 30 mg, one capsule, - Eliquis 5 mg, one tablet - Lidocaine patch 4%, one patch - Protonix 40 mg, one tablet, - potassium 10 meq (milliequivalent), one tablet - oxycodone 10 mg, one tablet Upon entering the resident's room, an orange colored tube of medication labeled Neosporin and two packets labeled Calmoseptine was on top of resident #113's bed side table. Staff #176 identified the medication found on the table as Neosporin and Calmoseptine. Staff #176 stated that the resident is using the medication for itching around her groin area. Upon exiting the resident's room, a staff standing by resident#113 room door identified herself as the director of nursing (DON)/Staff #141, and stated that they are working on the self-administration. Review of the resident's clinical record did not contain any documentation stating that the resident has been assessed and cleared to self-administer medications. Furthermore, review of the resident's care plan did not reveal anything about self-administration of medication. Review of the resident's order summary report revealed that there were no orders for self-administration of medications. Additionally, the order summary did not contain a physician's order for Neosporin and Calmoseptine. Furthermore, the resident's medication administration record for December 2024 revealed no orders for resident to self-administer medication and no orders found for Neosporin and Calmoseptine. However, a Self-Administration of Medication Observation form with an effective date of December 4, 2024 timestamped 8:30 am was added to the resident ' s clinical record. The Self-Administration of Medication Observation form indicated that the medications the resident would like to self-administer were Neosporin and house stock zinc oxide. The storage of medication section documented that the resident was in the process of self-a

Based on observation, documentation, staff interview, review of policy and procedures the facility failed to ensure that corrective actions plans were set in place for legionella. Findings include: A review of the final report from the water sampling company testing collected on June 6, 2024 revealed that 3 residents' rooms and one nursing station tested positive for Legionella. According to the report, room #228 had a Legionella pneumophila serotype 2-15 at a concentration of 6.3 CFU (colony forming units)/ml (Milliliter). Room # 102 was found to have Legionella pneumophila serotype 2-15 at a concentration of 0.6 CFU/ml. Additionally, room #305 detected the presence of Legionella pneumophila serotype 2-15 at a concentration of 7.7 CFU/ml. The 400 Nurse ' s Station was also positive for the presence of Legionella pneumophila serotype 2-15 at a concentration of 25 CFU/ml. Review of the Legionella program and Infection Prevention and Control program did not reveal any documentation pertaining to the detection of Legionella in the facility ' s water system. An interview was conducted on December 04, 2024 at 10:24 AM with the Maintenance Director (Staff # 45). Staff #45 stated that for the process for legionella testing the water safety company would send a testing kit for legionella and from there the maintenance director would send back those water samples to the water safety company for results. The Maintenance Director (Staff #45) stated that the testing results of legionella would determine how often the testing needs to be completed. Staff #45 stated that when water testing results are positive for legionella then more testing will occur to determine if the levels of legionella have decreased. The Maintenance Director (staff #45) stated that he would monitor for legionella by flushing out the water system. A review of an email sent from the water safety company regarding the legionella testing done on June 6, 2024 was conducted with Staff #45 on December 4, 2024 at approximately 10:24 a.m. The email revealed that 4 out of the 5 locations sampled in the facility tested positive for legionella. In an interview with the Maintenance Director (staff #45) conducted on December 4, 2024 at 10:24 a.m., he stated that with positive legionella results the water testing company would come to the facility to test the water 3 additional times to ensure that the levels have decreased. Staff #45 stated that there were no previous records from the previous maintenance director in regards to results for legionella. A telephonic interview was conducted December 04, 2024 at 12:52PM with a water company representative (staff #477 ) stating that 3 out of 4 locations that were tested for legionella was greater than 1.0 CFU/ml. Staff # 477 stated that the water sample testing were completed on June 6, 2024. The results indicated that the facility water was controlled poorly. The water company representative stated that there should have been a corrective action plan s

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that residents are free from abuse from other residents. Findings include: Resident #8 was admitted to the facility on June 11, 2024 with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, mild cognitive impairment of uncertain or unknown etiology. The minimum data set (MDS) dated June 18, 2024 included a brief interview for mental status score of 13 indicating the resident was cognitively intact. A provider progress note dated August 13, 2024 revealed resident #8 and resident #26 who reside on Sunset Secured Behavioral Unit had a verbal altercation in the dayroom. The note stated that staff were present and able to immediately separate the two residents. The note stated Resident #8 currently was on one-on-one staff supervision and ongoing investigation was in progress to collect more details. The note stated DHS (Department of Health Services), APS (Adult Protective Services), Ombudsman, Police, Provider, Case manager and responsible parties were notified. The care plan dated June 24, 2024 revealed that the resident has potential for impaired thought processes r/t diagnosis of dementia. -Resident #26 was admitted to the facility on May 8, 2024 with diagnoses that included major depressive disorder, recurrent, unspecified, post-traumatic stress disorder, unspecified, dementia in other diseases classified elsewhere, unspecified severity, with agitation, generalized anxiety disorder The care plan dated May 8, 2024 revealed that the resident is/has the is/has potential to demonstrate verbally abusive behaviors related to major depressive disorder, pos traumatic stress disorder, dementia with agitation, anxiety disorder as exhibited by thinking people are outside his window and trying to kill him, paranoid delusions, visual hallucinations. Review of the behavioral health care plan dated June 10, 2024 revealed a risk assessment for identified behavioral triggers. The identified triggers were being around people, noise, and when unable to express himself properly and/or loses his thought when speaking. The quarterly minimum data set (MDS) dated August 12, 2024 included a brief interview for mental status score of 10 indicating the resident had moderate cognitive impairment. Further review of the MDS revealed resident presented with delusional behaviors. A progress note dated August 13, 2024 revealed a Change in Condition/s (CIC) reported on this CIC Evaluation are/were: "Behavioral symptoms (e.g. agitation, psychosis) and a verbal altercation between resident # 8 and #26. Staff present and able to immediately separate the two residents. Frankie Wyatt currently on one-on-one staff supervision. ON going investigation in progress to collect more details. DHS, APS, Ombudsman, Police, Provider, Case manager, responsible parties notified." Review

Based on clinical record review, staff interviews and facility documentation and policy review, the facility failed to ensure that 3 residents (#20,#15, #127) are free from abuse. The deficient practice could result in residents not protected from further abuse. Findings include: Regarding resident #20 and resident #152 -Resident #20 was admitted on March 20, 2019 with diagnoses of Huntington's disease, schizoaffective disorder, anxiety disorder, major depressive disorder, and alcohol dependence. A review of the clinical record revealed a BIMS (Brief Interview for Mental Status) score of "0" indicating the resident had severe cognitive impairment. It also included that the resident had a history of yelling, throwing things, pacing, wandering, refusing cares, cursing and hitting staff. -Resident #152 was admitted on March 9, 2021, with diagnoses that included Huntington's disease, bipolar disorder, PTSD (post-traumatic stress disorder), significant history of abuse and methamphetamine use. Review of the clinical record revealed the resident had a BIMS score of zero indicating the resident had severe cognitive impairment. The facility self-report submitted to the SA (State Agency) on December 6, 2022 revealed that resident #152 got up from her seat during dinner time and walked over to resident #20 and started punching resident #20 in the face with closed fists four to five times. Per the documentation, resident #152 then walked back to her chair in the day room and sat down. The facility report included a signed witness statement dated December 6, 2022 by the certified nurse assistant (CNA/staff #207) who wrote that during dinner time in the dayroom at 5:40 p.m., resident #152 got out of her seat, walked over to resident #20 who was sitting and watching television. According to the written statement, resident #152 started punching resident #20 in her face four to five times with a closed fist. Further review of the report included a signed witness statement dated December 6, 2022 by a registered nurse (RN/staff #212) who wrote that the RN left dayroom when dinner was winding down and went to chart at the nurses' station; and that, the CNA (staff #207) reported the attack to the RN; and that, both residents were separated immediately. The statement also included that resident #152 was removed from the dayroom and the RN administered an ice pack the PRN (as needed) pain medication to resident #20. Regarding resident #153 and resident #15 -Resident #153 was admitted to the facility on September 9, 2022 with diagnoses that included neurocognitive disorder due to alcohol related dementia, post-traumatic stress disorder, anxiety, depression, violent behavior, and alcohol abuse. The care plan dated September 6, 2022 revealed that the resident had impaired thought processes related to alcohol induced dementia and had a history of wandering and physical aggression. Review of the clinical record revealed the resident had a BIMS score of 13/15 indicating the

Based on clinical record review, staff interviews and facility documentation and policy review, the facility failed to identify residents who are at risk of unsafe wandering. The deficient practice could result in physical injury. Findings include: Resident #154 was admitted on March 15, 2023 with diagnoses of aphasia, stroke, muscle weakness, abnormalities of gait and mobility, altered mental status and repeated falls. A review of the hospital history and physical note dated March 11, 2023 revealed that resident was alert and oriented to person and place only. The baseline care plan dated March 16, 2023 revealed that the resident was confused. The wandering risk assessment dated March 16, 2023 revealed the resident was found to be disoriented and can be disturbed by environmental noise levels. The wandering risk assessment dated March 21, 2023 included the resident was found to be forgetful/short attention span and known wanderer or had a history of wandering. A progress note dated March 21, 2023 revealed the resident was outside with the police due to wandering through a residential neighborhood south of the facility. Per the documentation, the resident was previously seen in his room at 5:55pm by a certified nurse assistant (CNA/staff # 208). The documentation also included that the resident was agitated, had a small skin tear to the posterior left hand, was resistive to returning to the facility; and, was placed on a one-on-one monitoring. A review of the facility self-report submitted to the SA (state Agency) on March 21, 2023, revealed that at approximately 6:40 p.m. on March 21, 2023, resident #154 was seen by a neighbor walking down the street just south of the facility; and, was returned to the facility by the police. Per the documentation, the resident exited the facility through his room window which had been opened and the screen was pushed out. An interview with the assistant Director of Nursing (ADON/staff #7) was conducted on June 12, 2024. The ADON stated that stations one and two were not locked or secured; and that, the level of independence of each resident in the unit was determined by risks and cognition levels of each resident. A review of the facility's policy on Wandering and Elopement dated March 2019 included that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; and, if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on clinical record review, staff interviews and facility documentation and policy review, the facility failed to ensure that 3 residents (#20,#15, #127) are free from abuse. Findings include: Regarding resident #20 and resident #152 -Resident #20 was admitted on March 20, 2019 with diagnoses of Huntington's disease, schizoaffective disorder, anxiety disorder, major depressive disorder, and alcohol dependence. A review of the clinical record revealed a BIMS (Brief Interview for Mental Status) score of "0" indicating the resident had severe cognitive impairment. It also included that the resident had a history of yelling, throwing things, pacing, wandering, refusing cares, cursing and hitting staff. -Resident #152 was admitted on March 9, 2021, with diagnoses that included Huntington's disease, bipolar disorder, PTSD (post-traumatic stress disorder), significant history of abuse and methamphetamine use. Review of the clinical record revealed the resident had a BIMS score of zero indicating the resident had severe cognitive impairment. The facility self-report submitted to the SA (State Agency) on December 6, 2022 revealed that resident #152 got up from her seat during dinner time and walked over to resident #20 and started punching resident #20 in the face with closed fists four to five times. Per the documentation, resident #152 then walked back to her chair in the day room and sat down. The facility report included a signed witness statement dated December 6, 2022 by the certified nurse assistant (CNA/staff #207) who wrote that during dinner time in the dayroom at 5:40 p.m., resident #152 got out of her seat, walked over to resident #20 who was sitting and watching television. According to the written statement, resident #152 started punching resident #20 in her face four to five times with a closed fist. Further review of the report included a signed witness statement dated December 6, 2022 by a registered nurse (RN/staff #212) who wrote that the RN left dayroom when dinner was winding down and went to chart at the nurses' station; and that, the CNA (staff #207) reported the attack to the RN; and that, both residents were separated immediately. The statement also included that resident #152 was removed from the dayroom and the RN administered an ice pack the PRN (as needed) pain medication to resident #20. Regarding resident #153 and resident #15 -Resident #153 was admitted to the facility on September 9, 2022 with diagnoses that included neurocognitive disorder due to alcohol related dementia, post-traumatic stress disorder, anxiety, depression, violent behavior, and alcohol abuse. The care plan dated September 6, 2022 revealed that the resident had impaired thought processes related to alcohol induced dementia and had a history of wandering and physical aggression. Review of the clinical record revealed the resident had a BIMS score of 13/15 indicating the resident was cognitively intact. -Resident #15 was admitted to the facility on Nov

Based on clinical record review, staff interviews and facility documentation and policy review, the facility failed to ensure one resident (#154) was free from a condition or situation that may cause or suffer injury by failing to ensure the resident (#154) did not elope from the facility. Findings include: Resident #154 was admitted on March 15, 2023 with diagnoses of aphasia, stroke, muscle weakness, abnormalities of gait and mobility, altered mental status and repeated falls. A review of the hospital history and physical note dated March 11, 2023 revealed that resident was alert and oriented to person and place only. The baseline care plan dated March 16, 2023 revealed that the resident was confused. The wandering risk assessment dated March 16, 2023 revealed the resident was found to be disoriented and can be disturbed by environmental noise levels. The wandering risk assessment dated March 21, 2023 included the resident was found to be forgetful/short attention span and known wanderer or had a history of wandering. A progress note dated March 21, 2023 revealed the resident was outside with the police due to wandering through a residential neighborhood south of the facility. Per the documentation, the resident was previously seen in his room at 5:55 p.m. by a certified nurse assistant (CNA/staff # 208). The documentation also included that the resident was agitated, had a small skin tear to the posterior left hand, was resistive to returning to the facility; and, was placed on a one-on-one monitoring. A review of the facility self-report submitted to the SA (state Agency) on March 21, 2023, revealed that at approximately 6:40 p.m. on March 21, 2023, resident #154 was seen by a neighbor walking down the street just south of the facility; and, was returned to the facility by the police. Per the documentation, the resident exited the facility through his room window which had been opened and the screen was pushed out. An interview with the assistant Director of Nursing (ADON/staff #7) was conducted on June 12, 2024. The ADON stated that stations one and two were not locked or secured; and that, the level of independence of each resident in the unit was determined by risks and cognition levels of each resident. A review of the facility's policy on Wandering and Elopement dated March 2019 included that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; and, if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.