Health inspection·November 7, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the care and supervision to prevent accidents for 1 of 7 (Resident #1) residents reviewed for accidents and hazards. The facility failed to ensure that Resident #1, who had a history of wandering and was high risk for elopement on admission, was prevented from exiting the facility without staff supervision on 10/22/2025 and found wandering outside the facility alone approximately 20 minutes later by staff. The facility was not aware that she was not in the building when she was found. The noncompliance was identified as Past Noncompliance (PNC). The IJ template was provided to the facility on [DATE] at 5:05PM. The IJ began on 10/22/2025 and ended 10/23/2025. The facility corrected the noncompliance before the survey began on 11/06/2025. This failure placed residents at risk for elopement with the potential for serious injury or death. Findings Include: Record review of Resident #1's Face sheet dated 11/06/2025 reflected a [AGE] year old female admitted to the facility on [DATE] for respite care. Resident #1's diagnoses included: Alzheimer's disease (dementia that damages the brain), hypertension (high blood pressure), age-related cataract (cloudy appearance to the lens of the eye causing difficulty seeing), auditory hallucinations (hearing things that are not there), and generalized anxiety disorder (intense and excessive worry and fear). Record review of Resident #1 admission Elopement assessment dated [DATE] revealed Resident #1 was noted to have a score of 10, indicating she was high risk for elopement. Record Review of Resident #1's Orders on 11/06/2025 reflected a physician's order (start date not listed) with a revision date of 10/23/2025 that reflected, Admit to secure unit d/t (due to) hx (history) of elopement with active exit seeking behavior r/t (related to) Alzheimer's (dementia that damages the brain). Record review of Resident #1's admission MDS (Minimum Data Set) dated 10/28/2025 reflected a BIMS score of 3 (severe cognitive impairment). Review of Resident #1 care plan dated 11/06/2025 revealed Resident #1 was noted to have a Focus area that reflected, The resident is at risk for wandering Date Initiated: 10/17/2025 with a goal, The resident will not leave facility unattended through the review date. Date Initiated: 10/17/2025. Interventions/Tasks related to this Focus Area included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 10/17/2025 CNA, Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 10/17/2025, and If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Date Initiated: 10/17/2025. Resident #1's care plan had a Focus Area that reflected, The resident is at risk for falls r/t (related to) Date Initiated: 10/17/2025. The related Intervention/Tasks included an intervention dated 10/17/2025 stating, The resident needs a safe environment. Record review of Resident #1's Care plan dated 11/06/2025 reflected a Focus Area that reflected, Resident resides in the Secure Care Unit, related to diagnosis of Page 1 of 8 675821 675821 11/07/2025 Madisonville Care Center 411 E Collard Madisonville, TX 77864

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Alzheimer's with exit seeking and risk for elopement. Disoriented to place Date Initiated: 10/23/2025 Revision on: 10/23/2025. Record review of Resident #1's Physician Assessment Notes dated 6/25/2025 and signed by MD C reflected, Alzheimer's disease, agitation - between 4-6pm gets agitated more easily, seeing cats and dogs, someone is always stealing something, used her walker to lock [family member] out of the room, tries to hit people- on sertraline- eating okay, no Issues with chewing or swallowing- Uses walker but gets up In the night and rummages through things without the walker and takes and hides things- Had an episode of wandering a few weeks ago- apathetic, only wants to watch tv, won't participate in anything else See above, we are going to work back her seroquel since taking at 4 PM now and then wakes up later thinking is daytime againSundowners (a state of confusion or agitation that occurs in the late afternoon or evening, especially in people with dementia), better, not yelling out at TV or agitated at talkshow or blocking [family member] w (with) walker. The agitation has gone down. Record Review of Resident #1's Physician Assessment signed by MD D dated 10/16/2025 at 12:30PM, reflected, [AGE] years old female with a complex medical history who presented for evaluation of memory problems and behavioral disturbances associated with late-onset Alzheimer's disease. She experiences visual and auditory hallucinations, frequent falls, and episodes of agitation, particularly in the late afternoon. Her caregiver, [family member], reports wandering behavior, apathy, and nighttime coughing. Record review of Resident #1's Event Note dated 10/22/2025 at 5:00 PM reflected Resident #1 exited the front door and was missing for 20 minutes. The note reflected, notified by staff that resident was found outside on the sidewalk to the left of the building. Resident followed a visitor outside and then was questioned by therapy staff. Therapy didnt realize resident needed to be back inside the building. Staff redirected pt inside and pt was placed on 1:1 (one on one staff observation) until moved into secure unit. For the resident statement portion of the note, it reflected resident stated that she was pregnant and that she had to go outside to help with the kids. The RP and MD D were notified at that time. Record review of Accuweather website's weather history on 11/10/2025 for the area the facility was located on 10/22/2025 showed a high temperature of 83 degrees Fahrenheit and a low temperature of 53 degrees Fahrenheit for the day. Record review of Google maps on 11/10/2025 reflected the walking distance from the facility to the business at a nearby intersection as approximately 476 ft. or a 2 minute walk. In an interview with HA E on 11/06/2025 at 9:50AM, she stated that she was assigned to assist with the secure unit. She stated that Resident #1 was primarily Spanish speaking. She stated that the resident was not known to wander the unit. She stated that she would follow prompts from staff and was easily redirectable. In a Spanish Interpreter (Interpreter #2363) assisted interview with Resident #1 on 11/06/2025 at 10:00AM, she stated that she did recall going outside alone a few weeks prior. She stated that she went outside because one of her children was crying. She talked intermittently about the doll in her lap and described it as her child. She stated that she felt safe in the facility. In an interview with the ADMIN on 11/06/2025 at 10:40AM, he stated that the video footage for the facility was maintained on a two week loop and was no longer available for review. He stated that in his review of the video footage on 10/22/2025 at 4:00PM, the camera could see a visitor was going in and Resident #1 went out. The investigation revealed that staff followed her out to try to see if she was okay. He stated that Resident #1 was Spanish speaking. He stated that another staff member saw her outside unsupervised and walked her back in. He stated that he did a one-on-one training with the PTA after the incident. He stated it was the staff person's first position in a long term care facility. He stated that he should have stayed with her or called someone. He stated that they were able to estimate she was out of the facility for 19 minutes. He stated that Resident #1 was assessed and found to have no injuries. He stated 675821 Page 2 of 8 675821 11/07/2025 Madisonville Care Center 411 E Collard Madisonville, TX 77864

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few that she was seen leaving and found with her walker, and was just standing on the sidewalk when the staff found her. He stated that the cameras could only see her walking out the door on the front. The stated she was brought in a side door. He stated that Resident #1 was seen by the laundry on the side of the building. He stated that after the staff brought her back into the facility, she came to the ADMIN's office right away and told the ADMIN. He stated there was no indication that Resident #1 was attempting to leave prior to the episode. He stated that Resident #1 was able to safely ambulate alone. He stated that when he interviewed the resident she said she was trying to take her babies to school. He stated that Resident #1 had two baby dolls that she brought from home. He stated that she had been at the facility less than a month before the incident. In an interview with the RNC on 11/06/2025 at 10:50AM, she stated that she was in the facility when the Resident #1 eloped and did not realize it initially. She stated that she realized when she reviewed the camera footage after the resident was found. She stated that in the facility investigation the PTA, who was new to the facility, spoke some Spanish and attempted to speak with Resident #1. She stated she seemed relatively normal and he left her. Then, she stated a nurse aide in training saw her and brought her back in the facility. Interview with Student CNA A on 11/06/2025 at 11:10AM, she stated that in the afternoon of 10/22/2025, she found Resident #1 outside at the left side of the building. She stated she was walking toward the laundry room and Resident #1 was walking from the back of the facility, by the end of the paved walkway, towards her. She stated the resident was well dressed, no tears or debris on her clothing, and had no visible injuries or signs of distress. She stated that she did not recall a lot of traffic outside at that time, but stated she thought the road in front of the facility was busy. She stated that there could be traffic on the road around 5:00PM. She stated she could not recall exactly what time it was when she found Resident #1 outside. She stated that she could not understand what Resident #1 was saying as she walked in because she was speaking Spanish. She stated that she walked her back to her room and went immediately to the DON and the ADMIN to report that she had found Resident #1 wandering alone outside. She stated she last saw the resident with her family member less than an hour prior to finding the resident outside. She stated that she did every two hour monitoring. She stated she was not aware Resident #1 had a risk for wandering and elopement in her history or on her care plan. She stated that she had never seen Resident #1 wandering in the facility. Observation of the outside of the facility at 11:08AM on 11/06/2025 revealed a concrete walkway around the left side of the building that connected to a paved driveway that terminated directly to the street. There was a drainage ditch at the end of the driveway before the driveway to the adjacent business. It was approximately 500ft to the intersection with a state highway road. There was no sidewalk on the right side of the building. The left side of the facility had a business directly adjacent to the building. There was a fence behind the facility blocking access to a mostly dry creek bed that met a culvert on the corner of the right side of the building. There was less than three inches of water in the drainage ditch on the right side of the building. In an interview with Resident #1's RP on 11/06/2025 at 12:40AM, she stated that she was happy with the care for Resident #1. She stated that she was notified of the elopement after it happened. She stated the was out of the country on 10/22/2025. She stated that her husband had been in the facility that day to visit Resident #1. She said he told her that Resident #1 was in a good mood. She stated that prior to coming to the facility for respite, Resident #1 had a few episodes of wandering inside the house at night in the kitchen. She stated that her doctor started her on a medication to help her sleep at night and she had no other episodes. She stated she had a history of auditory and visual hallucinations at home. She stated Resident #1 was a very timid and polite. She stated that Resident #1 had been known to follow 675821 Page 3 of 8 675821 11/07/2025 Madisonville Care Center 411 E Collard Madisonville, TX 77864

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few people aimlessly and she could see how if she might have followed someone or politely exited the door if it was held open for her. She stated that she planned to bring Resident #1 home from respite on 11/15/2025. In an interview with RNC on 11/06/2025 at 1:05PM, she stated that a high-risk score for the elopement risk assessment was 10 or above. In an interview with the PTA on 11/06/2025 at 1:30PM, he stated that he had started at the facility a few months ago. He stated that on 10/22/2025 he walked out the entrance door and saw Visitor B, who was outside the facility and looked like he was trying to get in the front door. He stated that it was normal to use the code for visitors to get in the front door. He stated that as Visitor B went into the facility, Resident #1 walked out the door. He stated that he did not know Resident #1 and had not seen her in the facility. He stated that she was well dressed and walking steady with a walker. He stated that he asked her how she was doing in Spanish, because she appeared to possibly be Hispanic, and she said she was good. He stated that she seemed with it and he did not think much of it at the time. He stated that he should have checked with others to try to identify Resident #1. He stated that he and other staff had been watching the front door for any other residents who might attempt to leave. He stated that he did not recall a specific training on elopement at the facility, but stated that he knew to watch for anyone leaving the door who might be a resident. He stated that he did not let her out the door himself. He stated that on the video footage of the entrance door, it looked like Resident #1 came to the door right at the moment he pushed the code. He stated that she just went through the door right at the same time that Visitor B was coming into the facility. He stated that the risk to the residents of allowing them to leave the facility unsupervised is that they could get lost, hurt, or worse. In an interview with RN on 11/06/2025 at 1:48PM, she stated that she was assigned to Resident #1 as her nurse on 10/22/2025. She stated that Resident #1 liked to stay in her room, including eating her meals in her room, at that time. She stated that she had not seen her engage in any wandering behavior prior to her elopement that day. She stated that staff were to check on the resident every two hours for her monitoring requirements at the time, but stated that they were not watching her for wandering at the time because she did not seem like a risk. She stated that Resident #1 seemed content in the facility and was adjusting well from her observations. She stated that she primarily saw Resident #1 in the halls with family members, but could not say that she had not seen Resident #1 ambulate outside of her room alone. She stated that her family came to visit her often at the facility. She stated she last saw Resident #1 in the dining room with her family member. She stated it was after lunch, but she could not recall the time. She stated that she did not see Resident #1's family member leave the building. She stated that an elopement score of 10 or higher would indicate a resident was high risk. She stated that the elopement risk score should be done on admission and with any changes. She stated Resident #1 had no episodes of crying, restlessness, or behaviors. She stated that staff could look at the last elopement risk score or the care plan to know if a resident was at risk for wandering and elopement. She stated she did not check the care plan to know that Resident #1 was a risk for wandering and elopement. She stated that she should have checked the care plan for Resident #1. She stated that she did not know that Resident #1 was screened as a high-risk for elopement on her admission screening. She stated that if a resident was allowed to leave the facility unsupervised they could be hit by a car, kidnapped, or anything could happen. In an interview with Student CNA A on 11/06/2025 at 2:09PM, she stated that she was assigned to care for Resident #1 on 10/22/2025. She stated that she her with her family member and he was walking her around the building. She stated that she did not see him walk her by the entrance. She stated that she thought when she last saw the resident, she was with him by the dining area. She stated that she thought he was showing her around the 675821 Page 4 of 8 675821 11/07/2025 Madisonville Care Center 411 E Collard Madisonville, TX 77864

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few facility. She stated that he never took her outside. She stated it was probably less than an hour before she eloped was the last time she saw her. She had just admitted but Student CNA A did not know about any special monitoring prior to her elopement. She stated that her responsibilities for Resident #1's care included rounding on her every two hours and helping change her briefs when she was soiled. She stated that rounding on a resident meant to check them and their environment. She stated that she asked if residents were okay, tried to address any needs they might have. She stated she was expected to make sure there was not trash or fall hazards in the area, ensure that residents had water or other drinks available, and that they had their call light with them. She stated she did not think the facility had a sign-in sheet for visitors. In an interview with the DON on 11/06/2025 at 1:12PM, she stated that when a resident was admitted to the facility, a nurse did an initial assessment for elopement. She stated that Resident #1 was not a risk for elopement when she was first admitted to the facility. She stated that Resident #1 would not come out of her room after her admission. She stated that Resident #1's family member came to visit while her another family member was on vacation, and he was seen walking her around the building. She stated that on 10/22/2025 the family member walked her further than she had seen her walk in the building up to that point. She stated that a high risk for elopement score was over 10. She stated the risk assessment scoring was based on the ability of a resident to ambulate, and stated they would monitor them to see if they were walking near doors. She stated that if she had seen any exit seeking behavior the staff should increase monitoring and watch the resident's routine. She stated that Resident #1 was eating her meals in her room prior to 10/22/2025. She stated that it was her expectation that nursing staff watched Resident #1 for elopement during all her activities in the facility and keep communication between staff about her location. She stated that all residents were monitored on an every two hour schedule by the nursing staff, including Resident #1. She stated that if a resident had not attempted to elope or shown exit seeking behaviors, they stayed on an every two hour monitoring schedule. She stated that a resident had to have a high enough elopement risk score and show exit seeking behaviors for the facility to then do the secure care consult to assess a resident for the need for the secure unit. She stated that the facility did a teams meeting to do the secure unit assessment. It would be a combination of factors that would prompt the secure assessment. She stated that it was case by case as to what elopement score would necessitate further intervention for the elopement score. Interview with RNC on 11/06/2025 at 2:23PM, she stated that for a resident with a high risk score of 10 for elopement she would expect staff to monitor for exit seeking behavior and assess their capability to get out of the facility. She stated they would need more than a high risk score to know if they were a candidate for secure unit. They could keep them with every two hour monitoring without a reason to increase the monitoring schedule. She stated that when a resident screened for high risk for elopement, a care plan intervention was added automatically. She stated that staff should check the care plan to know if a resident was a risk for wandering or elopement. She stated that home wandering did not necessarily equate to a risk for elopement in the facility. She stated that when she viewed the video footage of Resident #1 exiting the front entrance on 10/22/2025, she looked like a visitor in the clothes she was wearing. She stated that after the incident the facility took the codes to the door away from everyone except staff. They changed door signage to make it more noticeable for visitors who might be complacent. It was changed from a sign with text only to a sign with a large red stop sign in the middle and the wording and formatting were adjusted. She stated that she did not recall seeing when Resident #1's family left the building on camera prior to the incident. She stated that the risk of allowing a resident to leave the facility was that they could get hurt. She stated that the 675821 Page 5 of 8 675821 11/07/2025 Madisonville Care Center 411 E Collard Madisonville, TX 77864

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few road in front of the building could be busy around 5PM. She stated that Resident #1 was gone over ten minutes to the best of her recollection. She stated the staff were not found to be neglectful in the investigation of the events. She stated there was not a sign in sheet that visitors were required to sign. She stated that she did not recall seeing when Resident #1's last visitor exited the front door. In a phone interview with Visitor B on 11/06/2025 at 2:51PM, he stated that he was visiting a resident at the facility on 10/22/2025. He stated that he had never seen Resident #1 in the facility prior to that day. He stated that he walked up to the door and put the code in. He stated that Resident #1 was at the door and looked like she was on her way out, so he opened the door. He stated that he thought they were just passing each other at the door. He stated that Resident #1 was well dressed. He stated that she smiled at him and asked how he was. He stated that she appeared to be steady on her feet with her walker. He denied observing any signs of distress or agitation in her demeanor. Observation on 11/07/2025 at 9:28AM revealed that in a seventeen minute time frame the road in front of the facility had regular car traffic with several semi-trucks traveling the street. In an interview with the DON on 11/07/2025 at 11:00 AM, she stated she was not aware of the actual findings from the facility's investigation related to the elopement incident. She stated that, from the clinical perspective, all required assessments were completed and the resident was relocated to a secure unit following the incident. The DON stated her expectations of staff regarding elopement prevention and response were for staff to continuously monitor residents for changes in behavior, remain alert to any variations that may indicate risk of elopement, and intervene timely. She stated staff were expected to notify her, the Director of Nursing, the physician, or the nurse practitioner so that medical related issues related to exit seeking behavior or elopement could be ruled out. The DON stated that the process typically began with obtaining labs for the resident. She stated there were pictures of residents on all face sheets to help assist staff to know a resident from a visitor. The DON stated her expectation was that staff would ask appropriate questions to establish whether an individual resided in the facility or not. The DON stated that if a resident was allowed to leave the facility unsupervised it could result in physical injury, becoming lost, or, in the worst-case scenario, death. In an interview with the ADMIN on 11/07/2025 at 11:37AM, he stated that through his investigation he determined the resident had followed a visitor to the front door and a visitor allowed the resident to exit the facility. The Administrator stated he obtained a signed statement from the visitor, who apologized and explained that he was simply being polite in letting the resident out. He stated that he became aware of the incident when staff coming from the side door observed the resident on the sidewalk and immediately escorted her back into the facility. He stated his expectations of staff regarding elopement prevention and response, were that if staff did not recognize an individual, they are expected to verify with the charge nurse, the Director of Nursing, or himself before allowing anyone to exit the building. He stated that the risk to the resident when allowing them to leave the building unsupervised was they could sustain a possible injury, such as a fall, or other adverse outcomes. Record Review of the facility Elopement Policy (no date) reflected: Policy Statement Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission. The assessment should be completed by reviewing the resident's medical history and social history. Information may be obtained by reviewing current medical records, if available, interview with resident/family, or conference with the interdisciplinary team member. The assessment tool should be completed, and interventions implemented as indicated. The Elopement Risk Assessment is to be completed at least quarterly and upon change of condition.2. All residents who are at 675821 Page 6 of 8 675821 11/07/2025 Madisonville Care Center 411 E Collard Madisonville, TX 77864

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team.3. The resident's current chart and assessments will be reviewed to determine what changes have occurred that would trigger elopement episodes.4. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes.5. Interventions into elopement episodes will be entered onto the resident's care plan and medical record.6. Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the nurses' notes. Director of Risk Management and\or Director of Nursing Services should be notified of elopement.7. If a resident is discovered to be missing, a search shall begin immediately. (See policy entitled Elopement Response.)Intervention Strategies1. Reduce physical discomfort (e.g., analgesia to reduce pain, more comfortable seating, and scheduled toileting).2. Use personal items, family photos, or familiar objects to label resident's room clearly.3. Maintain familiar routines as much as possible.4. Schedule regular ambulation program or opportunity for exercise.5. Reduce excess sensory stimulation (sensory overload), decrease noise level and confusion.6. Use simple, clear language. Tell the resident what you want him/her to do, not what you don't want them to do. (e.g., come with me instead of don't go outside).7. Approach the resident in non-threatening manner.8. Do not confront or argue with the resident. Acknowledge the resident's concerns and gentlyredirect the resident.9. Follow the resident to see where he/she goes. If the destination is safe, consider use of volunteer companion or family member as a suitable escort.10. Give resident something to do that makes him/her feel useful (e.g., winding yam or foldingtowels).11. Allow verbalization of feelings .12. Obtain information from family on pattern of physical activity, daily home routine, style ofcoping with stress, etc.Staff Training Staff will receive training during their orientation process and then annually regarding: Elopement prevention Operation of all exit devices Actions to take if elopement occurs Record Review of facility policy for Elopement Response (no date): Policy Statement Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented. Policy Interpretation and Implementation1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical.2. Determination of missing resident either by routine nursing rounds or door alarms:A. Note: A resident is determined missing when he/she leaves the facility without the staff's knowledge.B. A resident having a wander guard warning system that sets off an alarm by stepping outside a door and is found immediately does not constitute an elopement.C. A resident must demonstrate a free and willful intent to leave the facility without prior notification of staff or is a wandering, confused resident who leaves the facility unattended.3. Should an employee observe a resident leaving the premises, he/she should:A. Attempt to prevent the departure:B. Obtain assistance from other staff members in the immediate vicinity, if necessary:C. Instruct another staff member to inform the charge nurse or Director of Nursing that a resident has left the premises; andD. Be courteous in preventing the departure and in returning the resident to the facility.4. Should an employee discover the resident is missing from the facility, he/she should:A. Report to the charge nurseB. Determine if the resident is out on an authorized leave or pass. If not;C. Make a thorough search of the building(s) and premises. If not located;D. Notify the Administrator and the Director of Nursing;E. Notify the resident's responsible party.F. Notify the attending physician;G. Notify VP of Risk Management, ADO, COO, and VP of Clinical Services.H. If necessary, notify volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.);I. Provide search teams with resident identification information: andJ. Make an extensive search of the surrounding area.7. Post return resident evaluation and care:A. Upon any resident elopement resulting in 675821 Page 7 of 8 675821 11/07/2025 Madisonville Care Center 411 E Collard Madisonville, TX 77864

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few injury or death, the facility will immediately notify Risk Management, ADO, COO, and VP of Clinical Services.B. Any inquiries (e.g., press) should be referred to the Administrator. The Administrator will notify the VP of Risk Management.C. The facility will evaluate its elopement prevention program and all residents will be reassessed for elopement risk. 8. Documentation:An event note is to be made out on all residents who, without knowledge of the staff, leave the facility.Including the following: Date Time resident was first determined missing Responsible party notified and time Attending physician notified and time Emergency Personnel [NAME] ion of resident when located Where located and time locatedIf resident is located within the facility or immediately outside the nearest entryway, chart the following in the Nurses' notes: Date and time resident was first determined missing Location within or immediately outside the facility where found Condition of resident when found If injury or fall resulted, complete event note as above.Upon return of the resident to the facility, the Director of Nursing or charge nurse should: Examine the resident for injuries Contact the attending physician and report findings and condition of the resident. Follow orders Notify the resident's legal representative (sponsor) Notify search teams that the resident has been located Complete and file an incident report and Make appropriate entries into the resident's medical record . After an elopement the care plan coordinator will reevaluate the resident's care plan . The following actions were taken by the facility prior to surveyor entering on 11/06/2025 to abate the IJ: In an interview with ADMIN on 11/06/2025 at 2:40PM, he stated that after the elopement of Resident #1 all the residents in the facility had their elopement risk assessments redone and those with moderate to high risk for elopement had interventions in place to prevent elopement. Record review of the Elopement Risk Assessment History dated 10/24/2025 at 4:34PM reflected a list of 56 residents with a date of 10/22/2025 and a status listed as, Complete. Record review of Resident #1's 1:1 Monitoring Chart document dated 10/22[TRUNCA 675821 Page 8 of 8