Greentree Manor Nursing And Rehabilitation Center

South pod exit door, although the staff had heard the emergency door alarm going off.

The DON identified a statement provided by the Food Service Director identified on 11/26/25 at 1:15 PM, he observed a nurse aide (NA #1) bring Resident #1 through the front door, heard the front door alarm go off because of Resident #1's wanderguard and turned off the front door alarm and then the Food Service Director checked all the doors.

The DON stated the Food Service Director saw the South pod exit door had a green light, which indicated Resident #1 had exited out that door, and the Food Service Director then pushed on the door, opened it, and reset the door because the alarm was going off.

The DON identified staff did not exit out the South pod door immediately following the alarm being set off, which staff were expected to do, and indicated staff did not know the code to reset the exit door alarm.

Interview with RN #1 on 12/22/25 at 1:17 PM identified she was notified on 11/26/25 that an off-duty nurse aide (NA #1) brought Resident #1 into the building through the front doors after Resident #1 was found unattended in his/her wheelchair outside the building. RN #1 indicated the temperature was in the mid-sixties and Resident #1 was wearing long pants, a sweater, and sneakers. RN #1 indicated following the incident Resident #1 was assessed, no injuries were noted, Resident #1's doctor and responsible party were notified, and education was initiated the same day for all staff. RN #1 identified facility policy indicated staff were responsible for checking the alarm, checking the area, and making sure no one was outside the area.

Although requested, facility policies for Missing Resident/Elopement and for Wanderguard/Secured Exit were not provided.

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