Imperial, A Villa Center

jeopardy to resident health or safety

and safety has been maintained. On 10/23/2025 Resident wander assessment completed with a score of

• On 10/23/2025 Resident Care plan was reviewed by IDT and updated.Resident will continue to be

monitored by psych for behaviors and medication management.IDENTIFYING OTHER RESIDENTS AT RISKResidents who are assessed as an elopement risk have the potential to be affected.On 10/23/2025 residents residing in the facility were reassessed for risk of elopement to identify those at risk.On 10/23/2025 a 100% audit was completed by the facility's clinical management team on all residents who trigger for elopement risk.Residents deemed at risk for elopement had a care-plan review to ensure appropriate interventions are in place.Residents deemed at risk for elopement are in all facility elopement binders.

Binders are located on the nurse's unit and at the reception area.PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCE On 10/23/2025 in-servicing for staff was initiated by DON/Designee on the elopement guideline.On 10/23/2025 to the facility took measures to ensure signage is visible throughout the building for staff and visitors to be aware of residents who may be around when walking though doors. On 10/23/2025 in-servicing for licensed nurses initiated by the DON/ Designee on ensuring a resident re assessed for wandering when showing behaviors to ensure accuracy of care plan and interventions. MONITORINGThe DON/ Designee will review 5 residents who are at risk for elopement to ensure wander/elopement assessments are current and interventions are accurate weekly x 4 weeks, then monthly x 3 months to ensure adherence to the facility's guidelines and practices.Results will be reported to the QA committee for monitoring and follow-up.The DON is responsible for substantial compliance of this Plan of Action.The facility alleges the immediacy of these discrepancies have been removed on 10/23/2025

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