Billdora Senior Care

AM Resident returned safely to the facility by Maintenance Technician.11:58 AM Physician assessed

jeopardy to resident health or injury.11:59 AM Pain Assessment performed by Registered Nurse (RN) #1 with no pain safety verbalized.12:00 Noon Resident#1 placed on 1:1 monitoring upon return.12:01 PM Resident #1 reassessed for wander and elopement risk by RN #1 scoring moderate risk for elopement12:05 PM

monitoring12:15 PM Maintenance Supervisor assured all doors where functioning properly12:15 PM Director of Nurses and MDS Coordinator and Quality Assurance Nurse performed audit on 43 residents to identify risk for wandering and elopement.

Four other residents continue to be at risk for wandering and elopement1:00 PM Administrator called the Mississippi State Department of Health Hotline to report the event and reported on Attorney General Medicaid Fraud Site.1:15 PM Wonder and Elopement Binder was reviewed by Director of Nursing and Quality Assurance RN for updated risk assessment and current photo for five residents1:15 PM Updated Colored Signage signaling to check with nursing before allowing anyone out the door was completed by Staff Development Nurse.1:15 PM Dietary Aide suspended pending investigation and then terminated by AdministratorQuality Assurance Committee:Quality Assurance Performance Improvement (QAPI) conducted an emergency meeting on 1/20/2026 at 1:00 PMA Quality Assurance Performance Improvement (QAPI) Committee was held on 1/20/2026 at 1:00 PM with the following staff in attendance: Administrator, Business Office Manager, Infection Preventionist, Social Services Director, MDS Coordinator, Maintenance/Housekeeping Director, Medical Director, Certified Occupational Therapist, Director of Nursing, Activity Director, Dietary Manager, and Staff DevelopmentRoot Cause Analysis: The Dietary Aide tapped in the code to the door and allowed the resident to walk out the door without following resident-identification protocols.EducationStaff Development Nurse and Director of Nursing started on 1/20/2026 and ending on 1/21/2026. educating all staff on Elopement and Wandering Residents Policy, Code [NAME] Policy, Identifying Residents at Risk for Elopement, Resident Identification Protocols, Conducted Elopement Drills on each shift.

All staff educated on the above in services prior to beginning their shift.MonitoringBeginning 1/22/26 the Staff Development Coordinator and DON will monitor the competency of education regarding wandering and wandering risk and safety awareness of staff using knowledge testing of three staff members five days weekly for two weeks, then two staff members three days weekly for two weeks, then one staff member weekly for one month, then one staff member monthly for three months.Beginning 1/22/26 the Social Services Director will monitor the Elopement Binder to ensure each resident assessed as at risk for elopement has a current photograph and up to date risk assessment in the binder daily, five times weekly.Beginning 1/22/26 the Social Services Director will monitor residents at risk of wandering and elopement for alert ban placement five times each week for one month, then once weekly for one week, then monthly for three months.

Upon installation of Safe Wandering System, alert ban placement will be replaced by safe wandering system bracelet placement.

Facility alleges all corrective action completed on 1/20/2026.The SA validated the Corrective Action Plan on 1/29/26 through observations, interviews, and record reviews and determined that the IJ was removed on 1/21/26, prior to SA entrance on 1/28/26 and was determined to be Past Noncompliance.