Kadoka Nursing Home

Observation and interview on 5/27/26 at 1:30 p.m. with resident 1 revealed that she sat in a chair near the nurses' station with her walker in front of her.

She was neatly dressed, smiling, and calm.

She felt fine, but she had a corn on her right foot.7.

Observation on 5/27/26 at 3:20 p.m. revealed resident 1 was in an activity room seated next to another resident.

Two young family members were playing nearby. At 3:30 p.m., resident 1 approached administrator A and asked her about going out to the rodeo that day. Resident 1 accepted administrator A's explanation that it was too hot to be outside that day, and the rodeo may be over.Resident 1 commented that she had been up working since 8:00 a.m. that day anyway. 8.

Interview on 5/27/26 at 1:45 p.m. with Minimum Data Set (MDS) Nurse D revealed she worked one day per week at the facility.

She completed residents' MDS assessments, updated resident care plans, and attended resident care conferences. MDS Nurse D acknowledged that resident 1's care plan did not address her wandering, exit-seeking, or elopement risk, even though she knew resident 1 demonstrated those behaviors. 8.

Interviews on 5/27/26 at 2:20 p.m. and 3:00 p.m. with administrator A revealed that all staff were made aware of the above FRIs regarding resident 1 after those incidents occurred.

They were reminded how wandering and exit-seeking behaviors, and elopements were expected to be managed. On 4/28/26, the facility conducted a mock elopement drill.

Administrator A stated that high winds the night of resident 1's 3/21/26 elopement may have awakened her, causing her to get out of bed and leave her room.

The resident was also being treated for a urinary tract infection, which may have increased her confusion at that time.The facility's door alarm sounded properly when it was opened by resident 1, the staff responded to that alarm as they were expected to, and reacted properly when resident 1 was not able to be accounted for. 9.

Interview on 5/27/26 at 3:30 p.m. with administrator A, MDS Nurse D, director of nursing (DON) B, assistant DON C, and RN/social services director (SSD) E revealed resident 1's sundowning (increased confusion, anxiety, agitation that peaks in the late afternoon or early evening) correlated with her wandering and exit-seeking behaviors.

The resident was more inclined to wander and exit-seek after she returned from outings with her daughter, when she showed signs and symptoms of a potential urinary tract infection, when she verbalized a desire to go home, and when she packed a bag to go home.

Interventions that were implemented when resident 1 wandered and sought out facility exits included staff supervision, limiting the resident's off-grounds outings, verbal redirection, family phone calls or visits, anticipating the resident's needs for thirst, hunger, continence care, or physical exercise, and individualized diversion activities for the resident to engage in.

The above staff acknowledged that all of the above information related to resident 1 should have been in her care plan.

Administrator A, DON B, ADON C, and RN/SSD E, in addition to MDS Nurse D, were also responsible for ensuring that resident 1's care plan was revised to reflect her individualized needs.10.

Review of the provider's revised 4/11/26 Elopement of a Resident policy revealed that following a resident elopement, The care plan should be updated with additional approaches being implemented.