**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and supervise a moderately cognitively impaired resident to prevent elopement, for 1 (Resident #1) of 6 sampled residents. The lack of an effective monitoring plan resulted in Resident #1 eloping from the facility and being found approximately .25 miles from the facility on 10/19/2024. The facility staff was not aware that Resident #1 left the facility due to Resident #3 entering a code into the exit panel, disengaging the locking mechanism on the door, and Resident #1 exited without the electronic wander management system alarming. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to the residents. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, §483.25 (Quality of Care) at a scope and severity of J. The IJ began on 10/19/2024 at 11:19 AM, when Resident #1 was let out of the facility by Resident #3. Upon notification by Resident #3 to Housekeeper (HK) #6, a Code [NAME] was called, and the facility staff began searching inside the facility and around the perimeter of the facility. After facility staff were unable to locate Resident #1, the search was expanded off facility property. Resident #1 was located approximately .25 miles from the facility. The resident had exited the facility property without staff knowledge. The Administrator and the Nurse Consultant were notified of the IJ on 10/29/2024 at 12:34 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 10/30/2024 at 11:09 AM. Findings include: Review of a facility policy titled, Accidents and Incidents - Investigating and Reporting with a revised date of July 2017 revealed, any accident or incident occurring on facility property would be investigated and reported to the Administrator. Review of a facility policy titled, Unusual Occurrence Reporting, with a revised date of December 2007 revealed, the facility would report unusual occurrences or events affecting the health, safety, or welfare of residents. Interpretation and implementation indicated the facility would report events that could become life-threatening including, f. inoperable emergency systems, equipment. Review of a facility policy titled, Elopements, with a revised date of 12/2007, indicated staff were to investigate and report missing residents. And outlined implementation of investigation process. Page two of this policy was not provided to surveyors. Review of an undated facility procedure titled, Elopement Procedure Code White, outlined the steps to be taken during an elopement that included appointment of a leader, alerting staff to the even, searching for resident, notification and information to be provided to the responsible party, police, Administrator and Director of Nursing. Review of a facility policy titled, Wandering and Elopements, revealed the facility was to identify residents at risk and would use the least restrictive environment to prevent harm. The care plans of residents identified for wandering, elopement, or other safety issues would be updated with interventions to maintain the residents' safety. Review of a facility policy titled, Wandering, Unsafe Resident, revealed residents at risk for wandering, including elopement, would be identified and assessed for correctable risk factors by staff. The residents' care plan would be updated with interventions and would include a detailed monitoring plan. A review of a facility document titled, Facility Assessment Tool, dated 09/2023, indicated the purpose was to identify resources necessary to provide care and services required by residents residing in the facility. Section titled, Staff training/education and competencies, on page 9 and 10, revealed no training on resident wandering or elopement. Specific to Memory Care Neighborhood, on page 10, indicated the staff training included wandering and egress control. A review of the admission Record, indicated the facility admitted Resident #1 on 10/01/2024, with diagnoses of altered mental status, the body's inability to effectively use insulin and leads to elevated blood sugar, and a common lung disease that makes it difficult to breathe. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/14/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severe cognitive impairment. No behavior indicators were present. Resident #1 required partial to moderate assistance bathing; supervision with personal hygiene; set up/clean up assistance for oral hygiene and toileting; and was independent with eating, sitting, standing, walking, transfers, and repositioning in bed. Resident #1 was occasionally incontinent of bowel and bladder; had no indication of pain; no tobacco use; and had no falls. Resident #1 was receiving antianxiety and diuretic medications. Resident #1 had a wander/elopement alarm. A review of care plan, revised 10/20/2024, revealed Resident #1's was an elopement risk, was verbally and physically aggressive, was a fall risk, had suicidal ideation, had altered respiratory status, and had a need for placement on a secured unit. Interventions included assessing fall risk, offering diversions for distraction, addressing unmet emotional /physical needs, intervening when behavioral health consult, administer medications, encourage family visitation, identifying triggers of emotional distress, monitor for fatigue, and providing structured activities. The electronic wander management transmitter device was resolved and was no longer used. A review of Resident #1's Order Summary Report, revealed Resident #1 was admitted to the memory unit due to elopement risk on 10/19/2024. A review of the Nsg [Nursing] Admit/Readmit Assessment and Care Plan, dated 10/01/2024 at 3:45 PM documented Resident #1 was at high risk for elopement. No care planning information was entered. A review of the Nsg [Nursing] Elopement Risk with Care Plan, dated 10/01/2024 documented Resident #1 was at high risk to wander. Interventions included placement of an electronic wander management transmitter device. Interventions not put into place included identifying a wandering pattern; documenting wandering behavior and interventions; and identifying escalating triggers and deescalating behaviors of wandering /elopement. A review of the Nsg [Nursing] Elopement Risk with Care Plan, dated 10/19/2024 at 8:59 PM, documented Resident #1 was at high risk for elopement. There was no change in interventions. A review of the treatment administration record (TAR) dated 10/2024 revealed Resident #1 had treatments for a skin tear to the left and right hands; a scratch to the right wrist; and back of neck. A review of the Progress Notes, dated 10/14/2024 at 10:06 AM, revealed Resident #1 expressed aggressive behaviors toward staff and voiced threats about another resident to staff. Medication administered. A review of the Progress Notes, dated 10/15/2024 at 10:08 AM, revealed Resident #1 upset with staff. Medication administered. At 10:59 AM, revealed, Yelling Screaming Monitored, medication calmed resident. A review of the Progress Notes, dated 10/18/2024 at 3:53 PM, revealed Resident #1 was to upset to get weighed. A review of the Progress Notes, dated 10/19/2024 at 12:45 PM, revealed Resident #1 was receiving an antibiotic for a urinary tract infection (UTI), was ambulating, requested coffee, and stated they lost their way. Code [NAME] was announced at 11:32 AM, and a nurse gave instructions to other staff to search for the resident. The nurse went outside and notified the Director of Nursing (DON), the Administrator and the police department. A passerby notified the nurse of someone walking the creek line and took the nurse to the location of Resident #1. A review of the Progress Notes, dated 10/19/2024 at 4:11 PM, revealed Resident #1 had a skin tear to the right hand, a scratch to the left wrist, and a skin tear to the posterior base of the neck. A review of the Progress Notes, dated 10/19/2024 at 5:41 PM, revealed Resident #1 was sent to the emergency room and received a tetanus shot. A review of the Progress Notes, dated 10/20/2024 at 11:18 AM, revealed Resident #1 enjoyed walking outside and sitting at the windows in the dining room, voiced would like to leave. A review of the Progress Notes, dated 10/20/2024 at 1:17 AM, revealed Resident #1's electronic wander management transmitter device was removed on 10/19/2024. A review of the Progress Notes, dated 10/23/2024 at 08:27 AM, revealed during a provider assessment, Resident #1 voiced they felt trapped inside and wanted to go outside. A review of the Progress Notes, dated 10/28/2024 at 07:52 AM, revealed Resident #1 wandering hall and asking to leave the facility. A review of Nsg [Nursing] Skin Audit, dated 10/19/2024 at 3:05 PM, revealed Resident #1 had a scratch to the right wrist, the back of the neck and the left hand, post elopement. A review of Nsg [Nursing] Skin Observation Daily for Four Days, dated 10/23/2024 at 10:47 AM, revealed Resident #1 had a skin tear to the left hand. A review of an admission Record indicated the facility admitted Resident #3 on 07/26/2024 with diagnoses of fracture of the left humerus, muscle wasting and atrophy, and difficulty in walking. A review of the modified admission MDS with an ARD of 08/08/2024 revealed Resident #3 had a BIMS score of 15 which indicated the resident was cognitively intact. A review of Resident #3's, Order Summary Report, for the month of 10/2024 revealed an order dated 08/09/24 indicating Resident #3 was discharged from skilled care services to long term care on 08/11/2024. Review of the care plan, initiated on 07/26/2024, revealed Resident #3 had limited physical mobility related to rheumatoid arthritis, fracture of the left humerus, osteoarthritis, obesity, muscle wasting and atrophy, and muscle weakness. Resident #3 required the use of a motorized wheelchair for ambulation. On 10/19/2024, Resident #3 required education regarding safety and letting other residents out of the exit door. Interventions included changing the security code to doors monthly and documenting the change; Resident #3 would not have a roommate with an electronic wander management transmitter device; and Resident #3 was educated on the purpose of keypads/alarms/safety of all residents. A review of the Employee Memorandum Witness Statement, with a date of 10/19/2024, revealed Resident #3 admitted to entering the code allowing Resident #1 to exit, and the alarm did not sound when the door opened. A review of the Employee Memorandum Witness Statement, with a date of 10/19/2024, revealed Certified Nursing Assistant (CNA) #8 received notification of a missing resident while on lunch. CNA #8 took a vehicle, turned left from the facility, and began a search. A review of the Employee Memorandum Witness Statement, with a date of 10/19/2024, revealed Registered Nurse (RN) #9 began looking for Resident #1 after the Code [NAME] (missing person) was called. A lady stopped and notified RN #9 of (Resident #1) walking the creek line toward (a boat manufacturing company). The driver took RN #9 to the location of Resident #1. RN #9 got Resident #1 from the creek and up to the barbwire fence when the police and the DON arrived. A review of the Employee Memorandum Witness Statement, with a date of 10/19/2024, revealed Housekeeper (HK) #6 was in the breakroom and heard a knock on the door and was told by Resident #3 that Resident #1 went out the B-Hall door. HK #6 called code white and notified Laundry #7. HK #6 did not hear the alarm sounding. A review of the Employee Memorandum Witness Statement, with a date of 10/21/2024, revealed the Maintenance Director was notified of the elopement, arrived at the facility at 12:06 PM and checked the door on B-Hall. The alarm functioned properly on all doors. 11 (electronic wander management transmitter devices), on residents, were checked and worked. Alarm history was reviewed and revealed Resident #1's electronic wander management transmitter device alarmed multiple times, and the system was in good working condition. During a concurrent interview and observation on 10/28/2024 at 08:40 AM, Certified Nursing Assistant (CNA) #8 stated Resident #1 was wandering daily, and residents are taken outside to a fenced area at least twice daily. Resident #1 exited the dining room into the hallway to the exit door. CNA #8 redirected Resident #1 back to the dining room and offered an activity. Resident #1 refused. During an observation on 10/28/2024 at 08:50 AM, the Maintenance Director was testing door alarms. The Maintenance Director stated there were no residents on D-Hall with electronic wander management transmitter devices. The Maintenance Director stated all doors were tested weekly, on Monday, and the transmitters on the electronic wander management transmitter devices were tested daily to ensure they were working. During an interview on 10/28/2024 at 09:21 AM, the Director of Nursing (DON) did not know the residents that were at risk for elopement, and did not have a list of residents that wandered or had exit seeking behaviors. The DON asked the Maintenance Director if he had a list of residents that had an electronic wander management transmitter device, the Maintenance Director stated 4 residents currently had an electronic wander management transmitter device. During an interview and observation on 10/28/2024 at 9:35 AM, the Maintenance Director stated since the last elopement, the electronic wander management system was part of the action plan, and the electronic wander management transmitter devices were placed on residents, after notifications were made. The Maintenance Director stated he would be notified by staff, (Administrator and DON), during the morning meeting of the residents identified as requiring a transmitter device. The Maintenance Director would then take an electronic wander management transmitter device to the computer and link the number on the electronic wander management transmitter device to the resident's name in the computer. The electronic wander management transmitter device was then taken to the door and checked for operation. The Maintenance Director took an electronic wander management transmitter device into the hallway, from Administrators Office, and stood 15 feet from the front entrance of the facility. The Maintenance Director approached the front entry, entered the exit code (1 symbol and 3 numbers) on the exit panel and a low alarm sounded with a moderate tone and decreased to no sound (decrescendo). The panel was reset by moving the electronic wander management transmitter device away from the door. The Maintenance Director approached the door and set the transmitter device on the arm of the furniture near the door. After 20 seconds an audible alarm sounded and continued to sound until the transmitter device was moved away from the door. The Maintenance Director stated the distance from the monitor varies from 10 to 15 feet, and this one is closer, 6 feet. The Maintenance Director stated the handheld tester was used to check the 4 electronic wander management transmitter devices, currently being used, daily. The Maintenance Director demonstrated with the transmitter, a digital readout on the handheld tester displayed with the transmitter number and OK. The Maintenance Director stated OK meant the transmitter was functioning, the expiration date was located on each transmitter and must be replaced in March of 2025, batteries were no longer accessible, and the transmitter device must be replaced. During an interview on 10/28/2024 at 10:15 AM, the Director of Nursing (DON) stated Resident #3 had a BIMS of 15 and let Resident #1 out of facility using keypad at the end of the 200 Hall. The DON does not know how Resident #3 was aware of the door code. The DON state Resident #3 told housekeeping they let someone out the door. The DON stated she brought Resident #1 back to the facility in her personal vehicle, about noon on Saturday, after Resident #1 was found. During an interview on 10/28/2024 at 10:33 AM, Resident #3 stated they did let someone out the door because they wanted to go out. Resident #3 would not state how the code to the door was obtained. Resident #3 laughed when asked to demonstrate buttons pushed to open the exit door and stated, I just pushed any button. During a concurrent interview and observation on 10/28/2024 at 11:07 AM, the Maintenance Director demonstrated how the electronic wander management system was tested on B Hall the day of the elopement, by placing the electronic wander management transmitter device in their left boot, walked to the exit panel and entered the code. The panel made a decrescendo sound and did not deactivate the exit door. Maintenance Director stood at the exit door for 20 seconds and the alarm sounded. The Maintenance Director walked away from the exit door, past laundry and past room [ROOM NUMBER], left the transmitter device on the handrail and reset the panel, obtained the transmitter device, exited through the door and the alarm continued to sound. The Maintenance Director stated he was notified of the elopement by the Administrator on 10/19/2024 between 11:45 AM and 12:00 PM, and arrived at the facility about 12:30 PM, and changed the code on all of the exit panels. The Surveyors and the Maintenance Director viewed a video of elopement involving Resident #1 and Resident #3 on the B Hall. The following is a timeline of the video, from the facility's video system, shown to surveyors by the Maintenance Director. -Video view from the indoor camera located on B-Hall, faced the exit door, identified by the Maintenance Director as 1 B Hall. -On 10/19/2024 at 11:13 AM, Resident #1 was walking on the B Hall near room [ROOM NUMBER], away from the nurses' station toward the exit door. At 11:14 AM, Resident #1 entered Resident #1's room at the time), on left side of the hallway. At 11:16:46 AM, Resident #1 exited the room and turned left onto the B hall and walked toward the exit door. At 11:17:16 AM, Resident #1 arrived at the back exit door, a laundry aide was walking down the hallway at 11:17:36 AM and spoke with the resident. The Maintenance Director identified the laundry aide as Laundry #7. At 11:17:50 AM, Resident #1 walked from the back door toward nurses' station, and entered room [ROOM NUMBER]. At 11:18:30 AM, Resident #1 and Resident #3 exited room [ROOM NUMBER], turned left toward the exit door. Resident #3 was in an electric wheelchair. At 11:19:10 AM, Resident #3 positioned wheelchair, so it faced the exit panel and pressed 4 buttons on the exit panel, Resident #1 pressed on the door and exited the facility. Resident #3 immediately turned and moved away from the exit door. At 11:19:50 AM, Resident #3 entered room [ROOM NUMBER]. At 11:20:39, Resident #3 exited room [ROOM NUMBER] turned right onto B-Hall, toward the nurses' station. At 11:27:48 AM, Resident #3 pressed numerous buttons on the keypad then knocked on the Employees Breakroom door. The door was opened by a staff member identified by the Maintenance Director as Housekeeper (HK) #6. At 11:28:36 AM, HK #6 exited the employee breakroom, turned right toward the exit door. HK #6 entered the code on the exit panel and exited B-Hall through the doorway. At 11:28:40 AM, HK #6 reentered the door and moved towards the nurses' station out of view of the camera. Video view from the outdoor camera, located outside the B Hall exit, faced the garage/shed. The Maintenance Director stated the designation of the camera was 14 Big Shed. At 11:19:07 AM, Resident #1 exited the B Hall, turned right and followed the gravel road. At 11:28:40 AM, HK #6 exited the B Hall and went out of view. The Maintenance Director stated Resident #1 followed the creek and somebody should have gone outside and looked for the resident when the Code [NAME] was called. During an interview on 10/28/2024 at 11:39 AM, the DON stated Registered Nurse (RN) #9 found Resident #1 after a passerby told her someone was down the road. The DON does not know why they stopped to tell RN #9. During an interview on 10/28/2024 at 12:45 PM, the Administrator stated, Resident #1 was never signed out of the facility, and did not have a sign out sheet in the sign out logbook. During an interview on 10/28/2024 at 2:42 PM, the Resident Representative stated, Resident #1 had never left the facility before, when at home, the resident would have cabin fever and asked to go somewhere and family would take Resident #1 out for a drive. The Resident Representative stated they were informed Resident #1 was found one quarter of a mile from the facility in a creek, clothing was wet and muddy, had burs, and went under barbed wire fence and was cut. The Resident Representative stated Resident #1 was following the creek because Resident #1 knew it would lead to the Resident Representative's home. During an interview on 10/28/2024 at 9:15 PM, Certified Nursing Assistant (CNA) #2 stated they were familiar with Resident #1 and did not work the day of the elopement. CNA #2 stated, Resident #3 was bragging today, about the elopement, about opening the door and letting another resident out and stated I'm gonna use the code and let them (other residents) out. During an interview on 10/28/2024 at 9:30 PM, Licensed Practical Nurse (LPN) #1 stated they were familiar with Resident #1 who had an electronic wander management transmitter device in place and wandered constantly. LPN #1 stated a couple of weeks before the elopement, there were issues with the alarm system, and that the alarm would randomly go off, and indicated Resident #1 was at one of the doors when the resident was in the dining room, or in their room, and not close to the exit door. LPN #1 stated that on 10/04/2024 at 5:33 AM, Resident #1 was in bed and the electronic wander management system showed resident was at the door on the 200 Hall. LPN #1 stated the Maintenance Director was notified and was trying to figure it out. LPN #1 did not know if the Maintenance Director was able to find a problem with the unit. LPN #1 stated the electronic wander management transmitter device was not removed from Resident #1 to be repaired or replaced, and she did not believe it was ever removed from Resident #1. LPN #1 stated Resident #3 told other residents, on first shift, that Resident #3 was going to let all the residents out if given the chance because Resident #3 did not want other residents to come into the resident's room. A review of the Incident Report, number 24-00268, dated 10/28/2024 at 3:39 PM, revealed Law Enforcement (LE) #3 was dispatched on 10/19/2024 at 11:10 AM to an Agency/Officer Assist at the facility address, at the request of LE #10. LE #3 responded to a call at the nursing facility for a missing resident, Resident #1. LE #3 arrived at the dispatched location and observed vehicles on the side of the road and people in the field next to the road. LE #3 spoke with individuals identified as employees of the nursing facility, and Resident #1. During an interview on 10/29/2024 at 08:05 AM, LE #3 stated a call was sent out over the radio for a missing person at the facility. The officer responding was from the Sheriff's Department and LE #3 offered to respond for assistance as they were closer. LE #3 stated the call was located on a local highway and when turning onto the highway, three vehicles were located on the side of the roadway facing West. LE #3 stated he exited the patrol vehicle and entered the field where several people were gathered. LE #3 stated a nurse was present with three other individuals, one was identified as Resident #1 and another as a nurse and one as the Director (LE #3 did not have names of nurse or Director). LE #3 stated Resident #1 had blood on both hands, and the back of the shirt, and the clothing was not wet. LE #3 stated the creek bed was dry, and the concern was the 20-plus black angus [NAME], ranging in age from 3 to 6 years old, in the field facing the resident. LE #3 stated there was a hole in the barbed wire fence and Resident #1 was brought from the area of the creek through the open fence area with the barbed wire being held open so Resident #1 could get through without being caught in the fence. Resident #1 was placed in the Directors vehicle and returned to the facility. LE #3 stated Resident #1 repeated, I don't want to be here. During an interview on 10/29/2024 at 08:58 AM, the (Wander Management System Provider) office staff (WMSOS) #5 stated the wander management system was installed in the facility in March of 2024 and was not aware of any onsite service since that time. WMSOS stated the facility called last week and asked for a guide/manual that outlined testing. WMSOS stated testing should be done weekly on the doors and daily on the transmitters. WMSOS stated that when a resident, with an electronic wander management transmitter device in place, exited the door regardless of an electric wheelchair being present at the door, and a code being put in, the alarm should have sounded as soon as the resident crossed the threshold. During an interview on 10/29/2024 at 09:08 AM, the (Wander Management System Provider) owner (WMSO) #4 stated electrical interference could affect the functioning of the system and the facility should have called if there was a problem. The facility was not contacted about any issues with the transmitter devices. A technician was sent to the facility, regarding the alarm not sounding on Monday (10/21/2024). During an interview on 10/29/2024 at 10:20 AM, the Administrator was asked if a root cause analysis was done for the elopement and the Administrator stated, A Quality Assurance and Performance Improvement (QAPI) was not created for this elopement. Resident #1 was placed on the unit and an electronic wander management transmitter device was removed. The Administrator stated Resident #1 had exit seeking behaviors on 10/18/2024 and was walking the halls. The Administrator stated the electronic wander management system was installed as part of a Plan of Correction for a prior elopement. The Administrator stated he was not aware of issues or malfunctions of the system because the Maintenance Director checked the system. The Administrator stated the Maintenance Director did recreate the incident three times with Resident #3's wheelchair and received the same results. During an interview on 10/29/2024 at 11:15 AM, the Administrator stated there was no specific policy on Elopements, only unusual occurrences, accidents, and incidents. The procedure used for elopements outlined what was done in the event of a missing resident. During an interview on 10/29/2024 at 2:46 PM, the Nurse Consultant provided a copy of the electronic wander management system company's call for service dated 10/21/2024. Review of the document indicated the system was functioning properly, It was picking up 5 to 6 feet, when tested by the technician with the maintenance director. During a telephone interview on 10/30/2024 at 08:28 AM, Licensed Practical Nurse (LPN) #1 stated residents who wandered are assessed for elopement during the shift by observation on rounds every 2 hours, during medication pass and when walking the halls. Interventions would be used if needed, based on observations. If a resident had an electronic wander management transmitter device, it would be checked for each shift for placement and documented on the Treatment Administration Record (TAR). LPN#1 stated a there was a testing device in the medication cart for use to ensure the sensor was working properly but she had not received training on how it was used. LPN #1 stated Resident #1's sensor was activating the system on 10/4/2024 between 05:00 AM and 05:30 AM, and Resident #1 was in bed. LPN #1 stated the Maintenance Director was informed of the issue that morning. LPN #1 stated Certified Nursing Assistant (CNA) #2 reported that Resident #3 was going to let other residents out of the building. LPN #1 did not immediately notify anyone and did not believe it was important, and after some thought, notified the Minimum Data Set (MDS) Coordinator and Registered Nurse (RN) #9. During an interview on 10/30/2024 at 12:17 PM, LPN #11 stated residents at risk for elopement were identified by an assessment, upon admission, and if a resident had increased confusion, were antsy, wanting to leave seeking exit, verbalized they wanted to leave, or had a BIMS showing low cognition. An (electronic wander management transmitter device) would be put on, if the resident was ambulatory, and had exit seeking behaviors, and no comprehension. The device would be placed by (Maintenance Director), or another staff member. LPN #11 stated nurses used to check to confirm placement of the device and documented placement on the TAR, and the Maintenance Director checked functioning. Functioning is checked on the weekend by the nurses. LPN #11 stated the tester was located in the medication cart for use when the Maintenance Director was not available. At 12:18 PM, during interview, the door alarm sounded, LPN #11 observed control panel and left the nurses station, viewed the end doors of A, B and C halls, opened the door and observed the exit on the secured unit, and visualized the entry door and returned to nurse station, no doors were opened. The Administrator walked to the nurse's station, looked at the alarm panel, and returned to the front entry hall, no further action was taken by staff. LPN #11 stated an employee must have left the door open too long. During an interview on 10/30/2024 at 12:25 PM, the DON stated residents at risk for elopement were identified by the admission assessment. The DON stated the decision for placement of an (electronic wander management transmitter device) would be made after reviewing the residents. If a resident is at risk or high risk for wandering, had behaviors, BIMS score, and dignity, were used to determine placement of the device. The DON stated maintenance was responsible for placement of the (electronic wander management transmitter device) on the resident after he received notification. Maintenance would be notified during the morning staff meeting and the DON would follow up to ensure placement. The DON stated Resident #1's device was removed when the resident was placed on the secured unit, because there was no need for the device due to having closer supervision by staff. The DON stated wandering did not constitute placement of an (electronic wander management transmitter device), residents would be observed by staff who would report exit seeking behaviors and a device would be placed. During an interview on 10/30/2024 at 4:08 PM, LE #10 stated he was dispatched to a call for a resident that ran away from the nursing facility. The resident was described as (gender) wearing blue jeans and t-shirt with a beard and white hair. LE #10 responded from the Sheriff's Office to the scene. LE #3 with local police department radioed he was on scene just East of the nursing facility, in a field. Upon arrival there were pedestrians and vehicles off the side of the road, nurses and aides were walking Resident #1 back to the road. LE #10 was notified by LE #3 that the resident w[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #20) of 2 sampled residents. This resulted in a finding of a past noncompliance Immediate Jeopardy. The Facility's Administrator was notified of the findings of a past noncompliance Immediate Jeopardy on 02/07/2024. The findings are: Resident #20 had diagnoses of Psychophysiological insomnia, Dementia severity with agitation, Psychotic disturbance, Mood disturbance, and Anxiety. According to a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/24 revealed the resident received a score of 03 (severe cognitive impairment) on the Brief Interview of Mental Status (BIMS). According to progress notes on 02/05/24 at 5:24 PM Incident Description: Resident left building unassisted and went to A hall door to be let back inside. Immediate Intervention: Head to toe assessment per Registered Nurse (RN) with no negative findings. Returned to Unit with Certified Nursing Assistance (CNA) observation. On 03/13/24 at 09:30 AM, Surveyor asked Maintenance if the door to the unit was propped opened on the date of the incident with Resident #20. Maintenance said yes, the unit door was propped open on the date of the incident. On 03/13/24 at 9:57 AM, the Surveyor asked the Administrator if they performed a Root Cause Analysis of the event. The Administrator said yes. Surveyor asked was the secure unit door left propped open. The Administrator said yes, the nurse propped it open but that was not the issue. They saw on camera where the resident held down the front door for 15 seconds and walked out of the facility. The Administrator explained the plan of correction was to make the front door will sound nonstop even after held the secure unit door will make an audible sound if it is propped open. On 03/13/24 at 10:38 AM, during a phone interview a Fire Safety Company employee and he said they wanted the door to continuously go off, they had someone leave out the door and the door stopped alarming. He installed a lock that will only deactivate with an alarm pad and a key. He then installed a remote sounder in the dining room, to make it more audible to the facility. On 03/13/24 at 1:58 PM, during a phone interview with a Medical Device Company said they would be out within two weeks to install a new electronic wander management system for the facility. On 03/13/24 at 3:45 PM, during a phone interview Surveyor asked CNA #6 what happened the night of the elopement. CNA #6 said her and CNA #7 were getting up a two assist on Hall A. CNA #7 sent her to investigate as soon as 1 person could provide care. Found the resident outside at 5:30 am and took her to the nurse. The doors were then closed to the secure unit and CNA #7 stayed back there with the residents. Surveyor asked was the secure unit door propped open. CNA #6 said yes. Did the front door alarms go off. CNA #6 said, no they did not. Surveyor asked who propped open the secure unit door. CNA #6 said I don't know it was like that when we came in on shift. On 03/14/24 at 8:33 AM, During a phone interview the Surveyor asked CNA #7 what happened the night of the elopement. CNA #7 said they were getting a two assist up and they sent the other CNA to investigate. After giving care, they went back to the unit until the next shift came in. Surveyor asked was the secure unit door propped open. CNA #7 said yes, it was like that when we came in on shift. Surveyor asked if the front door alarm went off. CNA #7 said no it did not go off, they checked the front door with the nurse, and it was having trouble locking back in place after the incident. On 3/14/24 at 3:11 PM, Surveyor asked about elopement in-services prior to the incident. Nurse Consultant said no elopement in-services were completed prior to the incident. According to a time and date stamp Resident #20 eloped from the facility and was found outside of a facility door. The outside temperature on 02/04/2024 at 5:30 AM, was 46 degrees Fahrenheit. On 3/13/2024 at 4:06 PM, Licensed Practical Nurse (LPN) #1 was asked if it was normal to prop the secure unit door open. LPN #1 stated, no. LPN #1 was asked, have you ever seen the secure unit door propped open? LPN #1 stated, No, I've only been here for 3 days. LPN #1 was asked, have you been in-serviced on elopement and not propping the secure unit door open? LPN #1 stated, No, but I know not to prop the door open. On 3/13/2024 at 4:08 PM, LPN #2 was asked if it was normal to prop the secure unit door open? LPN #2 stated, no. LPN #2 was asked, have you ever seen the secure unit door propped open? LPN #2 stated, Last time I saw it, when Resident #20 got out. LPN #2 was asked, who propped the door opened? LPN #2 stated, The night shift, 7 P-7A. LPN #2 was asked, why did they prop the door open? LPN #2 stated, Because of staffing, there are times there is only 1 CNA for this entire building. LPN was asked, have you been in-serviced on not propping the secure unit door open? LPN stated, yes LPN stated, The old DON said it was care planned for resident #194 to get out. On 3/13/2024 at 4:16 PM, Business Office Manager (BOM), was asked, is it normal to prop the secure unit door open? The BOM stated, no. The BOM was asked, have you ever seen the secure unit door propped open? The BOM stated, I've never seen it propped open. The BOM was asked, does Resident #20 have exit seeking behavior? The BOM stated, That's why Resident #20 is down there. The BOM was asked, have you been in-serviced on not propping the secure unit door open? The BOM stated, yes. The BOM was asked, do you know what happened when Resident #20 eloped from the secure unit? The BOM stated, That evening the door was propped open, Resident #20 went out the front, she walked to the outside of A Hall, they were working on A Hall and didn't hear the alarm. I think they heard her knocking on the door. On 3/13/2024 at 4:22 PM House Keeping/Laundry Supervisor was asked, is it normal to prop the secure unit door open? The HK/Laundry Supervisor stated, It's not supposed to be propped open. The HK/Laundry Supervisor was asked, have you ever seen the secure unit door propped open? The HK/Laundry Supervisor stated, In the past, a couple of times at night when I'm here late. The HK/Laundry Supervisor was asked, are you aware of any resident who eloped from the secure unit. The HK/Laundry Supervisor stated, Resident #20 got out and everybody knew about it, and Resident #194 got out, but I don't know how far. The HK/Laundry Supervisor was asked, have you been in-serviced on not propping the secure unit door open? The HK/Laundry Supervisor stated she had been in-serviced. On 03/11/24 at 10:22 PM, the Surveyor interviewed CNA #05 and asked, How often do you work short staffed? She stated, Some days, not very often. People come in to help out. When asked, When are shorter on staff do you feel as though you can provide the residents with their daily care needs? She stated, On days were real short staffed, like the weekends, we are still able to provide it. It just takes longer. On 03/13/24 at 03:59 PM, the Surveyor interviewed CNA #04 (secure unit) and asked, Is it common practice for staff to prop the secure unit door open? She stated, no. When asked, When was the last time you saw it propped open? She stated, I'd say it has been over a month ago I saw it. Plan of Removal for past noncompliance Immediate Jeaporday was recieved from the Administrator and included the following: 1. Resident who exited will be assessed for injury (body audit) 2. Review resident's elopement assessment. 3. Update resident's elopement assessment. 4. Complete unusual occurrence for event. Notify (medical doctor) MD and family of unusual occurrence, intervention, and action plan, then document notification and any new orders. 5. Determine an immediate intervention. 6. Care plan the incident and intervention. 7. Record to closet care plan resident is at risk for elopement. Those residents who are high risk will be documented as such on the closet care plan. 8. Conduct an in-service with all staff on the elopement policy and what to do in the event of an elopement. 9. If the facility has not had an elopement drill; the facility should have an elopement drill Q shift. Evaluate how the staff perform/respond to the drill; then add the evaluation to the QAA and reeducate according to staff's response to the drill. 9. Elopement drills will be conducted after initial drill weekly X 4 weeks, then monthly. These drills will be conducted across varying shifts and coordinates with fire drills. 10. Audit all residents for elopement, identify their risks and update their elopement risks assessment. These must be current after this event. 11. Assure all residents at high risk for elopement are with an intervention in place. Ensure proper care planning and information recorded to resident's closet care plan. 12. Staff in each department will be in-serviced regarding residents who are demonstrating exit seeking and/or have exited the facility and been redirected back inside. These residents are to be placed as one on one until alternate safety measures can be implemented. Staff will immediately report to DON/Administrator. 13. Front door to facility to be evaluated by local company for proper functioning of the regress and alarming function. Door checks will be completed per Maintenance director as per protocol. 14. In-service with nursing staff on securement of the dementia unit door at all times. 15. Residents will have an elopement assessment at the time of admission, 72 hours, 1 month, quarterly, annually, and (when needed) PRN. 16. The facility will maintain a binder of at risk and high-risk residents, with a photo of the resident to be kept at the main nurses' station in case of actual elopement. 17. Copy of the current midnight census will be place on the elopement book each night shift. Inservice nurses on this practice. 18. Administrator/DON/Designee will monitor securement of the dementia care secure neighborhood door on each shift daily X 1 week, X 3-week, X 2-week, weekly X 2 weeks and PRN. 29. Facility Management will monitor for resident exhibiting exit seeking behavior daily with rounds and implement interventions as indicated to maintain resident safety. 20. Nurse management will review progress notes and incident reports daily to monitor for any behaviors related to exit seeking. 21. During nursing start up each a.m. the nurse management team will review all new admission assessments for risk scores and ensure a care plan been completed per Nursing/Admit/Re-admit screener. If any negative findings these will be corrected immediately during the meeting. The MDS closet care plan) will be updated to reflect any/all interventions in relation to identified risk. 22. Review nurses personal files. 23. Order an enunciator for the front door to enunciate alarm. 24. Place a door guard from 7PM to 7 AM every day until enunciator arrives and is installed. 25. The facility will in-service on the staff on the use of walkie talkies for communication between the main staff and the dementia unit staff. 26. The facility will purchase a camera to visualize the dementia unit from the main nursing station 27. The facility will order a wander guard system for the facility. 28. The facility will makeshift assignment for care areas and post the assignment for the staff to know the care areas they are assigned to. 29. The override access code to the dementia unit door (overriding the alarm) was changed. The administrator and DON will be the only two individuals with the override code. All other staff will need to input a code to enter/exit the dementia unit. 30. Local Fire contacted to modify front door keypad alarm continuously until is manually alarmed by physical access to the door. The code to the door will be reset at that time as well. 31. Local Medical company notified to review physical plant and install a wander guard system on all exit doors and entrance door. 32. Have an ad-hoc (Quality Assurance) QA meeting regarding the incident and the action steps taken to resolve the issue. The IJ was removed 02/07/2024 the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 03/12/24 at 8:00 AM when Elopement was found. Elopement drills, in-services, verification with fire safety, schedule of those who monitored the door, invoices/installation interviews for systems have been reviewed. A total of 15 staff interviews were conducted with staff from all shifts to very training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Nurse Consultant, Housekeeping, and Administration Staff. The staff interviewed verified they had been trained on Elopement in-services. A review of in-service sheets provided indicated all staff had been in-serviced excluding the six that were terminated before the incident. According to record review interview, and observation the facility failed to ensure resident safety from hazards by leaving the 1st bathhouse unlocked on the side by secure unit, the 2nd unlocked on the side by 200 Hall, and assessable bird seed in a Resident's room. This had the potential to affect 10 mobile/ambulatory residents on A, B, and C Hall. On 03/11/24 at 10:26 PM, Surveyor observed the bathhouse was left unlocked by the secure unit. Upon entry to the right is a plastic container sitting on a chair with lotion, deodorant, mouthwash, and other personal care items. Behind this plastic bin is an unlocked yellow metal locker, inside the locker is two sides filled with personal care items including three-gallon containers of perineal and skin cleanser rinse free, 9 boxes of triple blade razors with ten in each, moisture barrier anti-fungal cream that states on the back to Keep out of Reach of Children, and if swallowed, get medical help or contact a poison control center right away and states on the back to Keep out of the reach of children, if swallowed get medical help or contact Poison Control Center right away. On a shelf on the left-hand side right before the shower stall is a 4 fluid ounce container of Ketoconazole Shampoo 2% and a 3-ounce container of anti-fungal body powder. In the shower stall on the floor is a pump gallon container of shampoo and body wash about ¼ of the way full, shaving cream, a container of old spice pure sport, and various other personal care items strewn on the floor of the shower stall. In an alcove on the left-hand wall of the shower stall is give used razors, perfume, shampoo for men, and shaving cream. In an area along the back wall is a plastic bin that has razors, body wash, and shampoos sitting on a towel. The top drawer is opened with a curling iron, straightener, and a container of Ketoconazole Shampoo 2%. On the wall about waist high level is a gallon container of shampoo and body wash that is ¼ full. A spray bottle of solution is next to the container, the back label states Danger Keep out of Reach of Children. On 03/11/24 at 10:41 PM, Surveyor observed a second bathhouse is unlocked on the 200 Hall side, upon entry it is clutter with a large shower chair and a wheelchair in the hall area. In a shower stall that is not currently used it is cluttered with a shower chair, and a large plastic foam pad. In the back area of the shower stall is a ½ full container of drain cleaner and a full container sulfuric acid. In the back area of the room, is a whirlpool tub full of clutter, and a cabinet with care items including several bottles of perineal and skin cleanser rinse free that states on the back Keep Out of Reach of Children, and several bottles of Alcohol-Free Mouthwash that states on the back to Keep Out of Reach of Children. On 03/12/24 at 3:15 PM, Surveyor asked what the issue with unlocked areas that need to be secured. Housekeeper #1 said that a resident could get hurt. Surveyor asked Housekeeper #1 to pick up the container of drain cleaner and read where it says that is a hazardous chemical. Housekeeper #1 said that oh, it has a warning label, and it says poison fatal if swallowed and causes chemical burns. The surveyor asked Housekeeper #1 to pick up the container of sulfuric acid and read where it says it is a hazardous chemical. Housekeeper #1 said that it says sulfuric acid and that does not sound good. Surveyor asked Housekeeper #1 how long the chemicals has been in this room. Housekeeper #1 said that it has been here in since they started in September of 2023 and that the maintenance man was talking about fixing the room. On 03/13/14 at 4:00 PM, Surveyor asked if the doors should be unlocked to the bathhouse on the 200-hall side. Maintenance said the doors should never be left unlocked, and they were going to make a note to change them from manual locks to self-locking doors. The surveyor asked what the issue with doors could be being unlocked. Maintenance said a lot of things could be hurt or injured. The surveyor asked if the cabinets should be locked, and personal care items put away in the bathhouse that was unlocked by the secure unit. Maintenance said yes, it has been unlocked for as long as I have been here in October. The surveyor asked what could happen with this bathhouse being unlocked. Maintenance said they could ingest the chemicals and get hurt. On 03/15/24 at 4:13, review of a policy Environmental Hazards states Identification of Hazards showed open areas or items that should be locked when not in use g. Access to toxic chemicals. On 03/11/24 at 1:37 PM, a plastic container containing bird seed was observed on the floor near the window in room [ROOM NUMBER]. The plastic container containing bird seed was observed again on 03/12/2024 at 9:16 AM and on 3/12/2024 at 4:00 PM On 3/12/2024 at 4:01 PM, CNA #4 was asked, what is in the plastic container? CNA #4 stated, It's birdseed. CNA #4 was asked, why should birdseed not be left out on the secured unit? CNA #4 stated, Because of the safety of the residents. On 3/12/2024 at 4:13 PM, LPN #6 was asked, why should birdseed not be left out on the secured unit? LPN #6 stated, Because the residents could take it and eat it. On 3/15/2024 at 10:38 AM, the DON was asked, why should birdseed not be left out on the secure unit? The DON stated, For safety reasons.