Based on observation, record review, and interview, the facility failed to monitor and supervise a severely cognitively impaired resident to prevent elopement, and failed to ensure staff responded promptly to an exit door alarm and thoroughly check the area outside the building after a door alarm sounded for 1 (Resident #1) of 3 sampled residents (Residents #1, #4, and #5) who were at risk for elopement. Consequently, Resident #1 eloped from the facility without staff knowledge, traveled across rough ground, and was found by law enforcement in a dehydrated state. It was determined the facility's past non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, S483.25 (Quality of Care) at a scope and severity of J. The IJ began on 06/15/2025 at approximately 4:15 PM. The facility did not have camera surveillance, but staff suspect Resident #1 who resided on the secured 300 Hall followed a visitor to the secured 400 Hall, before exiting the facility via the North exit door. Resident #1 held down the door handle until it opened and went outside to a fenced-in area and removed two wood pickets from a fence. Resident #1 walked approximately 30 yards behind the facility to a tree line, then down approximately 100 yards of plowed field, then approximately 30 yards of waist high grass to a cemetery, which was where Resident #1 was found at 8:00 PM by an officer from the local police department. The resident had exited the facility without staff knowledge. The Administrator and the Registered Nurse Consultant (RNC) were notified of the Past Non-Compliance (PNC) IJ on 06/25/2025 at 11:24 AM. The facility was found to have returned to compliance on 06/16/2025 when the facility's corrective actions were completed. The findings include: A review of the admission Record indicated the facility admitted Resident #1 on 04/07/2025 with diagnoses which included intracranial injury, dementia, and type 2 diabetes.The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/21/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 04 which indicated the resident had severe cognitive impairment. Resident #1 was independent with sitting, standing, walking, transfers, and repositioning in bed, and was receiving antipsychotic, antianxiety, antidepressant, hypnotic, antiplatelet and hypoglycemic medications. A review of Admission/readmission Nursing Evaluation dated 04/07/2025 in Section III: Elopement Risk Evaluation revealed a score of 10 indicating Resident #1 was high risk for elopement although there was no documented history of elopement episodes for the past three months before admission to the facility. A review of Resident #1's Care Plan initiated 04/07/2025 revealed the resident required placement on a secured unit related to behaviors affecting self or others and risk for elopement. Interventions included: assist the resident to develop methods of coping and interacting, and distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or books. 06/16/2025 holidays could be possible trigger for elopement attempts, 06/16/2025 Resident #1 was placed on one to one. A review of a late entry Behavior Note written 04/13/2025 at 5:57 AM revealed at approximately 6:40 PM one of the Certified Nursing Assistants (CNA) was getting ready to take the smoking residents out when Resident #1 pressed down the handle of the door until it opened and then ran out and proceeded to try and climb a fence. Resident #1 was redirected and taken back in the building. A review of an Incident Report from the local police department revealed a narrative provided by a law enforcement officer (LEO), dated 06/16/25 at 12:16 AM. The narrative revealed that on Sunday, June 15, 2025, at approximately 5:55 PM, the LEO reported for start of his shift. Dispatch advised that there was a resident who walked out of [facility was named]. Multiple agencies such as the local fire department, state police, the sheriff department, a neighboring city ' s police department, and the state department of corrections began assisting in the search for the resident. The resident was located in a cemetery located approximately 1,500 feet from the facility at 8:02 PM. Resident #1 was returned to the facility, treated by Emergency Medical Services (EMS) and later transported to a local hospital for further treatment. The LEO and a detective walked to the rear of the facility where staff believed the resident walked out of. Once opening the door leading outside, an audible alarm sounded off, notifying that the door had been opened. He observed two pieces of the wooded fence to be higher than the rest of the fence, it was advised that the employees believed the resident had removed those two pieces of the fence to leave the area and walk off the property. When the detective attempted to secure the door leading outside, the door had trouble latching and locking therefore making it easy to open. It was also advised that earlier in the day the alarm from the door sounded and that an employee walked outside but did not further inspect the reason for the alarm sounding. It was advised that [Resident #1] was last seen at approximately 4:09 PM. The facility did not contact the police department until approximately 5:50 PM. The facility was not equipped with surveillance cameras and therefore it was only assumed how the resident walked out of the property. An Adult Protective Services report was completed. Further review of the Incident Report revealed an additional narrative from a second LEO dated 06/16/25 at 2:45 PM. This narrative revealed that on June 15, 2025, the police department was contacted by the facility regarding a missing resident. The missing resident was last seen at approximately 4:09 PM by nursing staff and was said to have exited one of the back doors of the facility. Resident #1 was located approximately 8:05 PM at a cemetery approximately 1,500 feet from the facility. Resident #1 was transported back to the facility after being examined by EMS. At approximately 8:23 PM, the resident was transported to the emergency room of the local hospital by EMS. An Adult Protective Services report has been completed. A review of a Facility Incident Report dated 06/15/2025 indicated Resident #1 was admitted to the secured unit of the facility on 04/07/2025. Resident #1 was independently ambulatory with no use of assistive devices. Resident #1's BIMS per the MDS was a 4 (which indicated severe cognitive impairment). The resident was noted per hospital note dated 04/06/2025 to have thought blocking, which involved an abrupt stop in the middle of a thought, making it difficult to continue. This thought blocking could make an accurate assessment of BIMS difficult. It was noted Resident #1 often turned away and disassociated from staff and declined to answer simple questions. The Findings and Actions Taken section revealed on 06/15/2025 the door alarm was noted to be going off. Staff checked the door. CNA #1 then went to Licensed Practical Nurse (LPN) #2 and got the door code, checked the door again and shut off the alarm. Staff completed a head count in the dining room and noted that Resident #1 was absent. The staff immediately began searching the facility interior and exterior for the resident. The DON (Director of Nursing) was notified at 5:40 PM. The Administrator was notified of the missing resident at 5:42 PM. Police were notified at 5:44 PM. Family was notified at 5:58 PM. The physician was notified at 6:00 PM. Resident #1 was located at a cemetery and returned to the facility at 8:03 PM. The temperature was 91 degrees Fahrenheit. A review of ER (emergency room) Record, dated 06/15/2025 at 8:28 PM, revealed EMS transported Resident #1 to hospital following an elopement from the nursing home that lasted approximately four hours and ended with the resident being found in a nearby cemetery. The resident was wet and sweating profusely when found. Resident #1 ' s body temperature was found to be 99.8 degrees Fahrenheit. The ER Record revealed Resident #1 presented to the ER with, and was treated for, dehydration. A review of a Witness Statement dated 06/15/2025 by LPN #2 revealed that she and Resident #1 were sitting on 400 hall. She offered to call Resident #1's dad. The LPN then called Resident #1's family member. LPN #2 was called to a different area in the facility to assist with another resident, so she took Resident #1 back to the 300 hall where they resided and left the resident in the dining room eating a honeybun. CNA #1 asked LPN #2 for the North end door code on 400 hall. She was later asked if she had seen Resident #1 and she told the CNA the Resident was in the dining room. LPN #2 was told that staff could not find Resident #1 after a head count. The staff on 300 and 400 halls then searched all the rooms and outside but could not find Resident #1. The DON was notified. LPN #2 said that she had not noticed any behaviors after Resident #1 spoke with family members on the phone. A review of a Witness Statement dated 06/15/2025 at 9:31 PM by CNA #1 revealed that she was assisting a resident in their room when she heard the alarm go off around 4:30 PM. She looked out of the resident's door but did not see anyone. CNA #1 stepped off the hall to ask the nurse for the code to the door. She looked again but did not see anyone, so she put in the code to silence the alarm. She did not know Resident #1 was missing until 5:00 PM when supper trays were passed, and the resident could not be found. CNA #1 said that she had seen Resident #1 earlier in the day talking on the phone but had not noticed any behaviors from the resident. A review of a Witness Statement dated 06/15/2025 by the Maintenance Director (MD) revealed that he evaluated all doors in the facility to ensure they worked properly. He repaired the North 400-hall courtyard fence that had been removed, and all courtyard fences were assessed for security with no negative findings. During an interview and observation on 06/24/2025 at 08:38 AM, the MD went to the secure unit with this surveyor. The secured units were shaped like a T, the 300 hall was vertical, and 400 hall was horizonal with two exit doors on both ends. There was a locked door between the 300 & 400 Halls. The MD held down the North (right side) door handle for 15 seconds and the door opened. An alarm sounded during the 15 seconds, then stopped when the door opened, then after five seconds, started alarming again. Outside the door was a wood picket fenced in area with a locked wood gate. The MD showed surveyor the two boards that was assumed Resident #1 removed to get out. The wood picket fence had three wood 2 x 4s on the opposite side for reinforcement and nails in each picket. After the elopement, the MD enforced the pickets with two additional wood 2 x 4s and wood screws in the top and bottom of every picket on the fence sections. The MD also placed a shrill alarm system on the top of both 400 hall exit that required a key to be turned off and the nurses were the ones to carry the key. The MD said that he monitored the outside gate every day and provided documentation for March, April, May, and through June 23. After the elopement on June 15, 2025, he initiated Door Monitoring ensuring the doors, keypad, mag locks, closers and alarms were properly functioning for the front lobby, 100 Hall, 200 Hall, the smoke area, service hall entrance and exit, 300 Hall entrance, 400 Hall entrance, 400 north exit and 400 south exit. The MD provided documentation showing this was monitored daily starting 06/15/25 and continued through 06/23/25 (current date). During a phone interview on 06/24/2025 at 9:00 AM, CNA #1 revealed at approximately 4:30 PM she heard the door alarm on the 400 hall going off, but she was assisting a resident in their room. She poked her head out of the room to see if anyone was at the door, but did not see anyone, so she finished with the resident. The alarm on the door continued to sound every few seconds. CNA #1 had not been working at the facility long, so she did not know the door code. She went to the 300 Hall to ask a nurse for the code. She came back to the 400 Hall, went to the door, opened it and looked outside but still did not see anyone outside. A little later after 5:00 PM, CNA #1 was asked if she knew where Resident #1 was, and was told that the resident was not found while passing supper trays at 5:00 PM. During a phone interview on 06/24/2025 at 10:37 AM, LPN #2 revealed she had been with Resident #1 previously on the 400 hall while passing medications. She said the resident kept saying Dad, Dad. She asked the resident if they wanted to call their dad. Resident #1 said yes, so a call was made, and after hanging up, Resident #1 said another family member's name. She asked if the resident wanted to call the second family member. LPN #2 called this person as well. LPN #2 reported working the 300 & 400 halls but was called to the front to get medication for another resident going on leave of absence with family, so she took Resident #1 back to 300 hall, gave the resident a honeybun and glass of water in the dining room, and asked the resident to sit and finish the honeybun until she got back. LPN #2 reported Resident #1 was standing in the dining room when she left. CNA #1 later came and asked for the code to the North door on 400 hall, which she provided. CNA #1 approached to ask if LPN #2 knew where Resident #1 was. LPN #1 said she last saw the resident in the 300-dining room eating a honeybun. CNA #1 told her that the resident was missing, and they started looking in all rooms on the 300 & 400 halls but couldn't find the resident. CNA #1 reminded her about the alarm going off. They went to the door and looked outside. At that time, they noticed some boards on the fence were missing. The DON was notified and an immediate search for the resident began. During an interview on 06/24/2025 at 11:30 AM, CNA #5 revealed that she occasionally worked in the 300 and 400 halls and was familiar with Resident #1. She said that the resident hadn't been here long but shortly after being admitted had tried to jump the fence outside. CNA #5 said she wasn't surprised that Resident #1 had eloped. Resident #1 had exit seeking behaviors and she had observed a bag packed and the resident waiting at one of the doors. CNA #5 reported thinking the facility was short-staffed, especially on weekends. During an interview on 06/26/2025 at 08:35 AM, the MDS Coordinator revealed that she was familiar with Resident #1. She said that the resident did not have exit seeking behaviors upon admission, but she was the one that completed the care plan and there were concerns for elopement in the hospital paperwork. She came in the night of the elopement so the LPN that had been working could go home. The MDS Coordinator had noticed that Resident #1 stood at the door more now, after the elopement, but was usually easy to redirect. During a phone interview on 06/26/2025 at 08:50 AM, the Medical Director revealed that he had been the Medical Director since September 2023. The facility notified him when a resident eloped, and he would give orders to send to the ER for evaluation and treatment. The Medical Director said he was familiar with Resident #1, and did not know if he had exit seeking behaviors but the resident had mentioned not wanting to be in a nursing home. During an interview on 06/26/2025 at 09:24 AM, CNA #6 revealed that she was familiar with Resident #1. She said the resident had been observed going to the doors before the elopement and was observed the day after the elopement beating on the door. CNA #6 said the resident was placed on one-on-one monitoring after the elopement, the codes on the doors were changed, they had to sign residents in and out whenever they went out to smoke or anytime they were taken off the secured units. She said that she was concerned that a resident getting out of the facility could be picked up by someone, bit by something out in the field, or just get hurt. During an interview on 06/26/2025 at 09:30 AM, CNA #7 revealed that she had observed Resident #1 pulling on the doors, before and after the elopement. CNA #7 said that she had worked 11:00 AM to 2:00 PM that day, so the elopement occurred after she left for the day. During an interview on 06/26/2025 at 10:15 AM, Medication Administration Certified (MAC) #8 revealed she was familiar with Resident #1. She said that she had observed Resident #1 standing at the door and pushing on it before the elopement occurred. During an interview on 06/26/2025 at 10:30 AM the DON stated Resident #1 did not have exit seeking behaviors before or after the elopement. The DON said that the facility process during an elopement is to search every room in the facility, then outside, to notify him (DON), the Administrator, the police department, and search until the resident is found. The physician is then called for an order to send to the ER for evaluation and treatment.During an interview on 06/26/2025 at 10:36 AM, the Administrator stated Resident #1 did not have exit seeking behaviors before the elopement. The facility had sent the resident to the ER for evaluation, then upon return monitored the resident one-on-one. Signage was posted on doors between 300 and 400 halls to remind families not to let anyone out. Maintenance had also reinforced fences on the outside on the secured units and installed another type of alarm on the doors that had to be turned off with a key. Also, the staff working on the secured units were to sign in/out all residents leaving the secured units. Review of a facility policy titled, Accidents and Hazards Policy with a revised date of 05/20/2022 revealed, the facility strives to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Following the incident and prior to the survey entrance date, the facility identified and addressed the issue with the following corrective actions: 1. Resident #1 was sent to the emergency room at a local hospital and treated for dehydration. Upon return from the hospital, the resident was placed on one-on-one monitoring. Correction completed 06/14/2025. 2. Resident #1's elopement risk assessment was updated, care plan updated to 1:1. Increased monitoring for 24 hours after family visits or calls for exit seeking behaviors and emotional distress. Correction completed 06/15/2025 3. Witness statements were collected from all staff and cognitive residents. Correction completed 06/15/2025. 4. Elopement Binder updated with Resident #1's new assessment. Correction completed 06/15/2025. 5. All residents verified for current elopement risk assessment. Updated care plans to reflect elopement interventions. Correction completed 06/15/2025. 6. Maintenance ensured all doors were secure, door alarms were functioning properly, and repaired the North 400 hall courtyard fence and areas were secure. Additional alarms with key turn offs were installed on 400 hall North and South doors. Correction completed 06/15/2025. 7. Signs were placed on doors reminding visitors to not allow residents to exit. Correction completed 06/15/2025. 8. Staff were in serviced on elopement policy and steps in the event of an elopement. Correction completed 06/16/2025. 9. Administrator/designee completed elopement drills on all three shifts with no negative findings. Correction completed 06/16/2025. 10. Door monitoring for front lobby, 100 hall, 200 hall, smoke area, service hall entrance, service hall exit, 300 unit entrance, 400 unit entrance, 400 north exit and 400 south exit. Correction completed 06/16/2025. 11. Sign in, sign out log by staff, for all secure unit resident when leaving the unit to smoke, attend activities, etc. Initiated 06/16/2025 and will be ongoing. Onsite verification of the corrective actions was completed on 06/26/2025 at 1:30 PM. A total of 15 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included 7 Certified Nursing Assistants (CNA), 1 Medicine Administration Certified (MAC), 2 Licensed Practical Nurses (LPN), The MDS Coordinator, Maintenance Director, Director of Nurses, Administrator and the Medical Director. The staff interviewed verified they had been trained on the elopement policy and steps in the event of an elopement. Elopement drills performed on 06/16/2025 on all 3 shifts with total of 29 staff members participated.