**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of nine sampled residents (Resident 1), who was identified with wandering episodes, was provided supervision, and maintained a safe and hazard free environment as indicated in Resident1 ' s care plan dated 2/21/2024. The facility failed to ensure a full bottle of hand sanitizer was not within Resident 1 ' s access or reach. As a result, Resident 1 ingested (drank) a toxic substance (hand sanitizer, a liquid or gel, typically one containing alcohol, that is used to clean the hands and kill bacteria, viruses, and other disease-causing agents on the skin) requiring admission to the General Acute Care Hospital (GACH) and was diagnosed with toxic encephalopathy (a neurologic disorder [nervous system problems] caused by consumption or exposure of harmful chemicals/toxins, that cause lead to altered mental status, memory loss, and visual problems). On 7/24/2024 at 3:58 pm., an Immediate Jeopardy (IJ - a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identified and the facility was notified of the IJ in the presence of the Assistant Administrator (AADM) and the Director of Nursing (DON), regarding the facility's failure to provide supervision and an environment free from accident hazards to prevent Resident 1 from ingesting (drinking) a toxic substance (hand sanitizer). The facility was aware Resident 1 had wandering behavior and would pick up items and place the items in her mouth. 1. On 7/7/24, Resident 1 was left unsupervised at the nurses' station and ingested approximately 160 cubic centimeters (cc- unit of measurement) of hand sanitizer. As a result, Resident 1 was admitted to the GACH and diagnosed with toxic encephalopathy and dehydration. 2. On 7/23/2024 at 1:22 pm, the facility's reception area was observed with no staff present and with a half full bottle of hand sanitizer on top of the reception desk. 3. On 7/23/2024 at 4:22 pm, during an observation of the facility's dining room Resident 1 was observed unsupervised with the door closed sitting next to a desk and one opened bottle (approximately 1 liter) of sanitizing wipes within reach of Resident 1. A sanitizing wipe was observed hanging out of the top of the container. 4. On 7/23/24 at 4:44 pm, during an observation of the facility's Maintenance Room, where cleaning solutions/chemicals were stored, the closet door was observed unlocked. There were no staff observed near the Maintenance Room to monitor and ensure no residents were not going inside the closet. Inside the Maintenance Room there was a door to a wired cage where cleaning solutions/chemicals were stored. There were observed stored several cleaning supplies and chemicals such as bleach and aerosols. The wired cage door was observed wide open, making cleaning supply available to residents. 5. On 7/23/24 at 5:57 pm, the facility's maintenance room door was observed opened with no staff present. On 7/26/2024 at 3:35 pm, the IJ was removed in the presence of the AADM, DON, Director of Staff Development (DSD), and Assistant Director of Nursing (ADON) after the onsite verification of the implementation of the IJ removal plan through observation, interview, and record review. The acceptable IJ removal plan included the following: 1. Resident 1 is being monitored by Licensed Vocational Nurse (LVN) for behavior manifested by an episode of ingesting fluids/liquid not suitable for human consumption. On 7/7/2024, Resident 1 was sent to acute hospital as ordered by the Attending Physician for further evaluation and is currently back in the facility with no sign or symptoms of intoxication. On 7/25/2024, IDT met to discuss resident current behavior and IDT recommended for facility to provide 1:1 supervision while awake. 2. On 7/25/2024 at 7:55am, Medical Director (MD), who is also Resident ' s primary physician, was contacted by the AADM and made aware of the facility's current IJ status. 3. On 7/23/2024, the Receptionist and DON removed the bottle of hand sanitizer on top of Facility's reception area. 4. On 7/23/2024, the Assistant Activity Director (AAD) and the DON removed the sanitizing wipes hanging on the top of the container inside of the facility's dining room. 5. On 7/23/2024, the Maintenance Director (MTD) locked the Maintenance Room and the wired cage. On 7/24/2024, MTD replaced the doorknob on the self-closing door located in the maintenance room, the door now self-locks. The MTD and/or Social Services Designee (MOD to check on weekend), will check the maintenance room around 10am, Minimum Data Set Nurse (MDSN) and/or Infection Preventionist (IP), (manager of the day (MOD) to check on weekend) will check around 3 pm and Desk Nurse and/or CART 2 Licensed Vocational Nurse (LVN) will check around 7 pm utilizing the Maintenance Room to ensure door was locked when room was unattended, noncompliance will be reported immediately to Administrator and/or DON. On 7/25/2024, the Registered Nurse (RN) Consultant reeducated the MTD the importance of locking the door where the facility keeps cleaning supply/chemicals to prevent visitors and residents' access. 6. On 7/23/2024 and 7/24/2024, The department heads consisting of the Business office manager, admissions coordinator, MDS Coordinator, Social Services Director (SSD), MTD, DSD, ADON, Dietary Supervisor, Discharge Planner, DON, immediately checked all the facility's common areas and removed all loose bottles of Alcohol-based hand rub (ABHR- is the preferred method for standard hand hygiene, kills the majority of viruses [an infectious agent that can only replicate within a living thing] from hands) to prevent any resident from accidentally ingesting toxic substances. 7. The IP, Activity Director (AD) would conduct daily room rounds before stand-up meeting at 9:30 a.m., utilizing a log Loose bottles hand sanitizer check to ensure that there are no loose bottles, noncompliance will be reported immediately to Administrator (ADM) and/or DON. of hand sanitizer available inside the facility for one month and weekly thereafter. Loose bottles of ABHR were disposed. Beginning 7/24/2024, Central Supply Staff will no longer order loose bottle hand sanitizer and removed current loose bottle hand sanitizer from the facility and disposed accordingly. 8. On 7/24/2024, the seven residents identified by the facility to be at risk of wandering were being observed by the licensed nurses when approaching ABHR dispensers to ensure residents will not accidentally or intentionally ingest ABHR. The monitoring will be documented on the electronic health record (EHR). Licensed Nurses to report immediately if resident safety is compromised to the ADM and/or DON and in the absence of ADM or DON, the incident would be reported to ADON or designee. Licensed Nurses to inform Certified Nursing Assistants by providing a list of residents identified to be at risk of wandering that are being observed by licensed nurses for when approaching ABHR dispensers to ensure residents will not accidentally or intentionally ingest ABHR. List of residents will be updated by Licensed Nurses when there is resident identified during admission to be high risk, when resident is being transferred or discharged or with change of condition. 9. On 7/25/2024, RN Nurse Consultant educated facility department heads which included (DON, ADM, AADM, DSD, IP, MD, AD, Social Services Designee, Dietary supervisor (DS), Business Office Manager (BOM), ADON, admission Coordinator) regarding the importance Identifying environmental hazards/risks (such as housekeeping chemicals or ABHR and implementing interventions to prevent accidents. The Department Heads that were not able to attend the in-service will be reeducated by DON before they return to work regarding the importance of Identifying environmental hazards/risks. Beginning 7/25/24 and ongoing the DON and ADON provided reeducation to all staff regarding the importance of maintaining toxic substances such as hand sanitizers out of reach of residents and importance of locking the door where facility keeps cleaning supply/chemicals to prevent visitors and residents' access. As of today, the facility has 121 total staff of which 17 are on vacation or out sick. There are 77 staff who completed the in-service, remaining 44 (including the 17 staff) Staff that were not able to attend the in-service will not be allowed to work until in service is completed. The DON and/or ADON and in the absence of both, the DSD and/or Infection Preventionist will review the checklist of facilities who were not in-serviced to ensure staff will be in-serviced before coming back to work. 10. On 7/25/24, the facility begun a Performance Improvement Plan (PIP) titled Toxic substances storage and supervision of residents with following goals and interventions: i. The resident environment remains as free of accident hazards as possible. ii. Each resident receives adequate supervision and assistance devices to prevent accidents by ensuring the MTD, the maintenance department staff and (4) housekeeping/laundry staff understood the importance of locking the door where the facility keeps cleaning supplies/ chemicals to prevent visitors and residents' access. Newly hired Maintenance staff and housekeeping staff will be in-serviced by MTD regarding the importance of locking the door where facility keeps cleaning supply/chemicals to prevent visitors and residents' access before 1st day of work. iii. The Interdisciplinary Team consisting of the BOM, Admissions Coordinator, MDS Coordinator, Social Services Director (SSD), MTD, DSD, ADON, DS, Discharge Planner, IP, AD, would conduct daily room rounds before stand-up meeting at 9:30 a.m., utilizing a log Loose bottles hand sanitizer check to ensure that there are no loose bottles, noncompliance will be reported immediately to ADM and/or DON. iv. Licensed Nurses to inform Certified Nursing Assistants (CNAs) by providing a list of residents identified to be at risk of wandering that are being observed by licensed nurses for when approaching ABHR dispensers to ensure residents will not accidentally or intentionally ingest ABHR. List of residents will be updated by Licensed Nurses when there is resident identified during admission to be high risk, when resident is being transferred or discharged or with change of condition. D v. Department Heads that were not able to attend the in-service will be reeducated by DON before they return to work regarding the importance of Identifying environmental hazards/risks. Department heads which did not attend the training, will not be allowed to work until in service is completed. (such as housekeeping chemicals or ABHR {Alcohol based hand rub) and implement interventions to prevent accidents. vi. The DON and/or ADON and in the absence of both, the DSD and/or Infection Preventionist would review the checklist of facility who were not in-serviced to ensure staff will be in-serviced before coming back to work. The PIP target end date is 8/30/24, the facility would evaluate its effectiveness weekly or as necessary to ensure its approaches/interventions are effective. If approaches are deemed ineffective the team will discuss new approaches/interventions. IF PIP is found ineffective QAPI committee which includes the ADM, the MD, the DON, ADON, MDS Coordinator, Medical Records Director, SSD, MTD, DSD, DS, Discharge Planner, IP, would update or revise interventions. Findings: During a review of Resident 1 ' s admission record, the record indicated the facility initially admitted Resident 1 on 2/17/2024 and was readmitted on 7/12//2024 with diagnoses that included toxic encephalopathy, dementia (loss of cognitive functioning-thinking, remembering, and reasoning), chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), and aphasia (loss of ability to understand or express speech, caused by brain damage). During a review of Resident 1 ' s care plan (CP) titled, Resident with wandering episode secondary to: Dementia initiated 2/21/2024, the CP indicated for interventions: Constant monitoring of whereabouts and maintain safe and hazard free environment. During a review of Resident 1 ' s Minimum Data Set (MDS- standardized data collection tool used to assess cognitive and functional status, and care needs) dated 6/23/2024, indicated Resident 1 had severe cognitive impairments (when social and occupational functions are limited where an individual may not be able to recognize people, use language, or execute purposeful movements). The MDS indicated Resident 1 required between partial/moderate to substantial/maximal assistance for Activities of Daily Living (ADLs – eating, oral hygiene, toileting, showers/bathing, dressing, personal hygiene, and toilet transfer. During a review of Resident 1 ' s History and Physical (H & P) dated 6/8/2024, the H & P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1 ' s nurse progress notes dated 7/7/2024 at 4:30 pm indicated Resident 1 had ingested 165 cc of hand sanitizer, called Medical Doctor (MD) with new orders to transfer out to hospital to monitor for symptoms of intoxication (is the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs). During a review of Resident 1 ' s nurse progress notes dated 7/7/2024 at 6 pm indicated Resident 1 was picked up by two Emergency Medical Technicians (EMTs- a person who is trained to give emergency medical care at the scene of an accident or in an ambulance) in an ambulance going to GACH for further evaluation for ingestion of alcohol hand sanitizer. During a review of Resident 1 ' s physician ' s order dated 7/7/2024 at 4:30 pm, indicated transfer resident to hospital for further evaluation of ingestion of hand sanitizer. During a review of Resident 1 ' s CP initiated on 7/7/2024 for behavioral problems, the care plan indicated, resident ingested almost 165cc of hand sanitizer, resident is more confused. Wandering. During a review of Resident 1 ' s GACH History and Physical (H&P) records dated 7/12/24 under assessment and plan indicated the following: Toxic encephalopathy due to ingestion of hand sanitizer, cognitive impairment (Problems with a person's ability to think, learn, remember, use judgement, and make decisions) and altered mental status upon admission, consistent with toxic encephalopathy. The same H&P indicated, monitor neurological status (consists of a physical examination to identify signs of disorders affecting your brain, spinal cord, and nerves) and mental alertness every 2 hours. Administer intravenous (a way of giving a drug or other substance through a needle or tube inserted into a vein) fluids and electrolytes (minerals in your blood and other body fluids that carry an electric charge) to manage dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work normally) due to ingestion. Provide activated charcoal (a fine, odorless, black powder often used in emergency rooms to treat overdoses) if within ingestion window to reduce systemic absorption (the movement of drug from the site of drug administration to the systemic circulation). Consult Poison Control Center for further management and antidote (a remedy to cancel the effects of poison) recommendations PRN (as needed) for complex cases. During an interview with LVN 3 on 7/23/2024 at 12:21 pm, stated that on 7/7/2024 at 4:30 pm while he (LVN 3) was sitting on the inside of the nurses ' station, LVN 3 observed Resident 1 who was sitting on a wheelchair grab a bottle of hand sanitizer which was full (221 cc) opened it, and started drinking it. LVN 3 stated that Resident 1 drank 165 cc of the hand sanitizer. LVN 3 admitted that Resident 1 was known (no time stated) to place items in her mouth that she could get her hands on, but that the behavior was not care planned. During a concurrent observation of the reception desk and interview with the DSD on 7/23/24 at 1:22 pm, the DSD confirmed and stated that there was no staff present at the reception desk. The DSD stated the sanitizer should be at the receptionist desk but was unable to state how the facility would prevent a confused resident with easy access from consuming the hand sanitizer. The DON stated the hand sanitizer could be toxic if consumed especially that residents are taking medications. During a concurrent observation of a desk in the admission ' s office and interview with the DON 7/23/24 1:27 pm, a loose bottle of hand sanitizer was observed within easy access for residents. The DON admitted the residents had access to the office and that the residents who are confused might consume the easily accessible hand sanitizer. The DON stated the potential effect if consuming hand sanitizer may be toxic and require medical attention. The affected resident may result in resident getting drunk. During a concurrent observation of Resident 1, interview, and record review with the ADON on 7/23/24 at 4:22 pm, Resident 1 ' s admission records dated 7/12/24 was reviewed. Resident 1 was readmitted to the facility on [DATE]. Resident 1 was observed sitting on a chair against the wall in the dining room unsupervised with the door closed. Right behind Resident 1 within easy access was a wall mount containing two boxes of gloves and another one next to the gloves containing about one liter of sanitizing wipes with one wipe hanging over the container. The ADON as well as the activities staff (AS) confirmed the observation. The ADON admitted that Resident 1 had easy access to the sanitizing wipes and could ingest them with her history of ingesting nonedible substances. During a concurrent observation and interview of the maintenance room (just across the hallway from the dining room approximately 30 feet from the dining room where Resident 1 was sitting) on 7/23/24 at 4:48 pm with the DON, the door was tied open using a string connected to the doorknob and a wire behind the door. There were no staff observed near the Maintenance Room to monitor and ensure no residents were not going inside the room. Inside the Maintenance Room there was a door to a wired cage where cleaning solutions/chemicals were stored. There were observed stored several cleaning supplies and chemicals such as bleach and aerosols. The wired cage door was observed wide open, making cleaning supply available to residents. The DON confirmed the observation and admitted that the room was easily accessible to residents. During a concurrent observation and interview with the DON of the Maintenance Room on 7/23/24 at 5:57 pm, The Maintenance Room was unattended, and the doors were open, and the caged door (containing cleaning supplies) was open. The DON confirmed and stated that residents had easy access and may consume the chemicals stored in the room. During an interview with Resident 1 ' s Primary Medical Doctor/Medical Director (PMD/MD) on 7/24/24 at 10 am, PMD/MD stated that Resident 1 required a 1:1 sitter after the incident on 7/7/24 for safety to prevent her from consuming toxic substances. The potential effects of consuming these toxic substances may result in metabolic acidosis (too much acid in the blood and can be life-threatening if not treated appropriately), esophageal strictures (narrowing of your esophagus (swallowing tube), cell injury, and death. During a review of the facility ' s policy and procedures (P&P) title Dementia-Clinical Protocol. Resident Behavior , release date 8/1/2023, the P & P indicated, The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements. During a review of the facility ' s P & P titled Alcohol-Based Hand Rub Dispensers, Installation and Use, release date 1/2024, the P & P indicated, Alcohol-based hand rub dispensers shall be installed in areas that facilitate access by healthcare personnel and maintain a safe environment for the residents and staff. The same P&P indicated processes which included: Residents with cognitive or behavioral challenges and will be observed when they are near Alcohol Based Hand Rub (ABHR) dispensers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision and follow their policy and procedures titled, Wandering-Unsafe Residents, to ensure two of three sampled residents (Resident 1 and Resident 2) would not elope (leaving facility without notice or permission) from the facility. The facility failed to: -Develop and implement a person-centered comprehensive elopement care plan for Resident 1 and Resident 2. -Ensure Resident 1 and Resident 2 received care and supervision to prevent accidents and elopement. -Implement elopement care plan interventions to monitor Wander Guard (a device that resident wear and when attempts to wander too close or through the doorway, the door monitor alarm sounds audibly) placement and functioning for Resident 1 and monitoring resident's whereabouts for Resident 2. -Ensure the exit alarms were working properly. As a result, on 3/6/2022, Resident 2 eloped from the facility was found on the street the following day at 2:10 AM. Resident 2 was transferred to the General Acute Care Hospital with abrasions, laceration to left eyebrow, high temperature (fever) and change of Level of Consciousness (ability to relate to self and environment). In addition, Resident 1 eloped from the facility on 12/14/2022 and admitted to GACH 1 on the same day with lacerations (deep cut or tear in skin) and hematoma (a mass of clotted blood) to forehead. Resident 1 eloped again on 12/22/2022. and was admitted to GACH 2 on 12/24/2022 with blunt head trauma (when the head is impacted by a force). On 12/28/2022 at 3:06 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the Director of Nursing (DON), the Infection Preventionist and the Social Services Director, regarding the facility's failure to properly identify residents who were at risk for elopement and to prevent Resident 1 and Resident 2 from eloping from the facility. On 12/30/2023 at 4:48 p.m., while onsite at the facility, the IJ was lifted after the Administrator (ADM) and DON submitted an acceptable Removal Plan (interventions to correct the deficient practices) which was verified and confirmed through observation, interview and record review. The IJ was removed in the presence of the DON. The acceptable removal plan was as follows: 1. On 12/29/2022, Registered Nurse Supervisor and Licensed Nurse conducted a resident head count. All 87 residents were accounted for every four hours for 24 hours. Licensed Nurse and Certified Nursing Assistant (CNA) or designated staff member shall do a head count at the beginning of each shift and shall complete the log provided thereafter. 2. A designated staff was assigned to monitor the entrance/exit door for 24 hours until the new wander guard system and monitor at the Nursing station is installed. The designated staff shall check each person coming out of the exit door. Procedure as follows: -For staff members they must present their identification badge prior to exiting. -For visitors, upon entering they will be given a visitor's name tag /badge to be worn during their visit and must be surrendered upon exit. All other individual who attempts to exit and is not a staff member nor a visitor must be validated first before they can be let out. (May refer to the binder with resident's pictures). All residents' photos were compiled in a binder and placed by the exit door for reference. On 12/29/2022, maintenance supervisor inspected the wander guard system and wander guards and have identified that the system is no longer at its full function. A new wander guard system order was placed on 12/29/2022. 3. The DON and Minimum Data Set (MDS) coordinator re-assessed all 87 residents for elopement/wandering risk., all residents at risk for elopement will be reviewed further and based on the recommendations of the Interdisciplinary Team (IDT) members will obtain an order for wander guard or 1 to 1 (1:1) sitter until deemed stable/safe; residents who are at risk for elopement may have to be placed closer to the nursing station or farther from the exit doors whichever is appropriate/safer for the resident's needs. IDT to follow up and shall be completed by 12/29/2022. 4 residents were identified to be high risk for elopement; care plans were reviewed and renewed. IDT was conducted on 12/29/2022. 4. The DON provided an In-service training and re-education to all staff on Accidents/Hazards and Supervision with Emphasis on Elopement and Wandering on 12/28-12/29/2022. 5. The DON or designee shall review all the new admissions and re-admissions for elopement risks and validate the accuracy of the initial assessment. In addition, the DON or designee shall review any change of condition that is related to elopement and validate accuracy of assessment and the interventions that was put in place. Any findings shall be corrected immediately and shall be discussed daily during stand-up meeting for follow up. 6. A monitor shall be installed at the Nursing station for nurses to be able to monitor live footage of the exit doors within the next 10 days. The DON placed an order for a new Wander Guard system on 12/29/2022 and shall be installed within 10 days. A review of the facility's policy and procedure on Elopement and wandering shall be done and necessary changes will be made as needed recommended by the Quality Assurance and Assessment (QAA) committee. 7. Director of Staff Development shall conduct a follow up in-service on Accidents/Hazards/Supervision every week for one month then monthly for one month, then quarterly for two months, and as needed thereafter. 8. Administrator shall keep track on the findings, Trends, or any issues related to Accidents/Hazards/Supervision shall be discussed during the monthly Quality Assurance and Assessment (QAA) meeting for recommendations to ensure continued compliance. Findings: a. A review of Resident 1's Face sheet (admission Record) indicated the facility admitted Resident 1 on 1/20/2022 and readmitted on [DATE], with diagnoses including dementia (loss of memory, thinking and reasoning), psychosis (a mental disorder characterized by a disconnection from reality), depression (a mood disorder with feeling of sadness and loss of interest), and history of falling. A review of Resident 1's Physician's Orders dated 1/20/2022 indicated to place a wander guard alarm on the resident's left arm because of his tendency to wander outside the facility, monitor wander guard alarm for proper placement and functioning every shift, and change Wander Guard alarm every three months. A review of the Care Plan dated 1/20/2022 indicated Resident 1 had a tendency of wandering outside the facility. The goal indicated Resident 1 would remain inside the facility and would not manifest signs of elopement. The care plan approach indicated for staff to observe for signs of elopement such as verbalization of wanting to go outside / home by the resident, searching behavior, looking for exit doors, watching others exit the facility, monitor resident`s whereabouts, apply wander guard alarm on left arm of the resident, and that the Licensed Vocational Nurse / Certified Nursing Assistant (LVN / CNA) assigned to Resident 1 should know the resident`s whereabouts with proper endorsement during breaks. According to a review of Resident 1's Initial Wandering Assessment Guide dated 1/21/2022, the resident was ambulatory, able to walk alone, with a history of wandering. A review of Resident 1`s Physician's History and Physical (H&P) dated 1/22/2022 indicated, the resident had fluctuating (changing) capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 2/1/2022, indicated Resident 1 had intact cognition (able to make decisions consistent). The MDS indicated the resident did not have wandering behavior, required limited assistance with one-person physical assistance for activities of daily living (ADLs, such as transferring, walk in room and corridor, dressing, toilet use, and personal hygiene). A review of Resident 1's Physician's Orders dated 8/8/2022 at 2:30 PM indicated to transfer the resident to hospital for further evaluation and treatment for COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and transmitted from person to person), and high temperature of 101-degree Fahrenheit (F-normal temperature ranges between 97-degree F to 99-degree F). A review of Resident 1`s GACH 3 Physician`s Noted dated 8/9/2022 indicated the resident was transferred to the hospital for cough and shortness of breath. Resident 1 was positive for COVID-19 and his laboratory tests show acute kidney injury (a condition in which the kidneys suddenly cannot filter waste from the blood), and hypokalemia (lower than normal potassium [a mineral that body needs to work properly] in the blood). A review of Resident 1`s re-admission orders dated 8/11/2022, did not indicate an order for placement and monitoring of a wander guard alarm. A review of Resident 1`s Care Plans dated 8/11/2022 indicated no care plan was updated regarding Resident 1`s tendency to wander outside the facility. The MDS dated [DATE] after resident`s re-admission indicated Resident 1 had moderately impaired cognition (decisions poor, cues/supervision required). A review of Resident 1`s Investigation Report dated 12/14/2022 indicated the resident was missing and had eloped. The report indicated Resident 1 was already missing when the morning shift started at 7 AM. A review of Resident 1`s Investigation Report dated 12/14/2022 indicated Resident 1 was last seen on 12/14/2022 at 6:45 AM. The corrective action and plan of care indicated to apply a Wander Guard alarm to Resident 1's left arm. According to a review of the Facility`s Missing Person Report dated 12/14/2022, Resident 1 was found in GACH 1 on 12/14/2022 at 11 PM confused with multiple bruises on his face. A review of the GACH 1 Physician`s H&P form dated 12/14/2022 at 11:10 PM indicated Resident 1 was found altered and minimally responsive on a park bench. Resident 1 was noted to have a hematoma (an injury causes blood to collect and pool under skin) to the forehead. A review of GACH 1 Discharge Summary Notes dated 12/15/2022 at 7:23 PM indicated, A clinical picture concerning for possible intracerebral brain hemorrhage (ICH- bleeding in brain) and infections. The note indicated possible acute versus chronic laceration to Resident 1`s rectum. Given Resident 1`s unclear history, he will be treated empirically (treatment given based on experience without knowledge of cause) for possible sexual assault (offensive physical contact or bodily harm on a person). A review of Resident 1`s Actual Elopement Care Plan dated 12/14/2022 indicated the goal was for Resident 1 to have no daily episodes of elopement. The care plan approach indicated to observe for signs of elopement such as searching behavior, looking for exit doors and watching others exit the facility, monitor resident`s whereabouts, apply wander guard alarm to resident`s left arm as ordered, monitor wander guard alarm for proper placement and functioning every shift, change Wander Guard alarm every three months and LVN/CNA assigned to him should know the resident`s whereabouts and proper endorsement during breaks. A review of Resident 1`s Physician`s Order dated 12/15/2022 at 4 PM indicated to place a Wander Guard alarm on resident's left arm because of his tendency to wander outside the facility, monitor wander guard alarm for proper placement and functioning every shift, and change Wander Guard alarm every three months. A review of Resident 1`s Wander Guard Alarm Monitoring Log initiated on 12/15 - 12/22/2022, indicated no entries for monitoring. The Monitoring Log instructions indicated: After completing the signaling device test, make your initial in the box. Note special circumstances on the comment list (e.g., wristband replacement or damage to signaling device case). The form was blank and did not have a single entry. A review of the Elopement Risk assessment dated [DATE], indicated Resident 1 was a readmission who exhibited routine or sporadic (occasional) confusion, anxiety or disorientation, exhibits wandering with no purpose, searching or looking for exit doors, and had a history of elopement. The elopement risk assessment indicated Resident 1 was at risk for elopement. According to a review of Resident 1's Medication Administration Record (MAR) dated 12/15 - 12/22/2022, Resident 1 was not monitored for proper placement and functioning of Wander Guard alarm, per the physician's instructions. During an observation on 12/22/2022 at 3 PM, Resident 1 was observed in the hallway, walking around. During a concurrent interview, Resident 1 was asked if he left the facility and he stated yes. Resident 1 was not able to answer further questions and he repeatedly stated that he was okay. A small abrasion above Resident 1`s upper lip and a scratch on his chin were observed. A Wander Guard alarm was observed on the resident's left wrist. A review of Resident 1`s Nurses Notes dated 12/22/2022 documented by LVN3 indicated, at 6:30 PM Resident 1 was observed walking around the facility. The Nurses Notes indicated Resident 1 was always wandering inside the facility. At 7 PM nursing staff noted the resident was not in his room. The search for Resident 1 was initiated and staff searched throughout the facility and nearby neighborhood and was not able to find Resident 1. The note indicated that on 12/22/2022 at 10:30 PM, the police arrived at the facility and filed a missing resident report. A review of the GACH 2 Physician`s H&P dated 12/23/2022 at 1:23 PM indicated Resident 1 was found sitting down in the street with multiple abrasions (superficial injuries of skin). The physician`s notes further indicated Resident 1 appeared anxious, shaky and complained of pain to his left knee. A review of the GACH 2 Emergency Department (ED) Physician`s notes dated 12/23/2022 at 11:20 PM indicated Resident 1 showed possible signs of alcohol withdrawal (symptoms that occur when someone stops using alcohol after a period of heavy drinking) with tongue fasciculations (twitching and involuntary contraction and relaxation of tongue muscle) and bilateral (both sides) hand tremors (shake). The notes indicated Resident 1 was covered in paint and was suspected of possible huffing (a type of substance abuse that involves inhaling fumes from common household substances) versus alcohol withdrawal. The impression and plan indicated blunt head trauma. A review of Resident 1`s Nurses Notes dated 12/24/2022 at 10 AM indicated the facility received a call from GACH 2 informing that Resident 1 was admitted into the hospital. The note indicated Resident 1`s family member, physician and the police were notified. A review of the GACH 2 Physician Progress Note dated 12/27/2022 at 3:05 PM indicated Resident 1 tried to climb out of his bed and attempted to pull out his lines, which required bilateral (both sides) soft wrist restrains (device that limit a patient`s movement). During an interview on 12/28/2022 at 10:42 AM, The DON stated although there were surveillance cameras at the front and the back doors of the facility, according to the facility`s Administrator (ADM), there was no back up footage to be reviewed. The DON stated Resident 1 had a history of removing his Wander Guard alarm, but the facility did not develop any care plans for Resident 1`s repeated behavior to remove his Wander Guard alarm. The DON further stated she was not sure how Resident 1 exited the facility and that It might be from the front door or the back door. During an interview on 12/28/2022 at 12:20 PM, Director of Social Services (DSS) stated Resident 1 eloped from the facility for the first time on 12/14/2022 and he did not have a Wander Guard alarm because he never showed any exit seeking behavior. The DSS stated Upon Resident 1's re-admission back to the facility on [DATE], we placed a Wander Guard alarm. The DSS stated Resident 1, Never told me that he wanted to go home. The DSS stated Resident 1 eloped from the facility on 12/22/2022 with his Wander Guard alarm on his wrist. During an interview on 12/28/2022 at 1:50 PM, CNA 1 stated, Resident 1 was always walking around in the facility. He would enter inside other residents` rooms. He was confused and walking without a walker. CNA1 stated Resident 1 used to remove his Wander Guard alarm from his arm and we would find the Wander Guard alarm in his room. During an interview on 12/28/2022 At 2:35 PM, the DON stated Resident 1 did not have a Wander Guard alarm when he was readmitted to the facility on [DATE] because he was too weak and unable to ambulate but confirmed Resident 1 remained a high risk for elopement on 8/11/2022. The DON stated that after Resident 1 recovered and he was no longer weak, there was no re-assessment done regarding his ability to elope from the facility and consequently Resident 1 remained in the facility without a Wander Guard alarm on his person. The DON stated Resident 1 eloped from the facility on 12/14/2022. The DON stated the facility did not provide enough monitoring for Resident 1 to prevent him from eloping. During an interview and concurrent record review of Resident 1`s care plans on 12/28/2022 at 2:37 PM, the DON stated there was no form indicating how the assigned staff members were monitoring Resident 1's whereabouts and providing proper reports during breaks. The DON confirmed that care plan intervention requirement to check Resident 1`s Wander Guard during every shift was not performed during the month of December 2022. The DON stated Resident 1's care plan did not indicate the frequency of monitoring resident`s whereabouts. The DON also confirmed there was no documentation in Resident 1's medical record indicating that this monitoring was performed by the staff. The DON stated Resident 1's care plans were not updated after his first elopement which occurred on 12/14/2022. The DON stated the facility could have developed a more appropriated person-centered care plan for Resident 1 to prevent elopement. During an interview on 12/28/2023 at 2:40 PM, the DSS stated she was in charge of checking residents Wander Guard alarms. DSS stated, I check their alarms every week. The DSS stated that for Resident 1, she initiated the Wander Guard monitoring log on 12/15/2022 and did not perform the wander guard alarm check for Resident 1 on 12/22/2022. During an observation on 12/29/2022 at 3 PM, the Assistant Maintenance Supervisor (AMS) brought a tester for the facility door's Wander Guard alarm. During the observation the tester did not consistently trigger the alarm when the front door barrier was crossed. During a concurrent interview, the AMS stated the Wander Guard testing device was not setting off its alarm consistently. The AMS stated that when the Wander Guard alarm was in fact triggered, it was deactivated by a code manually entered on to the system platform. During an observation on 12/29/2022 at 3:09 PM, the AMS tested the Wander Guard alarm for the back door and the tester did not trigger the alarm when the back door barrier was crossed. During a concurrent interview with the DON, the DON stated and confirmed that the Wander Guard testing device was not setting off the alarm at the back door. During an interview on 12/30/2022 at 11:16 AM, regarding Resident 1's elopements on both 12/14/2022 and 12/22/2022, the facility Administrator (ADM) stated it was either the Wander Guard alarm system not working properly to recognize a breach, or the alarm engaged, and the staff deactivated the alarm without verifying weather or not a resident had exit the facility. During a telephone interview on 1/3/2023 at 10:43 AM, Family Member 1 stated, I know the facility is not a locked unit (a secured ward in a manner that prevents a resident from leaving the unit at will) and my family had a sensor on his arm. Family Member 1 stated, It is either the facility's alarm system was not working properly, or the staff simply did not pay attention when the alarm went off. Family Member 1 stated, I believe the facility could have done a better job supervising my family to prevent him from exiting the facility two times in one month. Family Member 1 stated, I visited my family in the hospital, he was confused, and he was repeating sentences. He was on restraints because the nurses told me that he was trying to remove his intravenous (IV - a way of giving a drug through a needle or tube inserted into a vein) access. During an interview on 1/3/2023 at 12:26 PM, CNA 2 stated that Resident 1 probably eloped at the back door because the alarm at the back door exit did not sound as loud as the alarm at the front door exit. CNA2 stated on 12/22/2022, he was assigned to Resident 1 during the 3PM-11PM shift, at around 4:30 PM, Resident 1 was agitated and wandering throughout the facility. During an interview on 1/3/2023 at 1:10 PM, LVN2 stated, On 12/14/2022, I was assigned to Resident 1. At 7 AM, we started to pass the breakfast trays. The staff reported to me that Resident 1 did not touch his breakfast tray and nowhere to be found. We initiated a search for Resident 1 which included asking the night shift nurses wether or not they had seen Resident 1. They told us that Resident 1 was last seen at 6:45 AM. LVN2 stated the potential outcome of not providing adequate supervision for residents is elopement and consequent injuries and/or harm. During a telephone interview on 1/3/2023 at 2:21 PM, The ADM stated, The DON and I normally review the facilities policies and procedures and update accordingly in the event there is an issue and requires a revision. The ADM stated he did not know what was the required time period within which the facility must review or revise its policies and procedures. The ADM stated the 'Safety and Supervision of Residents policy currently in place was not dated and the Elopement policy and procedure was revised on December 2007. The ADM stated, for the undated policies, I do not have a way to know when it was actually revised. During a telephone interview on 1/6/2023 at 4:10 PM, Resident 1`s assigned RN Care Team Manager (RN-CTM) for Aids Healthcare Foundation-Positive Healthcare stated that she visited Resident 1 in GACH 2 on 12/27/2022 and she observed Resident 1's wander guard alarm remained on his left arm. During an interview on 1/12/2023 at 10:06 AM, the DON stated, The Initial Wandering Assessment Guide was a form the facility was using previously to perform wandering assessment for residents. The DON stated, The facility is currently using the Elopement Risk Assessment because this form is more accurate. The DON stated there was no Elopement Risk Assessment done on 1/21/2022 (first admission) for Resident 1. b.A review of Resident 2's Face sheet indicated the facility admitted Resident 2 on 2/2/2022 and readmitted on [DATE] with diagnoses including dementia, encephalopathy (any brain disease that altered brain function or structure), and history of falling. A review of Resident 2's Physician's Orders dated 2/2/2022 indicated to place a wander guard alarm on resident `s left arm because of his tendency to wander outside the facility, monitor Wander Guard alarm for proper placement and functioning every shift, and change wander guard alarm every three months. A review of the Care Plan dated 2/2/2022 indicated Resident 2 had a tendency of wandering outside the facility and needed a Wander Guard alarm due to history of elopement from other facility as reported by the discharging hospital, family, and the physician. The care plan goal indicated Resident 2 would remain inside the facility and will not manifest signs of elopement. The care plan approach indicated to observe for signs of elopement such as verbalization of wanting to go outside / home by the resident, searching behavior, looking for exit doors, watching others exit the facility, monitor resident's whereabouts and apply Wander Guard alarm on left arm of the resident. According to a review of Resident 2's Initial Wandering Assessment Guide dated 2/3/2022, the resident had dementia, was ambulatory and able to walk alone, with a history of wandering. A review of Resident 2`s Physician's H&P dated 2/5/2022 indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 2`s Elopement Care Plan dated 3/6/2022 indicated Resident 2 was nowhere to be found when the RN was making his rounds at 12:30 PM. The nurses searched throughout the facility, and the neighboring blocks. The care plan indicated that on 3/7/2022 at 1:05 AM, a police officer called the facility and reported that they found Resident 2 on the street. On 3/7/2022 at 2:10 AM the police dropped off Resident 2 at the facility. The care plan approach indicated for the staff to observe for signs of elopement such as verbalization of wanting to go outside/home by the resident, searching behavior, looking for exit doors, watching others exit the facility, monitor resident`s whereabouts, apply wander guard alarm on left arm of the resident and LVN/CNA assigned to the resident should know the resident`s whereabouts and proper endorsement during breaks. A review of Resident 2's Physician's Orders dated 8/16/2022 indicated to transfer resident to hospital for COVID-19, generalized weakness, and temperature of 102.9-degree Fahrenheit. A review of the Elopement Risk assessment dated [DATE], indicated Resident 2 was a readmission who exhibited routine or sporadic (occasional) confusion, anxiety or disorientation, exhibits wandering with no purpose, searching, or looking for exit doors, and has a history of elopement. The elopement risk assessment indicated Resident 2 was at risk for elopement. A review of Resident 2's Incident Investigation Report dated 11/1/2022 at 5 PM, indicated the nursing staff noted Resident 2 was not in his room when he was making his rounds. Staff searched throughout the facility, building and nearby neighborhood and was not able to find Resident 2. The note indicated that on 11/2/2022 at 12 PM, the facility received a call from GACH 1 reporting Resident 2 was in the hospital with some abrasions, laceration to left eyebrow and change of Level of Consciousness (ability to relate to self and environment). A review of GACH 1 physician's H&P dated 11/1/2022 at 11:35 PM indicated Resident 2 was brought into the Emergency Department (ED) after a ground level fall. Resident 2 reported that he was walking down the sidewalk and fell on his head. Resident 2 was noted to have a three-centimeter (cm) laceration above the left eyebrow which was sutured (to close a wound with threads) and ecchymosis (bruise) on his left cheek. A review of the MDS dated [DATE], indicated Resident 2 had intact cognition (was able to make decisions) and required limited assistance with one-person physical assistance for ADLs, such as dressing, toilet use, and personal hygiene). The MDS indicated Resident 2 did not exhibit wandering behavior. During an interview on 1/3/2022 At 2 PM, The DON stated there was no form indicating how the assigned staff members are monitoring Resident 2's whereabouts and providing proper reports during breaks. The DON stated Resident 2's care plan does not indicate the frequency of monitoring resident's whereabouts. The DON also confirmed there is no documentation in Resident 2's medical record indicating that this monitoring was performed by the staff. The DON stated that Resident 2's care plans were not updated after his first elopement which occurred on 3/6/2022. The DON stated that the facility could have developed a more appropriated person-centered care plan for Resident 2 to prevent elopement. A review of an undated policy and procedure titled, Wandering-Unsafe Residents, indicated the staff will identify residents who are at risk of harm because of unsafe wandering (including elopement). The staff will assess at-risk individual for potentially correctable risk factors related to unsafe wandering. The policy indicated that the resident`s care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. Nursing staff will document circumstances related to unsafe actions, including wandering by a resident. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. A review of an undated policy and procedure titled, Safety and Supervision of Residents, indicated resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident`s assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there is a change of condition. The policy indicated that resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.