**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#3) of three residents at risk for elopement out of 17 sample residents received adequate supervision and were kept free from elopement. Specifically, the facility failed to provide Resident #3 with the supervision necessary to prevent elopement. The facility's failures created a situation for the likelihood of serious harm to residents' health and safety if not immediately corrected. The facility was a totally secure building specializing in serving residents with severe mental illness, dementia and behavioral health issues. The entire campus had a six-foot high security fence around the whole campus with a wired overhang in the unrestricted front resident space to discourage anyone from climbing over the fence. The back fenced-in areas did not have the wired overhang, but access was restricted in the overnight hours when staff were not able to monitor residents in those areas. Staff and visitors had to be keyed in and out of the front gate. Prior to his admission to the facility on 7/31/23, Resident #3 was diagnosed with dementia and schizophrenia and had a known history of untreated schizophrenia. He continued to refuse treatment and denied having the diagnosis of schizophrenia. While in the hospital, the resident was assessed to have decisional incapacity with an inability to take care of himself; because of this, he was assigned a court-appointed guardian. While at the hospital awaiting mandated placement, he eloped from the hospital setting and had to be returned to the hospital by a police escort. Resident #3 eloped from the facility on 12/30/24 at approximately 7:15 p.m. and was not noticed to be absent from the facility until 12/31/24 at 11:30 a.m. (approximately 16 hours later) when staff were gathering residents for lunch. After an initial search of the facility and the surrounding neighborhood on the morning of 12/31/24, the facility discovered the resident had spent the night at the local hospital. The hospital assessed the resident, gave him a referral to a local homeless shelter and released him. The resident left the hospital and was found shortly afterward by facility staff wandering in an open field near the hospital. Facility leadership viewed video footage of the outdoor space as a part of their investigation to determine how Resident #3 got out of the secured fencing. The resident was viewed on video surveillance going in and out of the doors to the front yard. He was seen unscrewing the yard lights and poking at the fence. He made several trips in and out of the building to the front fencing. At approximately 7:00 p.m. on 12/30/24, during a time when staff were occupied by an unrelated resident incident, Resident #3 was seen on camera with a packed bag leaving his room and exiting the facility through a nearby door. The resident walked the fence line to the opposite side of the yard until he was out of sight of the camera and was not seen back on camera after that, nor was he observed by any staff anywhere on facility grounds. Facility staff checked the fence where Resident #3 was last seen on camera and discovered two holes in the lower corner where the two pieces of fencing came together. The overhanging guard wire on the top of the fence had been unscrewed and removed. It was the conclusion of the nursing home administrator (NHA) that Resident #3 had used facility silverware to make the holes in the fence and unscrew the security wiring. Then the resident used the holes in the fence to insert his feet, enabling him to pull himself up and climb over the fence where he removed the overhanging security wiring. Findings include: Observations, interviews and record review confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/25/25 to 2/26/25, resulting in the deficiency being cited as past noncompliance with a correction date of 1/2/25. I. Situation of serious harm Resident #3 had been homeless for six years prior to his admission to the facility on 7/31/23 and expressed a desire to return to the city where he had been living prior to his admission to the facility. The facility failed to ensure that facility staff performed regular checks to ensure residents' presence in the facility, particularly when all residents in the facility were known to have a history of elopement-seeking behavior. An interview with the NHA revealed that the facility staff had stopped conducting resident checks to ensure residents' presence in the facility prior to Resident #3's elopement on 12/30/24. Additionally, the facility was not checking the security fencing that surrounded the entire building for breaches where residents could elope. The facility's failure to prevent Resident #3, who had severely impaired cognition, poor safety awareness and a high risk for an elopement attempt, from leaving the facility unsupervised placed the resident at serious risk of harm, serious impairment or death due to the resident's inability to make sound decisions and ensure his own safety. II. Facility plan of correction The corrective action plan the facility implemented in response to Resident #3's elopement incident on 12/30/24 was provided by the NHA on 2/25/25 at 8:45 a.m. The correction plan revealed the following: A. Immediate action On 12/31/24, the facility began their investigation and developed a root cause analysis to determine the necessary corrective actions. Corrective actions included: -Resident #3 returned to the facility and was placed on one-to-one monitoring, but this made him anxious so the facility placed him on 15-minute checks; -Resident rounding was reinstated to account for resident location, checking resident count every 15 minutes for two weeks. Initiated 12/31/24; -Fencing repaired. Completed 12/31/24; -Front yard surveillance camera was adjusted to give staff a view of the whole front yard; completed 12/31/24; -Instituting daily inspection of the fencing, repair as needed for 4 weeks. Initiated on 1/2/25; -New lighting was installed to light up a larger area of the yard. Lighting was placed in a location inaccessible to residents to prevent unscrewing of the bulbs. Completed 1/2/25; and, -Education provided to all staff on rounding, elopement prevention and midnight census count; initiated 12/31/24 and completed 1/2/25. B. Identification of others affected The facility determined the deficient practice had the potential to affect all the residents in the facility. C. Systemic changes The director of nursing (DON) and the assistant director of nursing (ADON) educated all of the staff on the staff expectations to provide resident supervision with rounding, and conducting ongoing midnight census - heads in beds count, with all residents in the facility. The elopement book was updated to include all residents in the facility. In the event of a resident elopement, the facility had a packet of pertinent information to provide to emergency personnel to aid in finding a missing resident. The front fencing would be replaced with a like-new eight-foot fence. The estimate was approved for the job to move forward on 2/26/25 and the date of completion was to be determined. D. Monitoring The facility would evaluate the effectiveness of the plan in quality assurance and program improvement (QAPI) committee meetings for three months and implement additional interventions as needed to ensure sustained compliance. III. Facility policy and procedure The Elopement and Wandering policy, dated 2/29/24, was provided by the NHA on 2/26/25 at 3:40 p.m. The policy read in pertinent part, It is a goal of the facility to provide a safe environment using least restrictive measure available in caring for residents who are exhibiting elopement behavior. The facility defines 'wanderers' as residents who move around the facility in a non-goal directed manner, but do not make efforts to leave the premises. 'Elopers' are defined as residents who make an overt or purposeful attempt to leave the facility and do not have the ability to identify safety risks. If the resident is identified as an elopement risk, the following will be maintained: -Elopement Resident Identification form, including the current color photo, physical description of the resident, as well as approaches for an individualized plan of care will be in the elopement binder; -Implementing and care planning interventions to address safety and decrease the risk of elopement; -A physical restraint use consent shall be obtained from the resident's responsible party if an electronic device is utilized; -A physician order will be required for the use of monitoring the device. The order will include checking the placement of the device every shift and checking the function of the device daily; and, -The care plan will be updated to include that an electronic alarm system is used for resident's safety. IV. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included schizophrenia, dementia and diabetes. The 1/9/25 minimum data set (MDS) assessment revealed the resident had severely impaired cognitive impairments with a brief interview for mental status score (BIMS) of zero out of 15. The resident was able to express ideas and wants and was able to understand verbal content in conversations. The resident was independent with most activities of daily living (ADL) but needed set-up or clean-up assistance with oral and personal hygiene and supervision with showering. The resident experienced hallucinations and delusions but was not assessed to be aggressive. The resident rejected evaluation of care and wandered daily during the assessment look-back period. The quarterly social services evaluation, dated 1/10/25, documented the resident completed a BIMS assessment and was found to be cognitively intact with a score of 15 out of 15 on the exam. B. Resident observation and interview Resident #3 was interviewed on 2/26/25 at 2:30 p.m. Resident #3 said he left the facility to return to the city where he had previously lived. He said he hopped the fence and started walking towards the highway. He said he had enough money saved to get a bus ticket, but he got thirsty on the way and stopped at the hospital for a drink of water. He said it was his downfall that he stayed at the hospital too long. Resident #3 said the hospital doctor talked to him and he thought the doctor was trying to find out if he was crazy. He said the hospital staff let him sleep in the back on a bed and in the morning he was given a referral to a local homeless shelter. He said he was going to the shelter when the police showed up and started asking him questions. Resident #3 said he did not trust the police because they were not telling him the truth about what was going on. He said he refused a ride with the police and then left the hospital on his own. He said the facility staff caught up with him and brought him back to the facility. Resident #3 said he did not want to move to another facility because he wanted to return to the city where he had several living opportunities and knew where to get a good sandwich. Resident #3 said if you leave the door open for me I will sneak out. On 2/26/25 at 3:33 p.m. Resident #3 was out in the front yard of the facility walking the perimeter of the fence, pushing on the fence and looking up at the overhanging security wiring. C. Record review 1. Care plans Resident #3's comprehensive care plan, initiated 8/1/23, documented that Resident #3 required placement on a secure neighborhood due to dementia and a history of elopement to unsafe environments. Resident #3's guardian wished for him to remain at the facility with no plan for discharge. Interventions included activities staff were to provide scheduled activities within Resident #3's capabilities, reviewing Resident #3 every 180 days by the interdisciplinary team (IDT) for appropriateness of secure unit placement, monitoring Resident #3 for exit-seeking behavior and redirecting him away from doors and promoting engagement in meaningful activity. Resident #3's comprehensive care plan included a care focus for elopement risk, initiated on 8/1/23 and revised 1/3/25. The care focus revealed that Resident #3 was an elopement risk related to previous elopements at a prior facility and a dementia diagnosis. Resident #3 would often express a desire to be outside, even to sleep. Resident #3 was often found walking along the fence trying to manipulate it so he could get out and would acquire objects to help him meet this goal. While wandering, Resident #3 would often look for weakness in the fence or an opportune time to leave the facility. Resident #3 could become agitated when being checked on or monitored. Interventions included identifying patterns of wandering and determining if wandering was purposeful or random without a goal, distracting Resident #3 by offering him the opportunity to sit outside listening to rock music, encouraging exercise, like jogging; and talking about animals (initiated 8/1/23, revised 1/3/25), implementing one-to-one supervision if needed and, if implemented, following the resident at a close enough distance that staff could see Resident #3 and intervene when needed, ensuring staff did not directly follow him and cause an increase in paranoia symptoms, if the one-to-one supervision was upsetting to Resident #3 switching staff members and giving him space (initiated 1/3/25), conducting frequent visual checks on Resident #3 throughout the day and night to ensure location and safety (initiated 2/25/25) and providing active listening when Resident #3 voiced ideations of leaving the facility in order to promote redirection (initiated 2/26/25). 2. Preadmission Screening and Resident Review (PASRR) The PASRR Level II evaluation, dated 7/23/23, documented that Resident #3 had been living on the streets, was unable to care for himself and ended up in the hospital for treatment of significant swelling in his legs. He had a long history of untreated schizophrenia, with symptoms including paranoid ideation, delusional thoughts, disorganized thinking and speech, flight of ideas and tangential (vague) speech. The assessment further revealed that Resident #3 had problems with his foot but could stand and ambulate independently. He would likely benefit from prompts and set up for showering. He could toilet and complete basic ADLs with little assistance. Due to his symptoms of psychosis, he would benefit from a supervised setting. Resident #3 was in denial about his mental health diagnosis and his need for treatment. Resident #3 lacked insight into his need for more stable housing and need for care. He was resistant to placement in long-term care and wanted to feel independent. Because Resident #3 did not meet the requirements for court-ordered medication, the PASRR assessor recommended the resident be offered an opportunity to accept medications on a voluntary basis. 3. Elopement and wandering risk assessment An elopement risk assessment, dated 1/10/25, revealed Resident #3 was an elopement risk related to previous elopement at a prior facility, dementia diagnosis, and history of being homeless. He spent most of his time outside on facility grounds walking and poking at the fence. This was documented as the rationale for continued need for the resident's secure placement. The assessment indicated the resident's guardian did not want the resident to return to community living. D. Resident #3's elopement incident on 12/30/24 The facility's investigation, dated 12/31/24, revealed the following information: On 12/31/24 at approximately 11:30 a.m. facility staff discovered that Resident #3 was not in the facility when they went to look for him for the lunch meal. Staff initiated an immediate search for the resident and were not able to locate him on the facility grounds or in the immediate neighborhood. Facility staff called the police for assistance and called the local hospital. At 11:30 a.m., the hospital was able to confirm that Resident #3 was at the hospital and they had assessed him. Resident #3 would not get a ride with the police and left the hospital on foot. Facility staff drove to the hospital and found the resident wandering in an open field. Resident #3 accepted a ride with staff to return to the facility. The investigation revealed that none of the staff on duty on the evening of 12/30/24 could give an accurate account of when Resident #3 was last seen in the facility. -Nursing staff had not conducted a monitoring check on the resident at any time on the evening of 12/30/24. The nurse on duty the morning of 12/31/24 documented on Resident #3's December 2024 medication administration record (MAR) that the resident's 6:00 a.m. magnesium and multivitamin tablets were administered. However, it was later discovered through the investigation that the resident was not in the facility at that time. Additionally, staff were not following the care plan to monitor Resident #3's exit-seeking behavior, notice his behavior at the fence looking for weakened fencing areas or monitoring his activity while standing at the fencing. Staff had stopped conducting frequent visual checks of the resident to monitor his location in the facility. It was not until after the resident's elopement that the intervention for frequent visual checks of Resident #3 was added to the resident's care plan. As a part of the facility's investigation, the NHA reviewed video footage of the facility for 24 hours. The video footage revealed Resident #3 had spent the evening of 12/30/24 going in and out of the building, examining the fencing. At one point early in the evening, the resident was observed unscrewing the light bulbs at the far end of the front facility yard. The resident was later seen, at approximately 7:00 p.m,. leaving his room and exiting the door near his room with a packed bag. The resident was then seen on the camera outside, walking the fencing and heading toward the side of the yard where he had spent most of his time that evening and in the location where he had unscrewed the outside light bulbs. The video footage revealed Resident #3 could be seen walking the fencing at 7:00 p.m. until he disappeared off-camera a few minutes later. The resident was not seen back on camera any time after that time. The NHA examined the fence in the area where the resident was last seen and found two holes mid-level in the fencing, one on each side, in the corner where the two pieces of fencing met and the over-hanging wiring had been unscrewed and removed in that section. When interviewed by the NHA upon Resident #3's return to the facility, the resident said he had packed a bag of his belongings and climbed over the fencing with the intention of returning to the city where he previously lived. Resident #3 told the NHA he did not cut the wires on the fence but he did unscrew the wires at the top of the fence and climbed over the fence. Resident #3 said he wanted to get to the city and stay with friends. The NHA asked the resident if he would like a referral sent to other facilities within the desired city's area and the resident agreed but stated he wanted to be able to walk into the community. The NHA explained to Resident #3 the importance of being safe and that the facility would need to contact his guardian to get approval. In conclusion, the investigation report documented that Resident #3 had eloped the facility between 7:00 p.m. and 7:15 p.m. on the evening of 12/30/24 and none of the staff noticed his absence until approximately 16 hours later, on 12/31/24 at approximately 11:00 a.m. V. Staff interviews Resident assistant (RA) #2 was interviewed on 2/25/25 at 1:45 p.m. RA #2 said the staff were conducting 15-minute checks of all residents to make sure residents were present in the facility and the back doors were locked every evening after the last resident smoke break. Licensed practical nurse (LPN) #1 was interviewed on 2/25/25 at 3:45 p.m. LPN #1 said the nurses were locking the back exit doors every evening after the last resident smoke break at 7:30 p.m. to ensure resident safety and minimize the risk of elopement attempts. LPN #1 demonstrated how the doors were locked. The locking mechanism was observed in practice and verified and the back doors were securely locked after the locking button in the nurse's station was activated. LPN #1 said facility staff took turns conducting 15-minute head counts to ensure all residents were accounted for. LPN #1 provided the resident head count binder and the resident head count procedure was observed in practice. Certified nurse aide (CNA) #2 was interviewed on 2/25/25 at 3:50 p.m. CNA #2 provided the resident head count checkbook and said staff from all disciplines took turns rounding and counting all residents to ensure that all residents were accounted for. CNA #2 said if the head count was not accurate, the staff would check the sign-out book to see if a resident was out on a known leave. CNA #2 said if there was no resident on an approved leave, the staff would alert the supervisor on duty and all staff would initiate a search using the census list to find out which resident was missing, while other staff would initiate a search on and off grounds for the missing resident. RA #1 was interviewed on 2/26/25 at 10:24 a.m. RA #1 said she assisted the CNAs with providing non-direct care resident-related tasks. RA #1 said one of the tasks she performed was monitoring Resident #3 in the dining room to make sure he did not remove silverware from the dining room because he was using it to loosen the fencing so he could elope from the facility. RA #1 said Resident #3 was on 15-minute checks and she had assisted staff in monitoring Resident #3's location since his last elopement in December 2024. RA #1 said Resident #3 spent most of his time in his room watching television or walking around the front yard pushing on the fencing. Registered nurse (RN) #2 was interviewed on 2/26/25 at 10:43 a.m. RN #2 said Resident #3 got up early and ate breakfast in the dining room and then spent the early afternoon before lunch wandering the facility's front yard. RN #2 said Resident #3 ate lunch in his room and then resumed wandering the yard but he rarely wandered in the hallways. RN #2 said Resident #3 had not attempted to elope on the day shift but he did successfully elope one time on the overnight shift. RN #2 said she had seen the resident checking the front fencing, pushing and pulling on the chain links. RN #2 said Resident #3 was hard to talk to but he had told staff that he did not believe that he belonged in the facility. RN #2 said the facility had a button to lock the back doors where there was no overhanging security fencing at 5:00 p.m. because there was less staff around to monitor that area on the evening and overnight shifts. RN #3 was interviewed on 2/26/25 at 10:51 a.m. RN #3 said he was aware that Resident #3 had eloped from the facility on 12/30/24 but he did not think that the resident wandered without intention. RN #3 said Resident #3 was on 15-minute checks all day, and staff regularly checked the perimeter fencing for signs of damage that would affect security and elopement prevention. He said the back facility doors were locked starting at 5:00 p.m. every evening. RN #3 said Resident #3 sometimes needed redirection when he was fixated on examining the front fencing but that staff had to also give him space if he became frustrated and agitated with the staff's attention and monitoring. He said staff also had to monitor Resident #3 closely at mealtime to make sure he did not take the silverware out because he would use it to disable the security fencing. CNA #1 was interviewed on 2/26/25 at 10:51 a.m. CNA #1 said she was recently hired and knew who Resident #3 was and had heard about his elopement. She said the resident had not attempted to elope since then. She said Resident #3 wandered outside during the daytime and spent a lot of time in his room. CNA #1 said if Resident #3 eloped from the facility, again staff would initiate a code and initiate an immediate search for the resident. CNA #1 said she had not yet received training on how to respond to a resident elopement. The NHA was interviewed on 2/25/25 at 5:30 p.m. The NHA said she arrived to work on 12/31/24 to find that the staff were unable to locate Resident #3 while conducting rounds to gather residents for the lunch meal. She said while staff initiated a search for the resident, she reviewed video footage of the facility inside and outside. She said she observed the resident on camera going in and out of the facility several times. The NHA said that at approximately 7:00 p.m., Resident #3 was observed leaving his room with a packed bag, going out front towards the security fence and disappearing off camera. She said she checked the fencing where the resident disappeared and discovered there were holes in the fence and the top overhanging security wire was removed. The NHA said staff alerted local police of the resident's absence and called the local hospital and discovered the resident was at the hospital. She said she sent staff to go get the resident and bring him back to the facility. The NHA said the IDT conducted a root cause analysis and found that staff had stopped conducting rounding to check for residents' presence in the facility and the integrity of the fencing was not being monitored. The NHA said following Resident #3's elopement incident, resident rounding had been initiated to ensure all residents were in the facility, the lighting had been replaced so that no one would unscrew the lightbulbs and the camera had been readjusted to give staff a full view of the entire yard. However, the NHA acknowledged that the facility cameras were not being continuously monitored by staff, so staff would not necessarily see a resident climbing over the fence, even with the camera readjustment. The NHA said the fencing was immediately repaired but it was found to be in poor condition in some areas, so the facility planned to replace the fencing just in the front at this time with a like-new eight-foot fence. The NHA provided the estimate and approval for the like-new eight fence for review. The NHA was not sure when the project would be completed.