**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of video footage, staff interviews, and resident interviews, for one (1) of six (6) sampled residents, the facility staff failed to adequately supervise Resident #1 while the resident sat in the secured courtyard on the evening of 07/27/23. Subsequently, a pizza delivery person who was leaving the facility held open the secured gate to allow Resident #1 to pass through. These failures resulted in an immediate jeopardy situation. The immediate jeopardy was identified on August 4, 2023, at 3:04 PM. The facility provided a plan of action to address the immediacy on August 4, 2023, at 10:02 PM and it was accepted. After the plan was verified the IJ was removed on August 7, 2023, at 2:21 PM while the survey team was onsite. After the removal of immediacy, the deficient practice remained for the potential for minimal harm, with the scope and severity of D. The findings included: A review of the facility's Elopement (Pink Alert) Policy with a revision date of 05/17/18 documented, 1. Elopement Prevention- section C- In the event of elopement Pink Alert a search is conducted immediately, If the resident is not located within ½ hour of sustained search, the Administrator and Director of Nursing are to be called regardless of the day or hour . 2. Elopement Drill Procedures. Section A. Schedule - the elopement drill schedule is reasonable intervals as scenario determines. The schedule is carried out by the Safety Committee. Section B. Staffing - search party participants search rooms, boiler room, beneath beds, storage, equipment, laundry, staff development rooms, trash bins, parking areas, beneath stairways, parking areas, parked vehicles and surrounding shrubbery. Section D. Documentation - Elopement Checklist -SCC (Safety Committee Chair) completes the checklist .checklist is maintained by the SCC. Review of a document titled, Elopement Drill Check List documented, The front desk (alert Code Pine (sp)) and Safety Officer are to be notified within 5 minutes, the DON and Administrator are to be notified within 15 minutes, the physician is to be notified within and half hour. If the resident is not found within one hour the police department is to be notified .If resident is not found in less than two hours (DOH) is to be notified. Next the Ombudsman followed by the Adult Protective Services. A review of a policy titled, Wandering & Wander Guard Policy dated 07/30/18 documented, .Section 5. A missing resident is considered a facility-wide emergency. If a resident is missing, the elopement /missing resident emergency procedure will be initiated .If the resident is not located, notify the Administrator and Director of Nursing services, the Legal Representative, the Attending Physician, Law Enforcement Officials, and Required Government Agencies. Review of an untitled policy dated 01/01/23 documented, Policy Statement: Inspire Rehabilitation and Wellness Center is committed to the safety of our residents, staff, visitors, and property; while respecting the privacy, rights of our residents, staff, and visitors. The courtyard is fenced and can be used for outdoor visitation and outdoor activities. This area is monitored by surveillance camera and screen is at the receptionist area for monitoring by the receptionist. The receptionist is present in the lobby 24 (hours) X 7 (days-a-week) .The exit gate is secured by wander alert and every person entering or leaving needs to be buzzed in or out to prevent any resident from leaving without authorization. The document included an Elopement Drill Check List that lacked documented evidence of who conducted the outlined task and times the task was done, including: the time front desk staff announced the Pink Alert, the time the Administrator, DON, and physician were notified of the drill, and documented evidence of communication that staff checked on all non-nursing units (basement , kitchen, administrative offices, elevators, roof access if there [applicable], dining area, building premises, parking lot, smoking area, patio [and] lobby) for [Resident #3] . Review of a policy titled, Elopement/Missing Resident dated 05/2023 documented, The facility will identify residents who are risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. A situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision if necessary, would be considered an elopement section 3. If a resident is missing, initiate the elopement /missing resident emergency procedure .if the resident was not authorized to leave, call a code for the missing resident [Code Pink] .follow search protocol . The facility's assessment dated [DATE] documented, Inspire has a surveillance camera system, nurse call system, door alarm system .wanderalert complaint entry/exit ways . Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Dementia with Agitation, Cognitive Communication Deficit, and Muscle Weakness. A review of an admission nursing note dated 07/05/23 at 9:28 PM documented, .Alert oriented X 2 (name and time) .Medical history of the following: Acute Encephalopathy, 2/2 Delirium and Toxic Encephalopathy, Dementia with Agitation .Discharge diagnosis Living alone and unable to care for self .He was transferred to [Nursing Home Name], a skill [skilled] nursing facility for further therapy . Review of a document titled, Elopement Risk Evaluation, dated 07/05/23, revealed staff failed to complete sections D - Mobility and E - Diagnosis. Resident #1, however, had an Elopement Risk Score of 0 and was documented as not at risk for elopement. A review of progress notes dated from 07/05/23 to 07/11/23 lacked documented evidence of staff noting elopement attempts or elopement concerns for Resident #1. An admission Minimum Data Set, dated [DATE] documented Resident #1 had a Brief Interview for Mental Status summary score 04, Resident #1 was coded for wandering that occurred 1 to 3 days during this assessment period. Additionally, under section Functional Status - the resident was coded for requiring supervision and support by the physical assistance of one staff person when off the unit. A review of Resident #1's care plan revealed it did not outline how staff would supervise Resident #1's locomotion while off the unit. Progress notes dated from 07/12/23 to 07/26/23 lacked documented evidence of staff noting elopement attempts or elopement concerns for Resident #1. The Medication Administration Record (MAR) revealed the resident was administered Xarelto 20 mg po for Atrial Flutter and Valproic Acid 250 mg for Mood Disorder at 5 PM on 07/27/23. An observation of the facility's surveillance video showed a pizza delivery person entering the lobby at 6:16 PM on 07/27/23. It was then observed that the pizza delivery person held the secured exit gate open so Resident #1 could pass through. Resident #1 was then seen self-propelling in a wheelchair and exiting the facility courtyard at 6:17 PM on 07/27/23 unsupervised and without the knowledge of facility staff. The resident was noted to be wearing a long sleeve shirt, long-leg pants, and socks. The resident, however, was not wearing shoes. Per World Weather, the following temperatures were listed for 07/27/23. Morning- 77 degrees Day - 93 degrees Evening - 91 degrees Night - 79 degrees https://world-weather.info/forecast/usa/washington_1/27-July/ Review of the State Agency Facility Reported Incident Form #DC-12139, documented, Date of Alleged Event - 07/27/23- Approximately around 7:30 [PM] after receiving [pronoun] dinner during routine rounds, [Resident #1] was not observed on the unit or the dinning facility, after the looking in the facility the resident was not located and an elopement was called. Family and police notified, neighborhood search was initiated, and the facility staff went to the resident home .Update from provider dated 07/28/23 [Resident #1] has not been located. We discovered [pronoun] was let out [secured gate] by the Pizza delivery driver . 2nd Update 07/28/23 at 12:52 PM .Administrator, Social Worker and Administrator in Training went to [local hospital] to confirm the identity of [Resident #1]. Resident located at [local hospital] resident is alert, oriented X4 (name, place, time, and situation) .per the hospital, they are ready to discharge [pronoun] back to the facility . A review of a social worker's progress note dated 07/27/23 at 10:30 PM documented, The following hospitals were called to inquire if the resident was located at their hospital to which they indicated [Resident #1] was not. [Local hospital #1] was contacted at 10:20 PM, [Local hospital #2] was contacted at 10:30 PM, [Local hospital #3] was contacted at 10:40 PM, [Local hospital #4] was contacted at 11:00 PM, [Local hospital #5] was contacted at 11:00 PM, [Local hospital #6] was contacted at 11:20 PM, and [Local hospital #7] was contacted at 11:30 PM. A review of a nursing supervisor's progress note dated 07/27/23 at 10:32 PM documented, Resident had [pronoun] dinner and [pronoun] plate was taken around 5:40 PM by the CNA. [Resident #1] was last seen by the CNA [a] few minutes before 6 PM in the hallways and wheeling [pronoun] around. [Resident #1] usually goes downstairs and comes back to [pronoun] room. Later on, Employee #4 (Receptionist) reported that [Resident #2] saw [Resident #1] leaving the facility. Code Pink (missing person) was called by the receptionist. A review of a social worker's progress note dated 07/27/23 at 11:30 PM, documented, Writer contacted DC Adult Protective Services . to file a report on [Resident #1] eloping from the facility . A review of a nursing progress note dated 07/28/23 at 12:30 PM documented, At around 11 AM, during continued search attempts [Resident #1] was located at [local hospital #4] 2 staff members went to [local hospital #4] name] to identify [Resident #1] in-person. Identity confirmed for [resident's name] and [pronoun] is in stable condition .Per [local hospital #4] resident is alert, oriented X4 and was picked up from Massachusetts Avenue. Per the nurse at the ER, the resident was at the side walk and reported that [pronoun] just felt weak and a passerby to call 911 . [Resident #1] was registered in their system at 11:07 PM last night. Per labs done at the hospital, there are no critical findings and are within normal limits. Per the hospital . They are ready to discharge [Resident #1] back to the facility .Physician and family notified . A review of a hospital Discharge summary dated [DATE] documented, patient discharge instruction for [Resident #1]. Patient Information arrival date and time 07/28/22 at 00:22 (12:22 AM). discharge date and time 07/28/23 at 12:14 [PM] In addition, the discharge instructions documented, No concerning findings on labs or imaging of XR (x-ray) of the hip. Please return if you have any concerning symptoms. According to the hospital's discharge summary, the resident was evaluated for Weakness. It should be noted the resident check in time in the ER approximately 6 hours after [pronoun] left the facility. A review of an Elopement Risk assessment dated [DATE] indicated Resident #1 was at risk for elopement with a score of 4. A second Elopement Risk Assessment was conducted on 07/31/23, in which Resident #1 received a score of 8 and was categorized as at risk for elopement. A review of the facility's investigative notes and progress notes dated from 07/27/23 to 08/01/23 lacked documented evidence of the specific times when investigation activities occurred, such as when Code Pink was called, when the Administrator was informed of Resident #1's elopement, when the police were notified of Resident #1's elopement, and when the family and physician were informed of Resident #1's elopement. During an observation on 08/01/23 at approximately 2:30 PM, the surveyor had to identify herself before staff buzzed her into the secure gate. Also, observed was signage posted outside/inside the gate located near the intercom system that documented, Do not let any resident follow behind you when you leave. The door will be buzzed out for you individually. The resident needs to sign out before leaving the facility. During an initial observation of Resident #1's room on 08/01/23 at approximately 3:00 PM showed Resident #1 sleeping, wander guard on left ankle, bed in low position, fall mat on left side, and wheelchair at the foot of the bed on the right side. During face-to-face interview starting at 6:19 PM on 08/01/23 to 4:18 PM on 08/02/23 with Employee #6 (Unit Manager), Employee #2 (DON), Employee #3 (QA/Educator) Employee #1 (Administrator), and Employee #5 (the nursing supervisor who completed the Elopement Assessment) revealed they could not provide the surveyor with a key code to delineate what the different scores meant for the facility. However, they admitted to using assessments and residents' behavior to determine elopement risk. During a face-to-face interview on 08/01/23 at 4:48 PM, Employee #3 (Staff Educator/ Quality Assurance/ Infection Preventionist) stated that after Resident #1 eloped on 7/27/23, she began educating staff, including Employee #4 (Receptionist), on Elopement Prevention, Reaction, Ensure Resident Safety. Additionally, a review of the post-test provided to staff revealed that the tests had not been graded. There were no teaching tools available. Also, Employee #3 stated that she didn't grade all tests, and during teaching, she engaged with employees to make sure they understood and that her test served as a teaching tool as well. During a face-to-face interview on 08/01/23 at approximately 6:00 PM, Employee #10 (assigned CNA) she stated that she picked up Resident #1's dinner tray between 5:30 PM and 5:45 PM. The employee reported that she heard an announcement for Code Pink around 6:30 p.m. to 7:00 p.m. and was instructed to check all residents on the unit. Having searched the unit and being unable to locate Resident #1, Employee #7 (RN) went to the courtyard to look for the resident. In addition, Employee #10 reported that Resident #1 has gone to the courtyard independently and returned to the unit in the past. During a face-to-face interview on 08/01/23 at 6:07 PM, Employee #11 (CNA) stated that she gave Resident #1 [pronoun] dinner tray around 5:00 PM on 07/27/23 and last saw the resident sitting in [pronoun] wheelchair in the hall of the unit around 6:00 PM. In addition, the employee said a nurse told her to check all residents. When she checked Resident #1's room, the resident was not in the room. The employee also said she then went to the courtyard to look for the resident, but she could not locate the resident. Furthermore, Employee #11 reported that Resident #1 has gone to the courtyard independently and returned to the unit in the past. During a face-to-face interview on 08/01/23 at 6:19 PM, Employee #6 (2nd Floor Unit Manager) he stated that the DON (Employee #2) called him on 07/27/23 between 6:15 PM and 6:30 PM informing him that Resident #1 eloped. The employee stated that he was very surprised because of the resident's cognitive impairment and the resident had no issues prior with elopement concerns. Furthermore, the employee said that he called and spoke with staff to include Employee #5 (assigned nurse/Supervisor), Employee #10 (assigned CNA) and Employee #7 (RN who worked on the floor) who reported they were informed by Employee #4 (Receptionist) who made them aware that Resident #1 was outside the gate. In addition, the employee said that he spoke with Employee #4 (Receptionist) who reported that Resident #2 made him aware that he observed Resident #1 rolling past the gate in a wheelchair. During a second observation of Resident #1's room on 08/01/23 at 6:30 PM, Resident #1 was observed sleeping, wander guard on left ankle, bed in low position, fall mat on left side, and wheelchair at the foot of the bed on the right side. During a face-to-face interview on 08/01/23 at 6:50 PM, Employee #2 (DON) stated that staff called her and informed her that Resident #1 had been observed outside the gate by another resident. Her and the administrative staff went to the facility and continued the elopement protocol including searching for the resident, educating staff, and reassessing elopement residents. During a face-to-face interview on 08/01/23 at 7:12 PM, Resident #2 stated that [pronoun] saw [Resident #1] outside the locked gate rolling down the street in a wheelchair between 6:15 PM and 6:30 PM on 07/27/23. Resident #2 said [pronoun] told Employee #4 (Receptionist) that a resident was outside the gate rolling down the street in a wheelchair. Then Resident #2 said, [Employee #4] saw on camera that [Resident #1] got out with the pizza man when he [Resident #4] buzzed the pizza man out. During a face-to-face interview on 08/02/23 at 8:31 AM, Employee #4 (Receptionist) stated that he had multiple responsibilities including monitoring residents sitting in the courtyard via the surveillance camera, buzzing individuals in and out of the secured gate surrounding the courtyard, and making announcements on the loudspeaker. When asked what happened on 07/27/23, Employee #4 reported that Resident #2 informed him that another resident was outside the secured gate. Because he had no idea what resident was outside the gate, he notified all five units that a resident had been observed outside by Resident #2, and staff should verify residents on each unit. After a few minutes, the staff on Unit One informed him that Resident #1 wasn't on the unit, so he announced, Code Pink (missing person) over the loudspeaker. The employee was asked how Resident #1 got out of the secured gate since he controls who enters and exits the gate and monitors residents in the courtyard. Employee #4 said, I don't know. I looked at the monitor screen to buzz the pizza delivery guy out, but I didn't see [Resident #1]. I took my eyes off the screen to call staff to pick up the pizza. I assume the resident left out the gate with the pizza guy. In addition, the employee stated, I saw Resident #1 in the courtyard on 07/27/23 but [pronoun] went back to [pronoun] floor before 3:00 PM. I don't recall [pronoun] coming back downstairs. Employee #4 was asked if he left his post after 3:00 PM on 07/27/23. Employee #4 said, I worked 12 hours that day and someone covered me earlier in the day when I went to the bathroom, but not around that time. The employee could not remember who covered him when he went to the bathroom. It should be noted that the job description for Employee #4 (dated 03/02/23) did not specify what the employee was expected to do when monitoring (supervising) residents in the courtyard. During an observation of the receptionist area including the surveillance screen on 08/02/23 at approximately 9:00 AM, the entire courtyard including the secured gate could be observed. Additionally, the screen showed people entering and exiting the gate. During a third observation of Resident #1's room on 08/02/23 at 11:20 AM revealed Resident #1 was lying in bed, awake, and oriented. According to Resident #1, [pronoun] left the facility recently to go to Marymount, Florida. During a face-to-face interview on 08/02/23 at 12:30 PM, Employee #13 (Receptionist) stated that [pronoun] was responsible for monitoring residents while in the courtyard. It should be noted the employee signed job description (dated 05/20/22) did not specify what the employee was expected to do when monitoring (supervising) residents in the courtyard. During a face-to-face interview on 08/02/23 at 2:37 PM, Employee #1 (Administrator) stated that staff called and informed him of Resident #1's elopement. Upon arrival at the facility, he continued elopement interventions, which included notifying public officials of Resident #1's elopement, searching in the community for the resident until 3:00 a.m. on 7/28/23, calling hospitals, checking an electronic health system for local hospital admissions, evaluating the wander guard system, and educating staff about elopement and the new entry and exit process at the secured gate. When determining if a resident is at risk for elopement, the clinical team meets and discusses risk factors, behaviors, medications, and diagnoses. During a face-to-face interview on 08/02/23 at 3:56 PM, Employee #7 (RN) stated that he last observed Resident #1 on 07/27/23 when he administered the resident's routine 5:00 PM medications. Also, Employee #7 didn't realize Resident #1 wasn't on the Unit until Employee #4 (Receptionist) called and told him Resident #2 saw Resident #1 outside the gate. Furthermore, Employee #7 reported that he searched the unit, courtyard, outside the gate, and down the street, but could not find Resident #1. During a face-to-face interview on 08/02/23 at 4:18 PM, Employee #5 (Assigned Nurse/Nursing Supervisor) stated that he arrived late (7:00 PM) to work on 07/27/23 due to an emergency. Upon entering the unit, he heard Employee #4 (Receptionist) announce Code Pink. He instructed nursing staff to check on all residents. Then he walked downstairs to talk with Employee #4, who told him that Resident #2 observed Resident #1 outside the locked gate rolling down the street in [pronoun] wheelchair. Afterwards, Employee #5 walked outside the gate and up the street looking for the resident but failed to locate Resident #1. After approximately 15 minutes, he returned to the facility and called the DON (Employee #2) to notify her of Resident #1's elopement. According to Employee #5's timesheet, he punched in at 7:00 PM on 07/27/23. During a face-to-face interview on 08/03/23 at 10:10 AM, Employee #8 (CNA) stated that Code Pink meant shooter. During a face-to-face interview on 08/03/23 at 10:15 AM, Employee #9 (CNA) could not articulate the meaning of a Code Pink. However, a review of the emergency codes badge noted intermittently on employee badges, revealed a list of codes. On the badge, code pink was defined as missing person. During a face-to-face interview on 08/03/23 at 11:17 AM, Employee #12 (HR Director) reviewed the job description for all Receptionists and commented, I don't see that they [receptionists] are responsible for supervising residents while in the courtyard. Additionally, Employee #12 said, During orientation they [receptionists] are paired with a partner and the partner tells them about supervision, monitoring, what to look for, and who to call in anything that is off-putting (altercation). However, Employee #12 did not have documented evidence of Employee #4's orientation related to resident courtyard supervision. Based on these findings, on August 4, 2023, at 3:04 PM, an Immediate Jeopardy (IJ)-J situation was identified. On August 4, 2023, at 10:02 PM, the facility's Administrator provided a corrective action plan to the State Agency Survey Team that was accepted. The plan included: 1. CORRECTIVE ACTION FOR THE AFFECTED RESIDENTS -Resident #1 was located at [local hospital #4] on 7.27.23. Resident #1 returned to the facility on 7.28.23. Resident #1 was assessed head to toe by the charge nurse. The were not negative findings. This is consistent with the discharge notes from the hospital including having no pertinent findings with labs and Xray. Resident #1's elopement risk assessment was -updated by the charge nurse on 7/28/2023 to ensure the resident receives proper interventions and prevent future incidences. Resident #1 was added in the elopement binder in all locations to ensure that staff are aware of his elopement risk and ensure his safety. The resident was given a Wanderguard and placed on 1:1 immediately. Resident #1's care plan was modified for elopement on 7.31.23 to ensure that resident's care plan outlines how staff have interventions for elopement in place and ensure residents safety to prevent further elopement incidences. The care plan continues to be updated and the most recent update was done on 8.4.23 outlining supervision and level of assistance for the resident. Due to the wanderguard, the exit gates will not open unless a staff punches in a code to specifically let the resident out. 2. IDENTIFICATION OF OTHERS WITH THE POTENTIAL TO BE AFFECTED -All residents have the ability to be affected by this deficient practice. A head count was done for all residents on 7.27.23 and all residents were accounted for within the facility. A house wide elopement evaluation was done for all residents on 7.28.23 and no other resident was found to be at risk for elopement. The elopement drill conducted on 2.17.23 with Check List had the Administrator and Director of Nursing's signature who conducted and coordinated the elopement drill with the date. The police was not called as that part is not done during the drills. The time of events during the drill will be incorporated in the next elopement drill. This deficient practice, however, cannot be retroactively corrected. Upon notification by DOH about the responses by the CNA about Code Pink a check was done by the Nurse Educator on 8.4.23 for all CNAs in house to reinforce the meaning of Code Pink. The rest of the CNAs will have reinforcement of the education upon the start of their shift. This will be on-going to ensure house-wide reinforcement is complete. 3. MEASURE TO PREVENT REOCCURRENCE -A robo-call was made to all staff and to all family members on 7.28.23 to educate them that they should not hold the door open for anyone else, everyone will be buzzed out individually. A notice was posted at all exits effective 7.27.23 to state DO NOT LET ANY RESIDENT FOLLOW BEHIND YOU WHEN YOU LEAVE. The door will be buzzed out for you individually. RESIDENTS NEED TO SIGN OUT BEFORE LEAVING THE FACILITY. Education for elopement was done for all staff on 7/27/23 by the QA nurse on 3-11 and 11-7 shift. The facility ensured 100% of staff present in the facility at the time were educated and ensured education thereafter for all staff at the start of their shift. The ADON educated all department heads on 7.28.23 during the Ad-HOC QAPI meeting and the department heads educated all their staff on elopement protocols. Education continued by the Staff Educator, QA Nurse and ADON for all employees as they resumed duty effective 7.28.23 onward. All residents who have orders for Wander Guard had their devices checked for function and proper placement on 7/27/2023 by the nursing staff. Maintenance checked all WanderGuard Door alarms and locks to ensure proper functionality on 7/28/2023. There were no negative findings from this audit. Nursing Staff continues to supervise all residents under their care with ensuring they round on the residents at least every 4 hours. Residents with behaviors or cognitive impairment that need additional supervision will be rounded on at least every 2 hours. Nursing staff will ensure hourly rounding is done for elopement risk residents to ensure safety. Supervisors/designee are responsible for rounding in social areas like dining rooms to ensure residents are monitored in common areas of the facility. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition (appears or acts differently than baseline), identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting, any assistance, etc. If any abnormality is noted, appropriate steps of complete assessment, notifications and documentation are required. In those cases, rounding may need to be more frequent as applicable to the change in condition. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse for any changes in the resident's condition and medical need. Additionally, the receptionist will notify the nursing supervisor when a resident is in the courtyard unattended for more than an hour. The receptionist will use a sign in/out log with time for residents in the courtyard going forward. -Receptionists were additionally educated on 7.27.23 by the Staff Educator and HR on their job description to elaborate Monitor visitor access area by emphasizing the importance of using camera surveillance to supervise resident activity in the courtyard and ensuring the gate is monitored while buzzing people out with special emphasis on a heightened level of supervision while food delivery personnel or visitors enter and exit the gate. Any person entering or exiting the courtyard is now required to identify themselves via intercom. In addition, they are instructed to ensure the gate is closed behind them and to not allow anyone access to get in or out of the courtyard besides themselves. The gate will then be unlocked if all the conditions are met. The receptionist/designee monitors this activity through camera surveillance. If any resident is leaving unauthorized at this time, the receptionist will not buzz them out. A resident council meeting was held on 7.28.23 by the Administrator reviewed and discussed safety policy for resident elopement. Administrator expressed the importance to always keep everyone safe by being aware of our surroundings. Provided residents with letters for continued educated about entry and exit from the premises safely when being buzzed in and out once being cleared to leave. 4. MONITORING CORRECTIVE ACTION -Nursing Director or designee will conduct a weekly audit of Wanderguard residents to ensure it is properly functioning and all WanderGuard are properly in place. This audit was started on 7.28.23 will be done weekly x 4 and monthly x 2. Negative findings, if any, will be corrected upon discovery. Maintenance manager or designee will audit Wanderguard doors, and locks to ensure proper functioning and that the receptionists are following procedures to secure the courtyard, including following entry and exit protocols, and monitoring surveillance cameras. This audit will be done weekly x 4 and monthly x 2. Negative findings, if any, will be corrected upon discovery. Elopement Binders will be audited by the Unit Managers to ensure that the list of residents at risk of elopement is accurate and consistent with the elopement assessment. These audits will be completed weekly times four and monthly times three. Negative findings will be corrected upon discovery. An audit will be done by the Administrator/Designee to ensure the courtyard is being supervised by the receptionist using the surveillance monitoring camera and there is use of the intercom to ensure each person is buzzed out is reminded to close the door behind them and not let others outside. This audit was started on 7.27.23 for 11-7 shift and scheduled to be done q shift x 3 days, daily x 3 days and weekly thereafter x 4 weeks, monthly x 2 months. Negative findings, if any, will be corrected upon discovery. All the above-mentioned audits will be tracked and reported to the QAPI committee monthly and audits will be completed weekly times four and monthly times three. Negative findings will be corrected upon discovery. All Findings to be reported to the monthly QAPI for further recommendations. Verification of the removal of the immediacy was performed by the survey team onsite on August 7, 2023, at 2:21 PM. Cross reference 22B DCMR sect. 3211.1 (d)