**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, record reviews and policy review, the facility failed to prevent neglect by failing to appropriately assess a resident as an elopement risk for 3 of 5 sampled residents reviewed for elopements (Residents #1, Resident #39, and Resident #6). Additionally the facility failed to implement facility Elopement Risk Evaluation/Assessment at the time of admission, facility failed to provide staff with instructions/policy procedure to communicate increase exit seeking behavior to identify need to increase supervision, failed to administer psychotropic medications as ordered, failed to instruct staff on what to do if a resident exits the 8 doors in the facility, and failed to do elopement drills. These failures allowed Resident #1 to elope from the facility undetected on 10/12/21 between 7:00 AM and 7:05 AM. The findings included: The facility's Policies and Procedures titled Elopement/Wandering Risk Guideline effective date 09/21/2016 and revised on 08/01/2020 has an Overview To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions. Process: Patient/Residents to be evaluated on admission, re-admission, 7 days post-admission, quarterly, with a significant change in condition, and elopement event using the risk tool. It further showed that if a patient/resident is identified as being at risk for elopement, the following steps are needed: complete an Elopement risk Alert and obtain a photograph, initiate individualized interventions based on Patient/Residents' risk, and document individualized interventions in the patient/resident Care plan and [NAME]. If a wander monitoring system device is utilized, check the placement of the device every shift and functionality every day. The staff will need to maintain the Elopement Risk Alerts in an easily accessible location and complete routine elopement drills monthly and review in QAPI meetings. Record review revealed Resident #1 was admitted to the facility from an acute care hospital on [DATE] with diagnoses that include Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder, and Anxiety Disorder. The Resident's Minimum Data Set (MDS) Comprehensive assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status of 11, which indicates moderate loss in cognitive ability and can be associated with poor decision-making skills. In Section E of the MDS, Resident #1 was assessed not to have wandering behaviors. In Section G of the MDS under Functional Status, Resident #1 needs supervision with walking in her room, corridor, and locomotion on and off the unit. Under Section N- medications, Resident #1 was assessed to take antipsychotic medication for the past 7 days, antianxiety medications for the past 7 days, and antidepressant medication for the past 7 days. Under Section P-restraints and alarms, the wander/elopement alarm was coded as not used. Another BIMS test was conducted on 10/13/21, which showed a new score of 13 out of 15, indicating intact cognition. Record review revealed a skilled nursing note dated 07/09/21 showed that Resident #1 was identified as an elopement risk. An elopement risk evaluation was conducted on 10/12/21, the day of the elopement incident, which was not done prior to that. The assessment showed a score of 4, which indicates that Resident #1 is at risk for elopement. Record review revealed Resident #1 Physician's orders for medications in October 2021, (prior to the elopement that occurred on 10/12/21) included the following: Aspirin 81 milligrams (mg) one tablet daily for antiarrhythmic; Atorvastatin 20mg one tablet daily for hyperlipidemia; Famotidine 20mg one tablet daily for GERD (gastroesophageal reflux disease); Ferrous Sulfate 325mg one tablet daily for a supplement; Losartan Potassium 100mg one tablet daily for hypertension; Nifedipine Extended-release 24 hour 60mg one tablet daily for hypertension; Prednisone 20mg one tablet daily for inflammation; Prozac 20mg one tablet daily for antidepressant; Trazodone 75mg in the morning for depression; Vitamin D3 tablet 5000 units 1 tablet daily for vitamin D deficiency; Benztropine Mesylate tablet 1 mg every 12 hours for extrapyramidal symptoms; Risperdal tablet 0.25mg one tablet two times a day for schizophrenia; Buspirone tablet 15mg one tablet three times a day for anxiety. During the Medication Administration Record (MAR) review, there were blank sections where the nurses would put their initials indicating if the medication was given or why it was not given. The medication Benztropine Mesylate had blanks for the dates of 10/1, 10/2, 10/6, 10/7, 10/10, 10/11 at bedtime. The medication Risperdal 0.25mg had blanks for the dates of 10/1, 10/2, 10/6, 10/7, 10/10, 10/11 at 5:00 PM. Trazodone 100mg had blanks for 10/1, 10/2, 10/6, 10/7 for the bedtime doses. The medication Buspirone had blanks for 10/1, 10/2, 10/6, 10/7, 10/10, and 10/11/21 for the 5:00 PM doses. A review of the Elopement drills that were provided by the facility showed no indication that Wandering and Elopement in-services were given in September as listed on the Education Calendar for 2021. This surveyor was provided education in-service attendance reports for abuse/mistreatment dated 08/21/21 and Missing Resident/Elopement/Abuse dated 10/12/21. The facility also conducted elopement drills on 10/13/21 and 10/14/21 after the incident on 10/12/21. A closer review of the Elopement drills after 10/12/21 did not show an education that included: an outside search that needs to be done outside the facility as far as the eye distance from the alarming exit door as a point of reference. An interview was conducted on 11/4/21 at 2:00 PM with the facility's Director of Nursing, who was asked why there were blank spaces when the nurse's initials should be there, and she was unable to provide a reason why. Resident #1's care plan reveals a focus of Resident has potential for drug-seeking type behaviors. History of drug abuse and drug-seeking since admission. Date initiated 07/16/21. Interventions include Anticipate and meet resident's needs (dated 07/16/21), Educate resident on successful coping and interaction strategies (dated 07/16/21), and resident will not wander out of facility (dated 07/16/21). An additional focus of the care plan includes a focus of the resident is an elopement risk/wanderer related to impaired safety awareness (date initiated 07/15/21) with interventions that include actual elopement on 10/12/21 (dated 10/12/21), assess for elopement risk (date initiated 07/15/21) electronic monitoring to place on the resident (dated 07/15/21). In an interview conducted with Staff H, CNA, via telephone on 11/01/21 at 11:59 AM, she was asked about the incident on October 12, 2021. Staff H stated that she was leaving the facility when Staff G, a Licensed Practical Nurse (LPN) asked her to look for Resident #1 on her drive home. At approximately 7:15 AM, Staff H located Resident #1 by a Speedway gas station located on US-1 and 16th street. Staff H stated that Resident #1 was about to turn right onto Highway US-1 going North. The Resident was observed wearing sweatpants, a shirt, and sneakers and carrying her purse. Staff H pulled into the gas station and approached the Resident on foot. Resident #1 stated, I do not want to go back to the hospital. Staff H reported that Resident #1 did not recall her name but knew her by face. Resident #1 agreed to get in the car, and Staff H then brought her back to the facility at approximately 7:20 AM. Staff H further stated that Resident #1 was very restless the night before. During the night, she kept coming out of the room and asked to leave, and she had her shoes and purse. She asked to leave multiple times during the night shift and was monitored by staff. According to Staff H, Resident #1 was more anxious than usual. When asked about her cognitive status before leaving the facility, she reported that Resident #1 was confused. She also said that Resident #1 exhibited exit behaviors before her leaving on 10/12/21 but nothing to the extent of her leaving the facility. An interview with Staff E, Certified Occupational Therapy Assistant (COTA), was conducted on 11/01/21 at 12:15 PM. Staff E stated that on 10/12/21, between 7:00 AM and 7:05 AM, she was in the gym working on her notes when she heard an alarm. She walked in the direction of the door that the alarm sounded from and poked her head out of the door but did not step out. The exit door was located between rooms [ROOM NUMBERS]. On her way to the exit door, she stated that the Resident in room [ROOM NUMBER]B told her that the skinny lady in room [ROOM NUMBER] was walking in the hallway toward the exit door earlier, but he did not see her leave. Staff E further stated that she returned to the nurse's station and alerted additional staff to what the Resident in room [ROOM NUMBER]B told her. She then asked Staff F, Certified Nursing Assistant (CNA), to check Resident #1's room to see if she was there. She did not call the police and is unsure if anyone called the police. The Director of Nurses and the Administrator had not arrived at the facility yet. Resident #1 was not located in her room or inside the facility. Staff immediately initiated a search of the grounds, including the parking lot. Staff G, who worked the night shift, went outside looking for Resident #1. In an interview with the Director of Maintenance on 11/01/21 at 4:25 PM it was revealed that the wanderguard will only lock the front door. Last Friday (10/29/21) they changed the whole wanderguard system but the keypads at the 7 other exit doors are not wired yet for the wanderguard system. The wanderguard will lock the door within 3 feet of the door and 15 pounds of pressure will open the door in case of fire. The Director of Maintenance is not sure when all doors will be fully wired for a wanderguard to be working on all 8 doors. In an interview conducted on 11/02/21 at 10:20 AM, with Staff J, Certified Nursing Assistant, she arrived at the facility at 7:00 AM, on the morning of 10/12/21. On her way to the nursing station, she heard from another staff that Resident #1 had escaped and that they listened to the alarm. According to Staff J, Resident #1 always says that she wants to go out and wants to leave and is known to be a little confused. On the morning of the incident, staff started looking for her outside and inside the facility. She was told to look for Resident #1 outside in the front parking lot of the facility. When asked if Resident #1 had a wander guard before she attempted to leave the facility, she said no. She further stated that because she had never left the facility before, she did not need one. According to Staff J, on 10/12/21, they did not have a supervisor in charge because it was too early. She further said that when she was educated on elopement, she was told to first check each room before searching outside the premises. Then you go out to look for the resident. When an elopement happens, they are supposed to tell someone in charge and follow the directions of the supervisor. Staff J stated that she did not participate in any elopement drills after 10/12/21. When asked as to how many exit doors does the facility have, she did not know. In a second interview conducted on 11/02/21 at 11:07 AM with Staff E, she stated that she was educated on elopement twice a year. The drills consisted of a code called BODYBEAR as an indication that a resident was missing. They needed to get to the nurse's station and receive the individual assignment from the supervisor. Once you have your instructions, you follow them and report your findings. On the morning of 10/12/21, she heard the alarm and told the nurses what the Resident in room [ROOM NUMBER] told her. She tried getting the staff around the facility to search for Resident #1, and she even looked outside the front of the facility. After the incident, the facility conducted an in-service on elopement which she did not participate. When she returned, she completed a test on elopement. According to Staff E, nothing new was part of the education, and that they re-educated staff on the same instruction you would follow if an elopement happened again. She did not know if the facility completed another drill after the incident on 10/12/21. When asked by the surveyor if she could see Resident #1 walking away when she peeked outside the door on 10/12/21, she said: I can see a partial view of the street, on both sides but more to the left. She then said Resident #1 must-have walked very fast. In an interview conducted on 11/02/21 at 11:57 AM, Staff K, Housekeeping, stated that on the day of the incident, she passed by room [ROOM NUMBER] to go to the nurses' stations. She is familiar with Resident #1, who usually comes out of her room at around 8:00 AM and goes outside the patio across from her room. On the morning of 10/12/21, she saw Resident #1 walking out of her room and did not think much of it. The next thing she heard was the alarm on the door. She walked in the direction of the sound and was told by Staff E, who was by the exit door, that Resident #1 had already gone and could not see her. She then started looking for Resident #1 around the building. She also reported that by the time she was ready to go into her car and drive around to look for Resident #1, another staff brought Resident #1 back to the facility. She could not remember when the last time was, she participated in elopement drills. When asked if this happened again: she said, they would not have to tell me anything; I would go looking for [Resident #1] right away. In an interview conducted on 11/02/21 at 12:15 PM with the Maintenance Director, he stated he helps with the elopement drills. He noted that elopement drills are conducted once a month for every shift. Before this year, they used to have a dressed-up teddy bear called BODYBEAR, which the facility would hide either inside or outside. Once announced, staff would have to come to the nurse's station to receive their assignments. Now they have changed the drills, they will call the name of the missing resident, and staff will follow the supervisor's instructions. In an interview conducted on 11/03/21 at 2:10 PM, during the Resident Council meeting, Resident #33 stated that when an alarm goes off in one of the 8 exit doors, there is no sense of urgency by staff. He further said that staff would take a long time before addressing the loud noise of the alarm. Resident #9 stated that the last time one of the alarm doors went off, it took staff 15 minutes to come to the door to check as to why the alarm sounded off. Record review of Resident #33 showed that he was initially admitted to the facility on [DATE]. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed that Resident #33 has a Brief interview of Mental Status (BIMS) score of 15, which is cognitively intact. Record review of Resident #9 showed that he was initially admitted to the facility on [DATE]. A review of the Quarterly MDS showed that Resident #9 is with BIMS score of 15, which is cognitively intact. 2. Resident #39 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, Major Depressive Disorder, and Type 2 Diabetes Mellitus. A review of the Physician's orders for Resident #39 revealed an order for a wander guard dated 08/15/20. A review of a nursing progress note dated 08/01/21 revealed: patient attempted to go out the door re-oriented patient back to facility patient appeared to be confused. An elopement assessment was not completed on Resident #39 until 10/12/21, when it was determined that the resident was at risk for elopement. An interview with the Director of Nursing (DON) on 11/05/21 at 10:30 AM revealed there are no additional elopement assessments for Resident #39. A review of the resident's care plan for elopement risk initiated 10/12/18 and revised on 07/08/20 revealed the following: a focus of resident is an elopement risk/wanderer .history of attempts to leave the facility unattended .secondary to dementia . Interventions dated 10/12/18 and revised on 07/08/20 include identify a pattern of wandering, and provide electronic monitoring device (wander guard) date initiated 10/12/18 and modified on 10/20/21. An interview was conducted with the Minimum Data Set (MDS) coordinator on 11/05/21 at 11:00 AM, which revealed the original order for the wander guard is uncertain due to medical records dating back to his admission are not in the facility anymore. 3. Resident #6 was admitted to the facility on [DATE] with diagnoses that include Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side, Hypertension, and Malignant Neoplasm of Prostate. The Quarterly minimum data set (MDS) dated [DATE] revealed in section C a brief interview of mental status (BIMS) score of 13, indicating an intact cognitive response. A review of nursing progress noted date 08/23/2021 reveals Resident #6 was up and about pacing in the hallway. The resident appeared to be very anxious, screaming and yelling at staff, and very difficult to redirect. A call was placed to (Psychiatrist). New order received for Xanax 0.25mg q 12 hrs. as needed (PRN) for anxiety. Noted and carried out. An interview with the DON on 11/05/21 at 10:15 AM reveals Resident #6 refused to have the wander guard put on his ankle, so they put it on the walker since he always uses his walker. Questioned the DON on why the wander guard was not put on when exit-seeking behaviors were identified on 08/23/21, and she stated that after he was seen by psych, he didn't have any more exit-seeking behaviors. The first elopement risk evaluation for Resident #6 was done on 10/13/21 and he was identified as at risk for elopement so the wander guard was placed on his walker on 10/13/21. An interview with Resident #6 on 11/05/21 at 10:45 AM revealed a wander guard on his walker. He further stated that he is not going anywhere because his legs are bad, and he would not get that far. Resident #6 also said that he wanted to leave when he was first admitted to the facility. He did not like the condition of the facility, but he knows now that he isn't going anywhere. The facility Immediate Jeopardy Removal Plan included: 1. On 10/12/21 The Director of Clinical Services and designee completed elopement risk assessments on all current residents to identify others that may be at risk. One new resident at risk was identified. 2. On 10/13/21 and 11/4/21 Elopement books were updated. 3. On 11/4/21, the Director of Clinical Services and designees-initiated education for Licensed Nursing Staff on completing the Elopement Risk Evaluation which is to be completed at the time of admission. This consisted of on-site education, phone education when available and education documentation if needed via mail. Education includes 18 licensed nurses. 4. On 11/4/21, the Director of Clinical Services was educated by the Regional Nurse Consultant on conducting New admission Chart reviews during the clinical meeting. 5. On 11/4/21 The Director of Clinical Services and designee-initiated education for Licensed Nurses and unlicensed staff on Change of Condition policy and reporting to the Director of Clinical Services any event of exit seeking behaviors. Staff included are Therapy (7), Housekeeping/Laundry (5), Dietary (7), CNAs (28), and Nurses (18) Administrative/department heads (12). 6. On11/4/21 The Director of Clinical Services was educated by the Regional Nurse Consultant on initiating interventions related to increasing supervision needs. 7. Licensed staff and unlicensed staff including Therapy (7), Housekeeping/Laundry (5), Dietary (7), CNAs (28), and Nurses (18) Administrative/department heads (12), will be in-serviced on any new resident identified with exit seeking behaviors by the Director of Clinical Services and/or designees. 8. On 11/4/21 Licensed staff and unlicensed staff education were initiated on reporting and communicating resident exit-seeking behaviors to their supervisor. Staff included are Therapy (7), Housekeeping/Laundry (5), Dietary (7), CNAs (28) and Nurses (18) and Administrative/department heads (12). 9. On 11/4/21 - Licensed Nursing Staff education was initiated on the administration of anti-psychotic meds. Education includes 18 Licensed Nursing staff. 10. On 11/4/21 - The Director of Clinical Services/designee will conduct a daily audit of the Electronic Administration Record to ensure resident psych medication is documented as given, and/or documented for refusal. 11. On 11/4/21 The Executive Director and Director of Clinical Services were educated on determining the root causes specific to elopements by the Regional [NAME] President of Operations. 12. The Executive Director led an additional Quality Assurance and Performance Improvement meeting on 10/13/21 with the Executive Director, Medical Director, Director of Clinical Services, Social Services Director, Plant Operations, Activities, Dietary Supervisor, Housekeeping Supervisor, CNA, Business Office Manager, Therapy Director and Unit Manager present. The Elopement Policy and Procedures were reviewed, and the root cause of elopement was discussed. 13. An additional ad hoc quality assurance performance improvement meeting was held on 11/3/21 with the participation of the Center Medical Director, Executive Director, Director of Clinical Services, Social Services Director, Unit Manager, MDS Coordinator, Plant Operations Manager, Human Resources, Housekeeping Supervisor, Dietary Director, Therapy Director, and Activities Director. The plan along with the root cause for the incident was discussed and approved by the Medical Director. The Facility's policy on Elopement was reviewed during the QAPI meeting. 14. An ad hoc quality assurance performance improvement meeting was held on 11/4/21 with the participation of the Center Medical Director, Executive Director, Director of Clinical Services, Social Services Director, Unit Manager, MDS Coordinator, Plant Operations Manager, Human Resources, Housekeeping Supervisor, Dietary Director, Therapy Director, and Activities Director. The plan along with the root cause for the incident was discussed and approved by the Medical Director. The facility's policy on Abuse and Neglect was reviewed during the QAPI meeting. 15. Plant Operations and or Designee will be responsible for conducting monthly elopement drills. Results will be brought and reviewed during the Quality Assurance Committee meeting. 16. 10/12/21 8:30 am The Plant Operations Manager rounded in the facility to validate all exit doors were secure and alarms functioning properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, record reviews and policy review, the facility failed to prevent a vulnerable resident with memory and cognitive deficits from exiting the facility unsupervised. The facility did not provide supervision to prevent an elopement of 1 of 5 sampled residents reviewed for elopement risk (Resident #1). The deficient practice allowed Resident #1 to elope from the facility undetected on [DATE] between 7:00 AM and 7:05 AM. The findings included: The facility's Policies and Procedures titled Missing Patient/Resident effective date [DATE] and revised on [DATE] has an Overview Staff will investigate cases of missing patient/resident and possible elopement. An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury. Procedure: Check Leave of Absence (LOA) book and Medical Record to ensure patient/resident is not on an authorized leave or medical appointment. Announce resident name) please return to your room, over PA system. Repeat three times to alert staff of a missing patient/resident. Assigned staff to search the grounds. If the patient/resident is not located after the initial search the point person will notify the Executive Director and Director of Nurses, Resident Representative, and Physician. The Executive Director and/or Director of Nursing or designee to notify local Law Enforcement. Upon return to the Center a physical evaluation will be completed to determine if further treatment is needed. Document in the Medical Record. Notify Physician, Resident Representative, Executive Director, Director of Nurses and Law Enforcement (if applicable) of patient/resident's return. Review and revise the interventions as indicated related to elopement and wandering risk and update the Care Plan and [NAME]. Record review revealed Resident #1 was admitted to the facility from an acute care hospital on [DATE] with diagnoses that include Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder, and Anxiety Disorder. The Resident's Minimum Data Set (MDS) Comprehensive assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicates moderate loss in cognitive ability and can be associated with poor decision-making skills. In Section E of the MDS, Resident #1 was assessed not to have wandering behaviors. In Section G of the MDS under Functional Status, Resident #1 needs supervision with walking in her room, corridor, and locomotion on and off the unit. Under Section N- medications, Resident #1 was assessed to take antipsychotic medication for the past 7 days, antianxiety medications for the past 7 days, and antidepressant medication for the past 7 days. Under Section P-restraints and alarms, the wander/elopement alarm was coded as not used. Another BIMS test was conducted on [DATE], which showed a new score of 13 out of 15, indicating intact cognition. Record review revealed a skilled nursing note dated [DATE] showed that Resident #1 was identified as an elopement risk. An elopement risk evaluation was conducted on [DATE], the day of the elopement incident, which was not done prior to that. The assessment showed a score of 4, which indicates that Resident #1 is at risk for elopement. Resident #1's care plan reveals a focus of Resident has potential for drug-seeking type behaviors. Hx. [History] of drug abuse and drug-seeking since admission. Date initiated [DATE]. Interventions include Anticipate and meet resident's needs (dated [DATE]), Educate resident on successful coping and interaction strategies (dated [DATE]), and resident will not wander out of facility (dated [DATE]). An additional focus of the care plan includes the resident is an elopement risk/wanderer related to impaired safety awareness (date initiated [DATE]) with interventions that include actual elopement on [DATE] (dated [DATE]), assess for elopement risk (date initiated [DATE]) electronic monitoring to place on the resident (dated [DATE]). Record review revealed Resident #1 Physician's orders for [DATE], (prior to the elopement that occurred on [DATE]) included the following: Aspirin 81milligrams (mg) one tablet daily for antiarrhythmic; Atorvastatin 20mg one tablet daily for hyperlipidemia; Famotidine 20mg one tablet daily for GERD (gastroesophageal reflux disease); Ferrous Sulfate 325mg one tablet daily for a supplement; Losartan Potassium 100mg one tablet daily for hypertension; Nifedipine Extended-release 24 hour 60mg one tablet daily for hypertension; Prednisone 20mg one tablet daily for inflammation; Prozac 20mg one tablet daily for antidepressant; Trazodone 75mg in the morning for depression; Vitamin D3 tablet 5000 units 1 tablet daily for vitamin D deficiency; Benztropine Mesylate tablet 1 mg every 12 hours for extrapyramidal symptoms; Risperdal tablet 0.25mg one tablet two times a day for schizophrenia; Buspirone tablet 15mg one tablet three times a day for anxiety. During the Medication Administration Record (MAR) review, there were blank sections where the nurses would put their initials indicating if the medication was given or why it was not given. The medication Benztropine Mesylate had blanks for the dates of 10/1, 10/2, 10/6, 10/7, 10/10, 10/11 at bedtime. The medication Risperdal 0.25mg had blanks for the dates of 10/1, 10/2, 10/6, 10/7, 10/10, 10/11 at 5:00 PM. Trazodone 100mg had blanks for 10/1, 10/2, 10/6, 10/7 for the bedtime doses. The medication Buspirone had blanks for 10/1, 10/2, 10/6, 10/7, 10/10, and [DATE] for the 5:00 PM doses. An interview was conducted on [DATE] at 2:00 PM with the facility's Director of Nursing, who was asked why there were blank spaces when the nurse's initials should be there, and she was unable to provide a reason why. In an interview conducted on [DATE] at 11:00 AM with the facility's the Director of Rehab, he stated that they use the BCAT (Brief Cognition Assessment Tool) to assess the cognitive level. Residents must be able to meet a specific criterion to be able to perform the test. The social worker will do her BIMS, and the SLP (Speech Language Pathologist) will conduct the BCAT to assess cognitive status. The BIMS is used as a baseline test when residents are admitted . The BCAT is more intensive with specific based questions that have 1 step command and 2 step commands. The test is very standardized and needs to be done by the book. He further stated that the BCAT could show specific goals for needs assessment and 1 to 2 steps goals. It is an excellent tool recognized by the American Speech-Language-Hearing Association ([NAME]). A nursing referral must be sent to have the SLP conduct the BCAT test. The lower the score on the BCAT, the more dependent the residents may be on all their Activities of Daily Living (ADL's). Someone with a low BCAT score will need maximum assistant, supervision, and everything must be structured for them. Someone with a score of 20 and below will have a high risk of getting hurt if they walk outside the facility and start walking, and they will need constant monitoring to avoid any accidents. A resident with a BIMS score higher than the BCAT will have to be reassessed with a new BIMS score. The Director of Rehab stated that cognitive levels could change and fluctuate from one day to another. The BCAT is more standardized, and it is a more accurate test. Resident #1 had a BCAT (Brief Cognitive Assessment Tool) conducted after the incident on [DATE]. The assessment was completed by the facility's Speech-Language Pathologist on [DATE], 3 days after the incident. The BCAT assessment showed a score of 18 out of 50, indicating severe cognitive-linguistic impairment. The Resident presents with severe impairments in sustained attention, auditory comprehension for following basic directions, short-term memory recall, and problem-solving skills. Resident required max verbal cues for redirection to structured tasks throughout the examination. An elopement risk evaluation was conducted on [DATE], the day of the incident, which was not done prior to that. The assessment showed a score of 4, which indicates that Resident #1 is at risk for elopement. In an interview conducted on [DATE] at 11:10 AM with Resident #1, she could not have a conversation with the surveyor and did not provide appropriate responses when answering the surveyor's questions. In an interview conducted with Staff H, CNA, via telephone on [DATE] at 11:59 AM, she was asked about the incident on [DATE]. Staff H stated that she was leaving the facility when Staff G, a Licensed Practical Nurse (LPN) asked her to look for Resident #1 on her drive home. At approximately 7:15 AM, Staff H located Resident #1 by a Speedway gas station located on US-1 and 16th street. Staff H stated that Resident #1 was about to turn right onto Highway US-1 going North. The Resident was observed wearing sweatpants, a shirt, and sneakers and carrying her purse. Staff H pulled into the gas station and approached the Resident on foot. Resident #1 stated, I do not want to go back to the hospital. Staff H reported that Resident #1 did not recall her name but knew her by face. Resident #1 agreed to get in the car, and Staff H then brought her back to the facility at approximately 7:20 AM. Staff H further stated that Resident #1 was very restless the night before. During the night, she kept coming out of the room and asked to leave, and she had her shoes and purse. She asked to leave multiple times during the night shift and was monitored by staff. According to Staff H, Resident #1 was more anxious than usual. When asked about her cognitive status before leaving the facility, she reported that Resident #1 was confused. She also said that Resident #1 exhibited exit behaviors before her leaving on [DATE] but nothing to the extent of her leaving the facility. An interview with Staff E, Certified Occupational Therapy Assistant (COTA), was conducted on [DATE] at 12:15 PM. Staff E stated that on [DATE], between 7:00 AM and 7:05 AM, she was in the gym working on her notes when she heard an alarm. She walked in the direction of the door that the alarm sounded from and poked her head out of the door but did not step out. The exit door was located between rooms [ROOM NUMBERS]. On her way to the exit door, she stated that the Resident in room [ROOM NUMBER]B told her that the skinny lady in room [ROOM NUMBER] was walking in the hallway toward the exit door earlier, but he did not see her leave. Staff E further stated that she returned to the nurse's station and alerted additional staff to what the Resident in room [ROOM NUMBER]B told her. She then asked Staff F, Certified Nursing Assistant (CNA), to check Resident #1's room to see if she was there. She did not call the police and is unsure if anyone called the police. The Director of Nurses and the Administrator had not arrived at the facility yet. Resident #1 was not located in her room or inside the facility. Staff immediately initiated a search of the grounds, including the parking lot. Staff G, a Licensed Practical Nurse (LPN) who worked the night shift, went outside looking for Resident #1. In a tour conducted on [DATE] at 12:10 PM, surveyors walked the path that Resident #1 walked when she left the faciity on [DATE]. Resident #1 walked out from Harbor Beach Nursing and Rehabilitation Center through the exit door on the North-West side. She walked down the ramp and turned left onto 16th Street, going [NAME] towards US-1. The side street (16th Street) did not have any sidewalk on one side of the road and had cracked uneven pavement. Highway US-1 had 6 lane highway, with 3 lanes on each side. Further, observation showed no crossing light/or traffic light at the intersection of US-1 and 16th street. It is unknown what side of the road the Resident walked on or if she walked in the street. The resident could have gotten lost, fallen, or been hit by a car. While Resident #1 was out of the facility unsupervised there was a high likelihood that she could have been seriously injured, seriously harmed, or died (Photographic evidence obtained). In an interview conducted on [DATE] at 12:33 PM with Staff I, Social Services Director, she reported that BIMS scores could vary from one day to the other. If a resident has a Urinary Tract Infection (UTI), or other comorbidities, their BIMS score might be affected. She may repeat the test for the BIMS depending on the discrepancies after a resident is all better. When asked if she is aware of the BCAT test, she said that SLP does it, but she is not very familiar with it. The BCAT may be done on residents with dementia or Alzheimer's because it is more detailed. Staff said that the BCAT is more accurate than the BIMS because they are going into more details with the questions, and it takes longer to do the test. Staff I, further stated that Resident #1's cognitive level and speech have improved since her admission to the facility. On [DATE], Resident #1's repeated BIMS score was at 13, which is cognitively intact. On [DATE] at 1:00 PM, Staff I indicated a new BIMS test would be completed for Resident #1 . In this test, Resident #1 was only able to answer the present year and scored 3 out of 15, indicating severely cognitively deficit. In a phone interview conducted on [DATE] at 1:48 PM with Resident #1's father, he stated that Resident's #1 communication and cognitive status have worsened since she was admitted to the facility. He further reported that Resident #1 is not able to verbalize her needs to him. A review of the Elopement drills that were provided by the facility showed no indication that Wandering and Elopement in-services were given in September as listed on the Education Calendar for 2021. This surveyor was provided education in-service attendance reports for abuse/mistreatment dated [DATE] and Missing Resident/Elopement/Abuse dated [DATE]. The facility also conducted elopement drills on [DATE] and [DATE] after the incident on [DATE]. A closer review of the Elopement drills after [DATE] did not show an education that included: an outside search that needs to be done outside the facility as far as the eye distance from the alarming exit door as a point of reference. In an interview conducted on [DATE] at 10:20 AM, with Staff J, Certified Nursing Assistant, she arrived at the facility at 7:00 AM, on the morning of [DATE]. On her way to the nursing station, she heard from another staff that Resident #1 had escaped and that they listened to the alarm. According to Staff J, Resident #1 always says that she wants to go out and wants to leave and is known to be a little confused. On the morning of the incident, staff started looking for her outside and inside the facility. She was told to look for Resident #1 outside in the front parking lot of the facility. When asked if Resident #1 had a wander guard before she attempted to leave the facility, she said no. She further stated that because she had never left the facility before, she did not need one. According to Staff J, on [DATE], they did not have a supervisor in charge because it was too early. She further said that when she was educated on elopement, she was told to first check each room before searching outside the premises. Then you go out to look for the resident. When an elopement happens, they are supposed to tell someone in charge and follow the directions of the supervisor. Staff J stated that she did not participate in any elopement drills after [DATE]. When asked as to how many exit doors does the facility has, she did not know. In a second interview conducted on [DATE] at 11:07 AM with Staff E, she stated that she was educated on elopement twice a year. The drills consisted of a code called BODYBEAR as an indication that a resident was missing. They needed to get to the nurse's station and receive the individual assignment from the supervisor. Once you have your instructions, you follow them and report your findings. On the morning of [DATE], she heard the alarm and told the nurses what the Resident in room [ROOM NUMBER] told her. She tried getting the staff around the facility to search for Resident #1, and she even looked outside the front of the facility. After the incident, the facility conducted an in-service on elopement which she did not participate. When she returned, she completed a test on elopement. According to Staff E, nothing new was part of the education, and that they re-educated staff on the same instruction you would follow if an elopement happened again. She did not know if the facility completed another drill after the incident on [DATE]. When asked by the surveyor if she could see Resident #1 walking away when she peeked outside the door on [DATE], she said: I can see a partial view of the street, on both sides but more to the left. She then said Resident #1 must-have walked very fast. In an interview conducted on [DATE] at 11:57 AM, Staff K, Housekeeping, stated that on the day of the incident, she passed by room [ROOM NUMBER] to go to the nurses' stations. She is familiar with Resident #1, who usually comes out of her room at around 8:00 AM and goes outside the patio across from her room. On the morning of [DATE], she saw Resident #1 walking out of her room and did not think much of it. The next thing she heard was the alarm on the door. She walked in the direction of the sound and was told by Staff E, who was by the exit door, that Resident #1 had already gone and could not see her. She then started looking for Resident #1 around the building. She also reported that by the time she was ready to go into her car and drive around to look for Resident #1, another staff brought Resident #1 back to the facility. She could not remember when the last time she participated in elopement drills. When asked if this happened again: she said, they would not have to tell me anything; I would go looking for [Resident #1] right away. In an interview conducted on [DATE] at 12:15 PM with the Maintenance Director, he stated he helps with the elopement drills. He noted that elopement drills are conducted once a month for every shift. Before this year, they used to have a dressed-up teddy bear called BODYBEAR, which the facility would hide either inside or outside. Once announced, staff would have to come to the nurse's station to receive their assignments. Now they have changed the drills, they will call the name of the missing resident, and staff will follow the supervisor's instructions. In a tour conducted on [DATE] at 6:00 PM, with the Regional Director of Clinical Services, she was asked to accompany the surveyor to the exit door that Resident #1 escaped from. Surveyor opened the exit door and peeked outside. Surveyor could not see a full view of the street from right to left, and only the ramp to the street was visible from the door (Photographic evidence obtained). The Regional Director of Clinical Services agreed that Staff E, should have stepped outside the door, and walked down the ramp, to have a full view of the street. The facility Immediate Jeopardy Removal Plan included: 1. On [DATE] the Director of Clinical Services and designees initiated education for staff on how to search for a resident who has eloped from an alarming door to include an immediate perimeter area search from the starting point of eye distance. The responder to the alarming door will be assigned to conduct the initial/immediate search. This education consisted of return demonstration to validate knowledge and phone education when available and education documentation if needed. Return education demonstration will continue upon staff return. 2. On [DATE] The Plant Operations Manager was educated by the Senior Maintenance Director on conducting monthly Elopement Drills. 3. The Director of Clinical Services and designee conducted elopement drills on each shift, daily for 3 days starting on [DATE] then weekly through [DATE], drills included post drill education based on response. 4. On [DATE] the Director of Clinical Services and designees initiated staff education on demonstration to follow elopement plan. Education initiated on [DATE]. Staff includes Therapy (7), Housekeeping/Laundry (5), Dietary (7), CNAs (28), Nurses (18), and Administrative/department heads (12). 5. On [DATE] Licensed nursing staff education was initiated to ensure the Elopement Risk evaluation is conducted at the time of admission. Education includes 18 licensed nursing staff. 6. On [DATE] Staff education was initiated on reporting and communicating resident exit-seeking behaviors to their supervisor. The Director of Clinical Services will be notified, and appropriate interventions will be reviewed. Staff Education includes Therapy (7), Housekeeping/Laundry (5), Dietary (7), CNAs (28) Nurses (18), and Administrative/department heads (12). 7. On [DATE] The Executive Director and Director of Clinical Services were educated on determining the root causes specific to elopements by the Regional [NAME] President of Operations. 8. The Executive Director led an additional Quality Assurance and Performance Improvement meeting on [DATE] with the Medical Director, Director of Clinical Services, Social Services Director, Plant Operations, Activities, Dietary Supervisor, Housekeeping Supervisor, CNA, Business Office. 9. An additional ad hoc quality assurance performance improvement meeting was held on [DATE] with the participation of the Center Medical Director, Executive Director, Director of Clinical Services, Social Services Director, Unit Manager, MDS Coordinator, Plant Operations Manager, Human Resources, Housekeeping Supervisor, Dietary Director, Therapy Director, and Activities Director. The plan along with the root cause for the incident was discussed and approved by the Medical Director. The Facility policies on Elopement were reviewed during the QAPI meeting. 10. An ad hoc quality assurance performance improvement meeting was held on [DATE] with the participation of the Center Medical Director, Executive Director, Director of Clinical Services, Social Services Director, Unit Manager, MDS Coordinator, Plant Operations Manager, Human Resources, Housekeeping Supervisor, Dietary Director, Therapy Director, and Activities Director. The Plan along with the root cause for the incident was discussed and approved by the Medical Director. The Facility policies on Elopement were reviewed during the QAPI meeting.