**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident and facility record reviews, and a review of the facility's policies titled Reporting Abuse to Facility Management (Revised February 2014), Elopements (revised February 2014), and the facility's Elopement Drill Process/Missing Resident Process, the facility failed to ensure residents were free from neglect, by failing to provide supervision and interventions to maintain resident safety, prevent elopement (a resident who is incapable of adequately protecting themself, who leaves the facility unsupervised and undetected), and minimize the risk of injury or death. This resulted in one (Resident #1) of three residents reviewed for elopement risk, departing the facility unescorted and remaining missing from the facility from 1:58 p.m. on 10/11/23 until approximately 4:00 a.m. the following morning (10/12/23), when located by the Sheriff's Office lying on a street, rain soaked, missing his shoes, with multiple abrasions, approximately four (4) miles away from the facility. On 6/6/23, Resident #1 was admitted to the facility's locked memory care unit due to exit-seeking behavior and was assessed as high risk for elopement. On 10/11/23 at 1:58 p.m. the facility's video camera captured Resident #1 exiting the facility behind a visitor. He passed the receptionist on his way out. There was an elopement binder at the reception desk for identification of residents at risk for elopement, and the receptionist was responsible for monitoring the residents who left the facility. On 10/11/23 at 5:30 p.m., while passing dinner trays, Certified Nursing Assistant (CNA) D discovered that Resident #1 was missing, 3.5 hours after he left the facility. A Code [NAME] (missing resident) was called, and a search was initiated. On 10/11/23 at 5:37 p.m., the Administrator and Director of Nursing (DON) were notified of the missing resident and at 7:00 p.m., the Sheriff's office was notified. On 10/12/23 at 4:04 a.m., the facility was notified by the Sheriff's office that Resident #1 had been located and transported to the hospital. Per the hospital's ER (emergency room) note, Resident #1 arrived at the ER accompanied by a Sheriff's deputy and EMS (emergency medical services). He had been found approximately four miles away from the facility, lying in the street. His clothing was wet due to rain, and he was without his shoes. He had mild abrasions to his left shoulder, left knee and forehead. Staff were aware of the resident's needs but failed to adequately supervise Resident #1, resulting in the resident eloping from the facility. The resident likely could have been hit by a car, been seriously injured, gotten lost and/or died. There were 57 residents identified as at risk for elopement as of 10/17/23. The locked memory care unit housed 19 residents. Immediate Jeopardy at a scope of J (isolated) was identified at 10:45 a.m. on October 16, 2023. On October 11, 2023, at 1:58 p.m., Immediate Jeopardy began. On October 17, 2023, at 4:30 p.m., the Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective October 13, 2023, after verification of the removal of immediacy. The facility remained out of compliance, and the scope and severity were reduced to D, no actual harm, with a potential for no more than minimal harm, due to the facility's failure to provide adequate supervision to ensure resident safety and prevent elopement. The findings include: Cross reference F689 Review of a facility report revealed that on 10/11/23 at approximately 5:30 p.m., it was discovered that Resident #1 was not in his room or on the Butterfly unit (locked memory care unit) when CNA D went to deliver his dinner tray. At approximately 5:36 p.m. CNA E called a Code Green (missing resident) which was led by Licensed Practical Nurse (LPN) B (Supervisor). At 5:37 p.m., facility staff notified the Administrator and Director of Nursing (DON) that Resident #1 was missing. Staff searched the interior and exterior of the facility and premises without locating Resident #1. A full head count was conducted which revealed the only unaccounted for resident was Resident #1. At 6:00 p.m., the Administrator and DON arrived at the center and began interviewing staff. They conducted an interior search of the building. A door inspection was completed by the Administrator with no areas of concern identified. At 6:15 p.m., department heads conducted exterior searches to include the busy, multi-lane street adjacent to the facility property, and another busy street close to the facility including store fronts, grocery stores, thrift stores, a big box store, and churches without locating Resident #1. The facility's Chief Executive Officer (CEO) and Chief Nursing Officer (CNO) were notified on 10/11/23 at 6:15 p.m. At 7:30 p.m., the Administrator reported that Resident #1 was missing to the Sheriff's office who arrived at the facility at approximately 8:15 p.m. At 8:30 p.m., the Sheriff's office conducted an interior and exterior search of the facility, deployed a K-9 unit, and attempted to deploy a drone, but due to the weather conditions at that time, the use of a drone was not possible. At 12:00 a.m. on 10/12/23, with the assistance of the Sheriff's department and access to facility outdoor video cameras, Resident #1 was observed exiting the facility at 1:58 p.m. on 10/11/23, ambulating behind an exiting visitor/family member. Resident #1 was fully clothed and was wearing shoes. At 4:00 a.m. on 10/12/23, the Sheriff's department returned to the facility and informed Registered Nurse (RN) A that Resident #1 had been located approximately four (4) miles away and was transported to an acute care hospital's emergency room (ER). A review of timeanddate.com on 10/17/23 at 10:47 a.m., found that the weather in the area of the facility on 10/11/23 at 6:00 p.m. was cloudy with rain, 75 degrees F (Fahrenheit), and 9 mph (miles per hour) winds. At 12:00 a.m. on 10/12/23, weather in the area of the facility included heavy showers, winds at 11 mph, and a temperature of 73 degrees F. The facility is situated several hundred feet off of a very busy 4-6 lane street (there are 4 lanes in front of the facility, two northbound and two southbound) with a speed limit of 45 mph. There are sidewalks on both sides of the street. The front entrance is located several hundred feet from the street via a winding, treed, and fenced access road. Resident #1 was found approximately four miles from the facility. This would have required the resident to walk along several busy roadways. Review of hospital emergency room documentation revealed that Resident #1 arrived on 10/12/23 at 6:00 a.m. via EMS and escorted by the Sheriff's department, after having been found lying in the street, wet and without shoes. Resident #1 was triaged at 6:14 a.m. His examination included x-rays of his left shoulder, left arm, and left knee. A computed tomography (CT) of his head, and a blood draw for laboratory studies were also completed. Results of the testing revealed that the resident had no significant injuries to his limbs or head. Laboratory studies showed dehydration and mild rhabdomyolysis (a condition caused by the breakdown of muscle tissue resulting in the release of lactic acid which can lead to impaired cardiovascular health, compromised blood supply and reduced kidney function, and in severe cases, can lead to death). Resident #1 was treated for minor abrasions and was administered intravenous hydration of two (2) liters of lactated ringers (an intravenous solution used to replace fluids, electrolytes and treat acidosis). Resident was admitted for observation, then released back to the facility on [DATE] at approximately 12:00 p.m. On 10/16/23 at 11:15 a.m., multiple residents were observed ambulating in the hall on the Butterfly (locked) unit. Three residents were sitting on a bench outside of the nurses' station, and several more residents were in the dining room. Staff were observed interacting with residents in the hall as well as those in the dining room. In an interview with Licensed Practical Nurse (LPN) B/Supervisor at this time, she stated she had been working on the day Resident #1 eloped. I was the supervisor that day but not the nurse on the Butterfly unit. When she was asked what her role had been, she stated she contacted the resident's responsible party to ask if Resident #1 was with her. She didn't know what led to the elopement; she just did what she was asked to do. When she was asked what the expectation was for rounding on the unit, she replied, There is usually at least one staff member in the hallway and another in the dining room, so they usually have eyes on the residents all the time. On 10/16/23 at 11:27 a.m., Housekeeper A was asked how she determined who was at risk for wandering. She replied, Residents that like to walk back and forth. Routine checks are every two hours for the residents. If a resident cannot be located it is reported to the nurse. When she was asked who could unlock the front door, she replied, The receptionist in the front lobby. She stated she received Abuse and Neglect training in September. On 10/16/23 at 11:45 a.m., an interview was conducted with LPN C. When she was asked if she was working on the day of the facility's most recent elopement, she replied, Yes, but I was not the nurse assigned to the Butterfly unit that day. When she was asked what happened, she replied, At around 5:30 p.m., they called a Code [NAME] (missing resident). We searched inside and outside of the building, but we weren't able to find him (Resident #1). We had to do an in-service on abuse/neglect and elopement drills. On 10/16/23 at 11:53 a.m., CNA E stated she identified residents who were at risk for wandering by observing residents that paced and did not sit still for periods of time. Some residents in the Butterfly unit are wanderers. She further stated she rounded on her residents every 1.5 hours. If she could not locate a resident, she would walk to find them and report it to the nurse. Routine checks (laying eyes on residents) included checking them for incontinence care needs and ensuring they had something to drink. When asked who could unlock the front door, she replied, The receptionist or the nurse overnight. On 10/16/2023 at 12:03 p.m., Registered Nurse (RN) B stated she identified residents at risk for wandering by reviewing reports and residents' diagnoses in the charts. She rounded on her residents every 1.5 to 2 hours. When asked what she would do if she could not locate a resident, she replied, Go look for the resident. Residents have the right to go off the unit. If a resident is 1:1 (one to one supervision), the staff member assigned to them will tail them. Routine checks are every two hours to ensure that all residents are accounted for. Anyone who has the key can unlock the front door. The key is kept safe with the receptionist. It is locked in the medication room/cart at night. An interview conducted on 10/16/23 at 2:20 p.m. with the Administrator and DON, revealed that they determined the root cause of the elopement was human error, the failure of LPN A and CNA C to appropriately supervise and prevent Resident #1 from exiting the unit/facility and the failure of the Receptionist, who was responsible for monitoring everyone exiting through the main entrance to ensure no residents eloped. Upon review of the video feed from 10/11/23, this interview also revealed that Resident #1 had followed a family member, who had been visiting his wife on the memory care unit, out of the facility's front door. There were no cameras outside of the Butterfly unit (locked unit) door inside of the facility. The Administrator and DON stated Resident #1's elopement occurred on 10/11/23 and the investigation was initiated on 10/11/23. A Code [NAME] was called, and a resident head count was completed. At approximately 1:55 p.m. on 10/11/23, the resident followed a family visitor out of the Butterfly unit and through both exit doors. A receptionist was at the main entrance door, but no staff were at the parlor door. The receptionist was sitting at the desk. The elopement book was located at the receptionist desk to help identify residents that were at risk. Main entrance camera footage was observed, and Resident #1 was seen exiting the building behind a visitor at 1:58:18 p.m. on 10/11/23. The DON stated Licensed Practical Nurse (LPN) A (7-3 shift) was assigned to Resident #1 on 10/11/23. She further stated LPN A did not supervise the resident and ensure the CNA was rounding every two hours. When the Administrator and the DON were asked why there was a 3.5 hour delay in staff realizing that Resident #1 was missing, the DON stated staff were passing dinner trays and realized the resident was missing at that time. On 10/17/23 at 10:35 a.m., LPN A stated she ensured all of her residents were accounted for by checking room by room at the start of her shift. She stated she left the unit around noon and when she returned to the unit, all rooms and residents were checked and documented on the check sheet. When she was asked to describe the system in place to prevent residents from leaving, she replied, There is a staff member assigned to sit outside the door. Staff are to check behind them when leaving and all doors have codes. Residents are identified as at risk for elopement by the list located on the front of the MAR (medication administration record). Also, residents will tell you they want to leave. Some residents will walk to the door and push on the door. LPN A confirmed she was on duty the day of Resident #1's elopement. She stated, I was in fear and worried about the resident. CNA C was unable to be reached for interview during the survey. A review of Resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, diabetes, dementia, wandering, depression, and anxiety. His emergency contact/responsible party was his estranged wife. The Quarterly Minimum Data Set (MDS) assessment, dated 9/8/23, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15 possible points, indicating severe cognitive impairment. The resident's initial History and Physical, written on 6/7/23 by the resident's attending physician, revealed he was admitted from another nursing home because of behaviors including that he was hard to control, had exit-seeking behavior with major depression and multiple comorbidities. Resident #1 was alert to himself, was somewhat confused, and needed assistance with activities of daily living (ADLs). His active 6/8/23 Physician's Orders were as follows: Admit to skilled long-term care. Glucagon Emergency Kit for hypoglycemia (low blood sugar related to diabetes) event. Aspart Flexpen (insulin) 5 units subcutaneously (SQ - beneath the skin) before meals. Lantus (insulin) 8 units SQ daily at 6:00 a.m. Trazodone (antidepressant and sedative) 50 milligrams (mg) at bedtime 9:00 p.m. Clopidogrel (blood thinner) 75 mg daily 9:00 a.m. Metformin (anti-diabetic medication) 500 mg twice daily, at 9:00 a.m. and 5:00 p.m. Resident Assessments were as follows: 6/6/23 - Wound/skin assessment: No skin issues noted. 6/6/23 - Elopement risk screen: Score 13 (10 or more = high risk) 8/29/23 - Elopement risk screen: Score 10 10/13/23 - Elopement risk screen: Score 13 10/15/23 - Resident re-admitted to this facility from [acute-care hospital]. Skin intact, warm to touch. A review of Progress Notes revealed: 6/9/23 - Mental Health Services Advanced Registered Nurse Practitioner (ARNP) - Resident with history of exit seeking; refuses to talk with writer; states he is the commander, and no one listens to him because they are ruining everything; states they are Mexicans. Started on Mirtazapine 7.5 mg for poor appetite, and Trazodone 50 mg for combination anxiety and depression. A review of Physician's Notes revealed: On 6/8/23, 6/11/23, 8/11/23, and 9/11/23, exit seeking was documented consistently. A review of Nursing Notes revealed: On 6/6/23, 6/10/23, 6/11/23, 6/13/23, 6/14/23, 6/27/23, 8/2/23, 8/5/23, 8/14/23, and 8/21/23, the resident's habitual wandering/exit-seeking behavior was described. On 10/13/23 at 12:00 p.m., [Resident #1] was readmitted to the facility via family drop off. Resident is alert x 1 to 2. Upon arrival to facility, resident is placed on 1:1 (one to one supervision). Resident was seen by ARNP upon arrival. Safety measures in place. On 10/16/23 at 8:45 a.m., the Interdisciplinary Team (IDT) Note revealed: Resident with an event occurrence on 10/11/23 with a brief hospital stay where he was diagnosed with lactic acidosis. Resident's wife brought him to the facility on [DATE]. Resident denies memory of event which is consistent with his baseline mentation. Resident's skin intact with minor discoloration at left forehead, elbow, and toe. Resident denies pain and discomfort, continues to be ambulatory pacing incessantly and seems to easily fatigue. Referral to therapy for screening due to impacted task tolerance. A review of Resident #1's Care Plan revealed: 6/6/23 Elopement risk: Locked unit monitored by staff. 6/6/23 Behaviors: Exit-seeking, dementia, agitation. Encourage and praise positive behaviors; observe for changes in mood, behavior, cognition, psychosocial wellbeing. Resident #1 is alert with confusion. He is able to make his needs and wants known to others. He is an exit seeker. Staff informed. Invite and escort him to and from activities in the [NAME] club activity room. At times he becomes agitated when trying to exit the building. He is able to be calmed down, redirected by calling his wife, and music and food with others. He prefers to do his own thing. 6/19/23 Psychotropic Medications: Administer medications as ordered; monitor for effectiveness of medications and review for dose reduction if applicable; observe for signs of adverse reactions; redirect as needed; notify Medical Doctor (MD) of changes in mood/behavior and document. A review of the facility's policy titled Reporting Abuse to Facility Management (Revised February 2014), revealed on Page 1: Policy Interpretation and Implementation, Item 2. f. revealed: Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. A review of the facility's policy titled Elopements (revised February 2014), revealed on Page 1, Item 4: If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building and premises. c. If the resident is not located, notify the Administrator and the Director of Nursing services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue squads, etc.). d. Provide search teams with resident identification information, and e. Initiate an extensive search of the surrounding area. A review of the facility's Elopement Drill Process/Missing Resident process on Page 1, revealed the following: 1. Code [NAME] = missing resident. 2. ED (Administrator) and DON are to be contacted immediately upon initiation of a code green. 3. Code green and room location are paged three (3) times when a resident is identified as missing. 4. Staff should report to the nursing station of the missing resident. 5. The licensed nurse assigned to that resident is the lead during the drill and/or actual missing resident response. 6. The licensed nurse will get the elopement binder, remove the search grid sheet, and assign staff areas to begin looking for the missing resident. 7. When the resident is located staff are to return the resident to the assigned nurse for evaluation and further reporting/documentation process per regulation. 8. Code [NAME] All Clear is then called three (3) times to alert staff the missing resident has been located. Throughout the survey, the facility provided its immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows: 1. 100% of all current residents were reassessed for risk of elopement as of 10/13/23. The responsible Party was the DON who used several nurses to complete assessments. 2. 100% facility head count of current residents completed on 10/11/23. All residents were accounted for except Resident #1. The responsible party was the DON. 3. All facility doors were immediately checked to ensure proper functioning by the Administrator on 10/11/23. 4. Suspension of three current staff who were responsible for Resident #1 and had previously been educated on the Elopement policy. Completed on 10/11/23 by the Administrator and DON. 5. Butterfly unit (locked unit) staffing was adjusted on 10/11/23 as follows: Two dedicated staff members at all times on the unit to support the needs of the population by increasing monitoring/supervision. Responsible party - DON. 6. Staff member to monitor front entrance of the Butterfly Unit 24/7 with documentation initiated on 10/11/23 pending full results of the investigation and implementation of Root Cause Analysis (RCA) findings. Responsible party - DON. This is ongoing. 7. Doors are checked seven days a week to ensure proper functioning. Responsible party - Administrator. Initiated on 10/13/23 and is ongoing. 8. There is a staff member to monitor the front entrance parlor door of the facility from 7:00 a.m. to 7:00 p.m. with documentation initiated on 10/13/23 pending full results of the investigation and implementation of RCA findings. Responsible party - DON. This is ongoing. 9. A red Screamer Alarm is now turned on by the licensed nurse at 7:00 p.m. The key for the alarm is kept secure with the licensed nurse and located on the North Wing medication cart. The alarm is deactivated at 7:00 a.m. when the receptionist comes on duty. Responsible party - DON. This is ongoing. 10. As of 10/13/23, residents who reside on the Butterfly unit will have activities on the unit to support the needs of the population. Responsible party - DON and Activities Director (AD). This is ongoing. 11. A department head will complete a head count of all residents upon arrival and before leaving five times a week to ensure all residents are accounted for. This was initiated on 10/13/23 and is ongoing. Responsible party - DON. 12. A head count of all residents will be completed on each shift seven days a week to validate and ensure all residents are accounted for. Initiated on 10/12/23 and is ongoing. Responsible party - DON. 13. The Activities Director was educated by the Administrator on 10/13/23 related to initiating activities on the Butterfly unit to support the needs of the population and to discontinue taking those residents to activities outside of the unit to mitigate exit-seeking behaviors. Responsible party - Administrator. 14. The Visitor/Vendor sign-in/out book was moved from the front entrance foyer to the reception desk on 10/13/23. Responsible party - DON. 15. A sign was posted at the reception desk and the Butterfly unit on 10/13/23 for staff and visitors to watch for residents who may be behind them and please do not allow them to exit. Responsible party - DON. 16. Facility education was initiated for current staff related to the facility's Elopement policy on 10/11/23. All staff not on duty on 10/11/23 were educated prior to starting their next shift. Responsible Party - DON. 17. Facility education was initiated on 10/11/23 for current staff related to missing residents, routine monitoring of residents, and supervision of residents to include watching residents tailgating behind other residents and/or visitors. Staff are to visualize the door to the Butterfly unit and ensure the door is fully closed when anyone is entering and/or leaving so residents do not exit unsupervised. All staff not on duty on 10/11/23 were educated prior to starting their next shift. Responsible Party - DON. 18. A timeline of events was completed by the DON on 10/13/23. No concerns. 19. Staff interviews regarding elopement were completed on 10/11/23. Responsible party - DON. 20. The facility conducted an Ad Hoc QAPI meeting on 10/13/23 to include a root cause analysis (RCA) with the IDT and CNO to review how the resident was able to exit the Butterfly unit and exit the front entrance of the facility without staff knowledge. The responsible party was the CNO. 21. The facility will conduct unannounced drills four times a week to include off shifts and weekends. This was initiated on 10/13/23 and is ongoing. Responsible Party - DON. 22. Residents at risk for elopement have their names and photos in a binder at the front desk and nursing station. This was 100% current as of 10/12/23. Responsible Party - DON. 23. Staff education about Elopement and Missing Residents to be completed upon hire and annually. Responsible Party - DON. 24. As of 10/13/23, residents are to be evaluated for risk of elopement upon admission, re-admission and/or significant change. Responsible Party - DON. 25. Care plans were reviewed and are current for residents at risk for elopement as of 10/12/23. Responsible Party - DON. 26. Resident #1 was assessed by the attending physician upon readmission to the facility on [DATE]. 27. Immediate Federal Reporting was completed on 10/12/23. Responsible Party - DON. 28. The Receptionist was suspended pending investigation on 10/11/23 and was terminated on 10/17/23. 29. Doors to the Administration area that lead to the front entrance are to be locked at all times as of 10/13/23. Responsible Party - Administrator. 30. Abuse/Neglect/Exploitation education was initiated on 10/11/23. All staff not on duty on 10/11/23 were educated prior to starting their next shift. Responsible Party - DON. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident and facility record reviews, a review of the facility's policy titled Elopements (revised February 2014), and the facility's Elopement Drill Process/Missing Resident Process, the facility failed to ensure residents were provided supervision and interventions to maintain safety, prevent elopement (a resident who is incapable of adequately protecting themself, who leaves the facility unsupervised and undetected), and minimize the risk of injury or death. This resulted in one (Resident #1) of three residents reviewed for elopement risk, departing the facility unescorted and remaining missing from the facility from 1:58 p.m. on 10/11/23 until approximately 4:00 a.m. the following morning (10/12/23), when located by the Sheriff's Office lying on a street, rain soaked, missing his shoes, with multiple abrasions, approximately four (4) miles away from the facility. On 6/6/23, Resident #1 was admitted to the facility's locked memory care unit due to exit-seeking behavior and was assessed as high risk for elopement. On 10/11/23 at 1:58 p.m. the facility's video camera captured Resident #1 exiting the facility behind a visitor. He passed the receptionist on his way out. There was an elopement binder at the reception desk for identification of residents at risk for elopement, and the receptionist was responsible for monitoring the residents who left the facility. On 10/11/23 at 5:30 p.m., while passing dinner trays, Certified Nursing Assistant (CNA) D discovered that Resident #1 was missing, 3.5 hours after he left the facility. A Code [NAME] (missing resident) was called, and a search was initiated. On 10/11/23 at 5:37 p.m., the Administrator and Director of Nursing (DON) were notified of the missing resident and at 7:00 p.m., the Sheriff's office was notified. On 10/12/23 at 4:04 a.m., the facility was notified by the Sheriff's office that Resident #1 had been located and transported to the hospital. Per the hospital's ER (emergency room) note, Resident #1 arrived at the ER accompanied by a Sheriff's deputy and EMS (emergency medical services). He had been found approximately four miles away from the facility, lying in the street. His clothing was wet due to rain, and he was without his shoes. He had mild abrasions to his left shoulder, left knee and forehead. Staff were aware of the resident's needs but failed to adequately supervise Resident #1, resulting in the resident eloping from the facility. The resident likely could have been hit by a car, been seriously injured, gotten lost and/or died. There were 57 residents identified as at risk for elopement as of 10/17/23. The locked memory care unit housed 19 residents. Immediate Jeopardy at a scope of J (isolated) was identified at 10:45 a.m. on October 16, 2023. On October 11, 2023, at 1:58 p.m., Immediate Jeopardy began. On October 17, 2023, at 4:30 p.m., the Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective October 13, 2023, after verification of the removal of immediacy. The facility remained out of compliance, and the scope and severity were reduced to D, no actual harm, with a potential for no more than minimal harm, due to the facility's failure to provide adequate supervision to ensure resident safety and prevent elopement. The findings include: Cross reference F600 Review of a facility report revealed that on 10/11/23 at approximately 5:30 p.m., it was discovered that Resident #1 was not in his room or on the Butterfly unit (locked memory care unit) when CNA D went to deliver his dinner tray. At approximately 5:36 p.m. CNA E called a Code Green (missing resident) which was led by Licensed Practical Nurse (LPN) B (Supervisor). At 5:37 p.m., facility staff notified the Administrator and Director of Nursing (DON) that Resident #1 was missing. Staff searched the interior and exterior of the facility and premises without locating Resident #1. A full head count was conducted which revealed the only unaccounted for resident was Resident #1. At 6:00 p.m., the Administrator and DON arrived at the center and began interviewing staff. They conducted an interior search of the building. A door inspection was completed by the Administrator with no areas of concern identified. At 6:15 p.m., department heads conducted exterior searches to include the busy, multi-lane street adjacent to the facility property, and another busy street close to the facility including store fronts, grocery stores, thrift stores, a big box store, and churches without locating Resident #1. The facility's Chief Executive Officer (CEO) and Chief Nursing Officer (CNO) were notified on 10/11/23 at 6:15 p.m. At 7:30 p.m., the Administrator reported that Resident #1 was missing to the Sheriff's office who arrived at the facility at approximately 8:15 p.m. At 8:30 p.m., the Sheriff's office conducted an interior and exterior search of the facility, deployed a K-9 unit, and attempted to deploy a drone, but due to the weather conditions at that time, the use of a drone was not possible. At 12:00 a.m. on 10/12/23, with the assistance of the Sheriff's department and access to facility outdoor video cameras, Resident #1 was observed exiting the facility at 1:58 p.m. on 10/11/23, ambulating behind an exiting visitor/family member. Resident #1 was fully clothed and was wearing shoes. At 4:00 a.m. on 10/12/23, the Sheriff's department returned to the facility and informed Registered Nurse (RN) A that Resident #1 had been located approximately four (4) miles away and was transported to an acute care hospital's emergency room (ER). A review of timeanddate.com on 10/17/23 at 10:47 a.m., found that the weather in the area of the facility on 10/11/23 at 6:00 p.m. was cloudy with rain, 75 degrees F (Fahrenheit), and 9 mph (miles per hour) winds. At 12:00 a.m. on 10/12/23, weather in the area of the facility included heavy showers, winds at 11 mph, and a temperature of 73 degrees F. The facility is situated several hundred feet off of a very busy 4-6 lane street (there are 4 lanes in front of the facility, two northbound and two southbound) with a speed limit of 45 mph. There are sidewalks on both sides of the street. The front entrance is located several hundred feet from the street via a winding, treed, and fenced access road. Resident #1 was found approximately four miles from the facility. This would have required the resident to walk along several busy roadways. Review of hospital emergency room documentation revealed that Resident #1 arrived on 10/12/23 at 6:00 a.m. via EMS and escorted by the Sheriff's department, after having been found lying in the street, wet and without shoes. Resident #1 was triaged at 6:14 a.m. His examination included x-rays of his left shoulder, left arm, and left knee. A computed tomography (CT) of his head, and a blood draw for laboratory studies were also completed. Results of the testing revealed that the resident had no significant injuries to his limbs or head. Laboratory studies showed dehydration and mild rhabdomyolysis (a condition caused by the breakdown of muscle tissue resulting in the release of lactic acid which can lead to impaired cardiovascular health, compromised blood supply and reduced kidney function, and in severe cases, can lead to death). Resident #1 was treated for minor abrasions and was administered intravenous hydration of two (2) liters of lactated ringers (an intravenous solution used to replace fluids, electrolytes and treat acidosis). Resident was admitted for observation, then released back to the facility on [DATE] at approximately 12:00 p.m. On 10/16/23 at 11:15 a.m., multiple residents were observed ambulating in the hall on the Butterfly (locked) unit. Three residents were sitting on a bench outside of the nurses' station, and several more residents were in the dining room. Staff were onserved interacting with the residents in the hall as well as those in the dining room. In an interview with Licensed Practical Nurse (LPN) B/Supervisor at this time, she stated she had been working on the day Resident #1 eloped. I was the supervisor that day but not the nurse on the Butterfly unit. When she was asked what her role had been, she stated she contacted the resident's responsible party to ask if Resident #1 was with her. She didn't know what led to the elopement; she just did what she was asked to do. When she was asked what the expectation was for rounding on the unit, she replied, There is usually at least one staff member in the hallway and another in the dining room, so they usually have eyes on the residents all the time. On 10/16/23 at 11:27 a.m., Housekeeper A was asked how she determined who was at risk for wandering. She replied, Residents that like to walk back and forth. Routine checks are every two hours for the residents. If a resident cannot be located it is reported to the nurse. When she was asked who could unlock the front door, she replied, The receptionist in the front lobby. She stated she received Abuse and Neglect training in September. On 10/16/23 at 11:45 a.m., an interview was conducted with LPN C. When she was asked if she was working on the day of the facility's most recent elopement, she replied, Yes, but I was not the nurse assigned to the Butterfly unit that day. When she was asked what happened, she replied, At around 5:30 p.m., they called a Code [NAME] (missing resident). We searched inside and outside of the building but we weren't able to find him (Resident #1). We had to do an in-service on abuse/neglect and elopement drills. On 10/16/23 at 11:53 a.m., CNA E stated she identified residents who were at risk for wandering by observing residents that paced and did not sit still for periods of time. Some residents in the Butterfly unit are wanderers. She further stated she rounded on her residents every 1.5 hours. If she could not locate a resident, she would walk to find them and report it to the nurse. Routine checks (laying eyes on residents) included checking them for incontinence care needs and ensuring they had something to drink. When asked who could unlock the front door, she replied, The receptionist or the nurse overnight. On 10/16/2023 at 12:03 p.m., Registered Nurse (RN) B stated she identified residents at risk for wandering by reviewing reports and residents' diagnoses in the charts. She rounded on her residents every 1.5 to 2 hours. When asked what she did if she could not locate a resident, she replied, Go look for the resident. Residents have the right to go off the unit. If a resident is 1:1 (one to one supervision), the staff member assigned to them will tail them. Routine checks are every two hours to ensure that all residents are accounted for. Anyone who has the key can unlock the front door. The key is kept safe with the receptionist. It is locked in the medication room/cart at night. An interview conducted on 10/16/23 at 2:20 p.m. with the Administrator and DON, revealed that they determined the root cause of the elopement was human error, the failure of LPN A and CNA C to appropriately supervise and prevent Resident #1 from exiting the unit/facility and the failure of the Receptionist, who was responsible for monitoring everyone exiting through the main entrance to ensure no residents eloped. Upon review of the video feed from 10/11/23, this interview also revealed that Resident #1 had followed a family member, who had been visiting his wife on the memory care unit, out of the facility's front door. There were no cameras outside of the Butterfly unit (locked unit) door inside of the facility. The Administrator and DON stated Resident #1's elopement occurred on 10/11/23 and the investigation was initiated on 10/11/23. A Code [NAME] was called, and a resident head count was completed. At approximately 1:55 p.m. on 10/11/23, the resident followed a family visitor out of the Butterfly unit and through both exit doors. A receptionist was at the main entrance door, but no staff were at the parlor door. The receptionist was sitting at the desk. The elopement book was located at the receptionist desk to help identify residents that were at risk. Main entrance camera footage was observed, and Resident #1 was seen exiting the building behind a visitor at 1:58:18 p.m. on 10/11/23. The DON stated Licensed Practical Nurse (LPN) A (7-3 shift) was assigned to Resident #1 on 10/11/23. She further stated LPN A did not supervise the resident and ensure the CNA was rounding every two hours. When the Administrator and the DON were asked why there was a 3.5 hour delay in staff realizing that Resident #1 was missing, the DON stated staff were passing dinner trays and realized the resident was missing at that time. On 10/17/23 at 10:35 a.m., LPN A stated she ensured all of her residents were accounted for by checking room by room at the start of her shift. She stated she left the unit around noon and when she returned to the unit, all rooms and residents were checked and documented on the check sheet. When she was asked asked to describe the system in place to prevent residents from leaving, she replied, There is a staff member assigned to sit outside the door. Staff are to check behind them when leaving and all doors have codes. Residents are identified as at risk for elopement by the list located on the front of the MAR (medication administration record). Also, residents will tell you they want to leave. Some residents will walk to the door and push on the door. LPN A confirmed she was on duty the day of Resident #1's elopement. She stated, I was in fear and worried about the resident. CNA C was unable to be reached for interview during the survey. A review of Resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, diabetes, dementia, wandering, depression, and anxiety. His emergency contact/responsible party was his estranged wife. The Quarterly Minimum Data Set (MDS) assessment, dated 9/8/23, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15 possible points, indicating severe cognitive impairment. The resident's initial History and Physical, written on 6/7/23 by the resident's attending physician, revealed he was admitted from another nursing home because of behaviors including that he was hard to control, had exit-seeking behavior with major depression and multiple comorbidities. Resident #1 was alert to himself, was somewhat confused, and needed assistance with activities of daily living (ADLs). His active 6/8/23 Physician's Orders were as follows: Admit to skilled long-term care. Glucagon Emergency Kit for hypoglycemia (low blood sugar related to diabetes) event. Aspart Flexpen (insulin) 5 units subcutaneously (SQ - beneath the skin) before meals. Lantus (insulin) 8 units SQ daily at 6:00 a.m. Trazodone (antidepressant and sedative) 50 milligrams (mg) at bedtime 9:00 p.m. Clopidogrel (blood thinner) 75 mg daily 9:00 a.m. Metformin (anti-diabetic medication) 500 mg twice daily, at 9:00 a.m. and 5:00 p.m. Resident Assessments were as follows: 6/6/23 - Wound/skin assessment: No skin issues noted. 6/6/23 - Elopement risk screen: Score 13 (10 or more = high risk) 8/29/23 - Elopement risk screen: Score 10 10/13/23 - Elopement risk screen: Score 13 10/15/23 - Resident re-admitted to this facility from [acute-care hospital]. Skin intact, warm to touch. A review of Progress Notes revealed: 6/9/23 - Mental Health Services Advanced Registered Nurse Practitioner (ARNP) - Resident with history of exit seeking; refuses to talk with writer; states he is the commander, and no one listens to him because they are ruining everything; states they are Mexicans. Started on Mirtazapine 7.5 mg for poor appetite, and Trazodone 50 mg for combination anxiety and depression. A review of Physician's Notes revealed: On 6/8/23, 6/11/23, 8/11/23, and 9/11/23, exit seeking was documented consistently. A review of Nursing Notes revealed: On 6/6/23, 6/10/23, 6/11/23, 6/13/23, 6/14/23, 6/27/23, 8/2/23, 8/5/23, 8/14/23, and 8/21/23, the resident's habitual wandering/exit-seeking behavior was described. On 10/13/23 at 12:00 p.m., [Resident #1] was readmitted to the facility via family drop off. Resident is alert x 1 to 2. Upon arrival to facility, resident is placed on 1:1 (one to one supervision). Resident was seen by ARNP upon arrival. Safety measures in place. On 10/16/23 at 8:45 a.m., the Interdisciplinary Team (IDT) Note revealed: Resident with an event occurrence on 10/11/23 with a brief hospital stay where he was diagnosed with lactic acidosis. Resident's wife brought him to the facility on [DATE]. Resident denies memory of event which is consistent with his baseline mentation. Resident's skin intact with minor discoloration at left forehead, elbow, and toe. Resident denies pain and discomfort, continues to be ambulatory pacing incessantly and seems to easily fatigue. Referral to therapy for screening due to impacted task tolerance. A review of Resident #1's Care Plan revealed: 6/6/23 Elopement risk: Locked unit monitored by staff. 6/6/23 Behaviors: Exit-seeking, dementia, agitation. Encourage and praise positive behaviors; observe for changes in mood, behavior, cognition, psychosocial wellbeing. Resident #1 is alert with confusion. He is able to make his needs and wants known to others. He is an exit seeker. Staff informed. Invite and escort him to and from activities in the [NAME] club activity room. At times he becomes agitated when trying to exit the building. He is able to be calmed down, redirected by calling his wife, and music and food with others. He prefers to do his own thing. 6/19/23 Psychotropic Medications: Administer medications as ordered; monitor for effectiveness of medications and review for dose reduction if applicable; observe for signs of adverse reactions; redirect as needed; notify Medical Doctor (MD) of changes in mood/behavior and document. A review of the facility's policy titled Elopements (revised February 2014), revealed on Page 1, Item 4: If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building and premises. c. If the resident is not located, notify the Administrator and the Director of Nursing services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue squads, etc.). d. Provide search teams with resident identification information, and e. Initiate an extensive search of the surrounding area. A review of the facility's Elopement Drill Process/Missing Resident process on Page 1, revealed the following: 1. Code [NAME] = missing resident. 2. ED (Administrator) and DON are to be contacted immediately upon initiation of a code green. 3. Code green and room location are paged three (3) times when a resident is identified as missing. 4. Staff should report to the nursing station of the missing resident. 5. The licensed nurse assigned to that resident is the lead during the drill and/or actual missing resident response. 6. The licensed nurse will get the elopement binder, remove the search grid sheet, and assign staff areas to begin looking for the missing resident. 7. When the resident is located staff are to return the resident to the assigned nurse for evaluation and further reporting/documentation process per regulation. 8. Code [NAME] All Clear is then called three (3) times to alert staff the missing resident has been located. Throughout the survey, the facility provided its immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows: 1. 100% of all current residents were reassessed for risk of elopement as of 10/13/23. The responsible Party was the DON who used several nurses to complete assessments. 2. 100% facility head count of current residents completed on 10/11/23. All residents were accounted for except Resident #1. The responsible party was the DON. 3. All facility doors were immediately checked to ensure proper functioning by the Administrator on 10/11/23. 4. Suspension of three current staff who were responsible for Resident #1 and had previously been educated on the Elopement policy. Completed on 10/11/23 by the Administrator and DON. 5. Butterfly unit (locked unit) staffing was adjusted on 10/11/23 as follows: Two dedicated staff members at all times on the unit to support the needs of the population by increasing monitoring/supervision. Responsible party - DON. 6. Staff member to monitor front entrance of the Butterfly Unit 24/7 with documentation initiated on 10/11/23 pending full results of the investigation and implementation of Root Cause Analysis (RCA) findings. Responsible party - DON. This is ongoing. 7. Doors are checked seven days a week to ensure proper functioning. Responsible party - Administrator. Initiated on 10/13/23 and is ongoing. 8. There is a staff member to monitor the front entrance parlor door of the facility from 7:00 a.m. to 7:00 p.m. with documentation initiated on 10/13/23 pending full results of the investigation and implementation of RCA findings. Responsible party - DON. This is ongoing. 9. A red Screamer Alarm is now turned on by the licensed nurse at 7:00 p.m. The key for the alarm is kept secure with the licensed nurse and located on the North Wing medication cart. The alarm is deactivated at 7:00 a.m. when the receptionist comes on duty. Responsible party - DON. This is ongoing. 10. As of 10/13/23, residents who reside on the Butterfly unit will have activities on the unit to support the needs of the population. Responsible party - DON and Activities Director (AD). This is ongoing. 11. A department head will complete a head count of all residents upon arrival and before leaving five times a week to ensure all residents are accounted for. This was initiated on 10/13/23 and is ongoing. Responsible party - DON. 12. A head count of all residents will be completed on each shift seven days a week to validate and ensure all residents are accounted for. Initiated on 10/12/23 and is ongoing. Responsible party - DON. 13. The Activities Director was educated by the Administrator on 10/13/23 related to initiating activities on the Butterfly unit to support the needs of the population and to discontinue taking those residents to activities outside of the unit to mitigate exit-seeking behaviors. Responsible party - Administrator. 14. The Visitor/Vendor sign-in/out book was moved from the front entrance foyer to the reception desk on 10/13/23. Responsible party - DON. 15. A sign was posted at the reception desk and the Butterfly unit on 10/13/23 for staff and visitors to watch for residents who may be behind them and please do not allow them to exit. Responsible party - DON. 16. Facility education was initiated for current staff related to the facility's Elopement policy on 10/11/23. All staff not on duty on 10/11/23 were educated prior to starting their next shift. Responsible Party - DON. 17. Facility education was initiated on 10/11/23 for current staff related to missing residents, routine monitoring of residents, and supervision of residents to include watching residents tailgating behind other residents and/or visitors. Staff are to visualize the door to the Butterfly unit and ensure the door is fully closed when anyone is entering and/or leaving so residents do not exit unsupervised. All staff not on duty on 10/11/23 were educated prior to starting their next shift. Responsible Party - DON. 18. A timeline of events was completed by the DON on 10/13/23. No concerns. 19. Staff interviews regarding elopement were completed on 10/11/23. Responsible party - DON. 20. The facility conducted an Ad Hoc QAPI meeting on 10/13/23 to include a root cause analysis (RCA) with the IDT and CNO to review how the resident was able to exit the Butterfly unit and exit the front entrance of the facility without staff knowledge. The responsible party was the CNO. 21. The facility will conduct unannounced drills four times a week to include off shifts and weekends. This was initiated on 10/13/23 and is ongoing. Responsible Party - DON. 22. Residents at risk for elopement have their names and photos in a binder at the front desk and nursing station. This was 100% current as of 10/12/23. Responsible Party - DON. 23. Staff education about Elopement and Missing Residents to be completed upon hire and annually. Responsible Party - DON. 24. As of 10/13/23, residents are to be evaluated for risk of elopement upon admission, re-admission and/or significant change. Responsible Party - DON. 25. Care plans were reviewed and are current for residents at risk for elopement as of 10/12/23. Responsible Party - DON. 26. Resident #1 was assessed by the attending physician upon readmission to the facility on [DATE]. 27. Immediate Federal Reporting was completed on 10/12/23. Responsible Party - DON. 28. The Receptionist was suspended pending investigation on 10/11/23 and was terminated on 10/17/23. 29. Doors to the Administration area that lead to the front entrance are to be locked at all times as of 10/13/23. Responsible Party - Administrator. 30. Abuse/Neglect/Exploitation education was initiated on 10/11/23. All staff not on duty on 10/11/23 were educated prior to starting their next shift. Responsible Party - DON. .