**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide appropriate supervision to 1 of 3 sampled residents assessed as at risk for elopement. The deficient practice allowed Resident #1 to exit the facility on 10/12/24 at approximately 8:50 PM, through an unsecured door on the second floor. The findings included: The facility's policy, titled, Wandering and Elopements, with a revision date of March 2019, documented, in part: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as at risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Record review revealed Resident #1, a resident with severe cognitive impairment, eloped from the facility on 10/12/24 at approximately 8:40 PM. The record revealed Resident #1 was observed by an individual from the community walking west on Silver Beach Road, a two-lane road with one lane traveling in each direction from east and west with a 30 miles per hour speed limit and no lighting. Resident #1 was found in an industrial area approximately 0.3 miles west of the facility. It was determined by the facility's investigation, that Resident #1 left her room and went through the Dining/Activities room to a staircase with two landings and 2 turns. Resident #1 then went through an area that consisted of the Human Resources office, Activities desk, and Staff Development office. At that time, there were no staff in this area as it was after hours and on a Saturday evening. Resident #1 then exited an unlocked door to an outside staircase that led to an unsecured area on the east side of the building with uneven terrain and then traveled west on Silver Beach Road and across Old Dixie Highway, a 4-lane road with two lanes traveling in each direction north and south. Resident #1 had to cross a set of two active railroad tracks used by Brightline, with trains that travel more than 80 miles per hour, as well as other transportation and freight interests/companies. Record review revealed Resident #1 was admitted to the facility on [DATE] and discharged to an Assisted Living Facility with a secure unit on 10/16/24. According to an Admission/Medicare 5-[NAME] MDS, dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00, indicating that the resident had severe cognitive impairment. The assessment documented Resident #1 did not exhibit wandering or exit seeking behaviors. The assessment documented that the resident required minimal assistance for bed mobility and transfer. Resident #1's diagnoses at the time of the assessment included Arthritis, Alzheimer's Disease, Dementia, Parkinson's Disease, Psychotic Disorder, History of falling and Sarcopenia. An Elopement Risk Evaluation, dated 10/07/24, concluded that the resident was an elopement risk based on: Cognitive status: Resident alert and continuous confusion. History of elopement/wandering: wanders, but has never eloped. Mobility: Ambulates independently with no device. Adjustment to facility placement: content with placement. Resident #1's care plan for elopement, initiated on 10/08/24, documented: Resident has a potential for elopement due to: has cognitive impairment, BIMS score is , has periods of increased confusion, is exit seeking, is (I) ambulatory, wanders the unit & wanders near exit doors 10/12/24 exited facility and redirected back to the facility. The goal of the care plan was documented as: Resident will remain safe and will refrain from leaving facility unsupervised thru the next review date. Interventions in the care plan included: - Discharge planning to a more appropriate level of care. - Facility has secured exit doors on the first floor. - Perform frequent observations of resident's whereabouts every shift. - Provide redirection when observed going towards exit doors. - Encourage resident to participate in activities of choice; provide 1:1s as needed. - Include resident in Elopement Book. - Update physician and responsible party if resident elopes. A Nurse's Progress note, dated 10/12/24 at 20:30, documented by Staff A, Licensed Practical Nurse (LPN), revealed, Note Text: At approximately 8:30p, this writer could not locate resident for her scheduled HS [hour of sleep] medication administration. A thorough search of the premises was initiated immediately. The resident was last seen in bed reading her bible. Facility protocols initiated. Staff conducted a head count and confirmed that resident was not on site. Following facility protocol resident was located outside of facility grounds by staff member. Resident appeared to be in stable condition, laughing, smiling, calm with bible in hand. Resident was assessed upon return to facility. Vital signs taken B/P 99/54, P 97, T 97.1, R 18, and O2 at 96% on room air. No visible trauma noted. Resident denies any pain or discomfort. No complaints voiced. Resident skin assessment completed. Resident skin is intact. 1:1 initiated and continued throughout shift. MD, DON, administrator, and resident primary contact [NAME] Colon made aware. Resident noted resting comfortably in bed at this time. During an interview with the Administrator and the Director of Nursing (DON), on 10/21/24 at 12:10 PM, when asked how Resident #1, a resident with severe cognitive impairment based on a BIMS score of 00, exited the facility, the DON replied, We figured out that she had come up the stairs and exited a door from the second floor. Then we went through an elopement drill and saw that the door was open. This isn't a resident area, and we had all of the doors secured with magnetic box, it was not done up here because it is not a residential area. Her coming up here showed us that residents could get up here. There has never been another resident up here, there is no elevator. Since then, we corrected that. The DON stated that Resident #1 was seen on camera at 8:36 PM around the dining room and then went upstairs. At 8:40 PM, an alarm sounded from the door that the resident exited from. At the time, there was no one in the dining room that would have heard the alarm and no staff in the area upstairs. The Administrator stated that there were no video cameras in the outside area where Resident #1 exited the facility and that the video was not saved. The Administrator stated that they were unable to determine the exact time that the resident exited the facility. When asked where the resident was going, the DON replied, She did not say, she was confused. When I interviewed her, she said that she was in the mountains in Puerto Rico. It was nighttime and she thought she was in the mountains of Puerto Rico. The DON stated that the resident was found approximately 0.3 miles west of the facility in an industrial area west of the facility on Silver Beach Road. The Administrator provided documentation of a Root Cause Analysis that documented: 1. Cognitively impaired and confused Resident exited facility from second floor by HR [Human Resources]. 2. high risk for elopement based on elopement assessment done by nurses scored as a 15. 3. Screamer on the second floor was not audible. 4. During the time, we locked the facility's doors and did not consider the second floor needed to be locked or secured. 5. The second floor was not identified as a risk area due it is not considered a resident common area. 6. Door not secured in a way that was consistent with the other doors. During an interview, on 10/21/24 at 3:30 PM with Staff C, Certified Nursing Assistant (CNA), when asked about Resident #1's elopement, Staff C stated that she was told there was a resident outside, by someone from the community and that she and Staff B, CNA, went outside and found the resident. She stated she was on the street when they found her and she stated the resident was giggling. She stated the resident was not injured. She stated she did not hear any alarms go off in the building when the resident left. During an interview, on 10/22/24 at 12:28 PM, with the Administrator and the DON, when asked about the member of the community coming in and informing the staff about Resident #1 being seen on Silver Beach Road, the DON replied, They heard a code green and then they started searching the areas. They were doing the code green, that was when the gentleman came in. while the two CNAs (referring to Staff B, CNA and Staff C, CNA) went with the individual, the rest of the staff were checking their own patients. One person, Staff A, saw that the door upstairs was open and understood that was where she most likely exited the building from. Once they saw that the patient was out of the building, that was when they called code green. When the Administrator and the DON were asked about the resident being observed on the second floor the previous evening, they stated that they were not aware of the observation. During an interview, on 10/22/24 at 4:49 PM, Staff D, CNA, stated that the resident was seen in the upstairs area the evening prior and redirected. On 10/22/24 at 5:03 PM, the Administrator and the DON were presented with an Immediate Jeopardy (IJ) template by the survey team, and informed that the Agency had determined that the deficient practice was determined to be Immediate Jeopardy. The facility's removal plan and corrective actions for the IJ included: On 10/12/2024, an Ad hoc QAPI (Quality Assurance and Performance Improvement) with Root Cause Analysis was performed with the IDT (Interdisciplinary Team) team, including: the Administrator, the Regional Director of Operations, the Regional Clinical Director, the Regional Maintenance Director. QAPI meetings were scheduled for the last Thursday of each month with the next scheduled meeting on 10/24/24. On 10/13/2024, all current residents' Elopement Assessment were reviewed and updated by nursing. There were no newly identified residents at high risk of elopement. On 10/13/2024, staff education was initiated to include Abuse and Neglect policy and procedure, Elopement policy and procedure, and new processes of closing the dining room door when the room is not in use. The Survey team confirmed via interviews and record reviews that 100% of all staff were provided the training. Elopement drills were conducted daily up to every shift daily to continue on for 14 days, then weekly for 4 weeks, then monthly thereafter. The Survey team confirmed via interviews and record review that 100% of staff participated in multiple elopement drills on all shifts. On 10/14/2024, the Senior Safety and Technology company installed Maglock (mag) on the second-floor exit door next to HR department office and the door between the unit and the Activities/Dining room for added security. The Survey team confirmed that all doors, mag locks and alarms were in working order and that the alarms were audible from a distance. On 10/15/24, education on the Identifying residents with behavioral symptoms that put the residents at risk for elopement was initiated. The Survey team confirmed via interviews and record review that 100% of all staff were provided the training. On 10/13/24, daily audits of the doors and alarms were initiated and the results reported to QAPI/QA Committee of the findings. The Survey team confirmed via observations, interviews and record review of the daily audits of the doors and alarms being audited for lock function and alarm sounding.