**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of medical records, facility policy and procedure review, and interviews with facility staff, the facility failed to provide supervision and identify hazards to prevent an unwitnessed exit from the facility for two (Resident #1 and Resident #8) of three residents sampled as high-risk for elopement. Resident #1 was a long-term care resident who was confused, at risk for elopement, known to wander, and had a wander monitoring device on at the time of his elopement. Resident #1 was unsteady on his feet, had a history of falling and age-related cognitive decline. Resident #1 was known to leave the facility every year on July 4th on a supervised leave of absence however on 07/04/2023, he did not go on his yearly supervised leave of absence. Resident #1 was able to exit the facility unsupervised through the front door which was equipped with a door alarm, a wander monitoring device alarm system and a sign with the words Push Until Alarm Sounds Door Can Be Opened In 15 Seconds. Resident #1 walked approximately 0.3 miles down a 2-lane road and was found on 07/04/2023 at approximately 7:12 p.m. sitting in a chair in the grass in front of a lake surrounded by bystanders. Staff arrived at Resident #1's location at approximately 7:12 p.m. The Resident was transported the hospital by Emergency Medical Services (EMS) and returned to the facility on [DATE] at 1:45 a.m. without injury. Resident #8 was a long-term resident who was confused, at risk for elopement, a known wanderer, known to push on doors, known to be exit seeking, and had a wander monitoring device on at the time of his unsupervised exit from the facility. Resident #8 was unsteady on his feet, had a history of falling, and age-related cognitive decline. On 07/05/2023 at approximately 9:40 a.m., Resident #8 was able to exit the facility without supervision through an exit door at the end of an uninhabited unit (the 600 hall). The door had an alarm and a sign with the words Push Until Alarm Sounds Door Can Be Opened In 15 Seconds. Resident #8 was located on 07/05/2023 at approximately 9:42 a.m. on the sidewalk that wraps around the building and escorted back into the building unharmed. These failures created a situation that resulted in the likelihood for serious injury and/or death to Resident #1 and Resident #8 and resulted in the determination of Immediate Jeopardy on 07/04/2023. The findings of Immediate Jeopardy were determined to be removed on 07/27/2023 and the severity and scope was reduced to a E after verification of removal of Immediate Jeopardy. Findings included: Review of the facility floor plan showed a North Unit consisting of a nurse's station and the 100, 200 and 300 halls, and a South Unit consisting of a nurse's station and the 400, 500 and 600 halls. The front lobby with a reception area and the main entrance is in the middle of the two units. The facility main entrance is across a two-lane road from Lake [NAME] a 2,272 acre Fish Management Area with a maximum depth of 10 feet. According to https://myfwc.com/fishing/[NAME]/sites-forecasts/sw/lake-[NAME] Review of weather history in the Lakeland during the two-day period 7/4/2023 to 7/5/2023 revealed: July 4, 2023, and July 5, 2023, Max temp: 97 degrees Fahrenheit. Minimum temp: 80 degrees (wunderground.com) Review of Resident #1's admission Record showed he was admitted to the facility on [DATE] with diagnoses that included unsteadiness on feet, age related physical debility, limitation of activities due to disability, history of falling, age related cognitive decline, difficulty in walking, muscle weakness, unspecified lack of expected normal physiological development in childhood, and major depressive disorder. A review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Resident Date (ARD)/target date of 04/09/2023 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating severe cognitive impairment. Section G Functional Status of the MDS showed the resident was independent and needed setup help only for bed mobility and eating and needed supervision with setup help only for transfer and personal hygiene. Resident #1 was independent with no set up or physical help from staff for walk in room, walk in corridor, and locomotion on and off the unit. He needed limited assistance with one-person physical assist with dressing and toilet use. Section P Restraints and Alarms revealed Resident #1 used a wander/elopement alarm daily. An interview was conducted with Staff I, CNA, on 07/25/2023 at 1:51 p.m. She stated she was doing patient care and heard the alarm going off at the front door. She was working on the South unit/400 hall. She said it was not a wander monitoring device alarm, it was just the door alarm going off. No other staff came out to see why the alarm was going off. She said she went to the door, looked out of the glass window, turned the alarm off, and went back to the unit because she did not see anyone. A receptionist was not at the desk at this time. When Staff I, CNA, went back to the unit the phone rang at the nurse's station and she answered it. It was a man who said he was down the street from the facility and believed one of the residents had gotten out. She ran called for the nurse on her South Unit/400 hall. The person that called said Resident #1 had collapsed. She got in her car and went down the street. She went to the park and came back around and didn't see him, so she came back to the facility. She decided to go one more time and observed the nurses were down with Resident #1, so she came back. Staff G, Licensed Practical Nurse (LPN), was one of the nurses and she was not sure who the other nurse was. Resident #1 was found across the street from the fire station training center near the lake. She saw people were taking videos. Resident #1 was sitting on a lawn chair with a whole lot of people around. She said they had enough staff that day. Resident #1 walks around and he had a wander monitoring device on. Normally, a resident can get to where the receptionist sits in the front lobby, and the wander guard alarm would sound, and someone would have to input a code to turn it off. When they found him, he was transported to the hospital, and she didn't see him until a couple of days later. When Administration interviewed her about the incident, she told them she didn't hear the wander monitoring device sound going off at the front door. Staff I, CNA, stated you can hear the alarm sounding on South/400 unit, but you cannot hear the alarm sounding on the North Unit /300 hall and this is where Resident #1's room was located. Staff G, LPN, was one of the nurses that found Resident #1 by the lake. During an interview on 7/25/2023 at 3:05 p.m., Staff G, LPN, confirmed she worked on the day of the incident. At 3:30 p.m., Resident #1 was walking around. He was not happy. He usually says I love you to everybody and was very friendly. He said he was not ok on this day and wanted to go outside, so she took him outside. The wander monitoring device was on at the time. She took him outside from 3:30 p.m. to 4:45 p.m. and they sat out on the front porch. Staff G, LPN, stayed with him the entire time they were outside. The wander monitoring device alarm went off when he was near the front door prior to them going outside. Staff G, LPN, told Resident #1 to step back so she could put the code in, and then she was able to open the door. Other residents were outside. At 4:45 p.m., everyone came in to get ready for dinner. Around 7:10 p.m., the nurse assigned to Resident #1 said they found a patient by the lake, and they said it was Resident #1. She and that nurse ran to the car, and they rode together. Resident #1 was found by the lake right before the fire station training center on the opposite side of the street. He was sitting in a lawn chair near where people were fishing in the lake. Staff G, LPN, stated she was the first one to get out of the car. The bystanders were videoing them. When they attempted to ask Resident #1 questions, one of the bystanders said you are not allowed to talk to him. He had written on a piece of paper that Resident #1 was looking for a former coworker that he used to work with. Every 4th of July, she comes to get him, and she didn't come this time. He kept saying he wanted to go to a local restaurant to see the former coworker. She stayed until 911 came. Resident #1 came back the same night. Staff G, LPN, stated she didn't know how he got out. On that night, she was only there to help. She helped with admissions, she was not assigned to residents, and there were plenty of staff on duty. When she came back to the facility after EMS took Resident #1, they did a head count and got statements from everyone in the building. She called everyone to let them know what was going on, including the Director of Nursing (DON) and the Administrator. The last time she saw him was around 4:45 p.m. She did not remember if there was a sidewalk. Around 7:00 p.m., she was on the North unit and did not hear the alarm go off. Staff K, Registered Nurse (RN), was the nurse assigned to Resident #1 on the day of the elopement. During a telephone interview on 07/26/2023 at 9:49 a.m., Staff K, RN, confirmed Resident #1 was assigned to her on the day of the elopement. She saw him as she was completing medication pass and saw him in his room eating around 6:00 p.m. Ten minutes after coming back from her lunch break, she received a call from a lady stating she may have one of her patients up the road. She asked the staff to check for all patients. Resident #1 was the only patient they couldn't locate. She asked her if he was Resident #1 and she said yes. Staff K, RN, drove about 2 minutes up the road and observed Resident #1 sitting in a chair. The lady that called was there and another guy out there was extremely aggressive so she couldn't assess him. There were no noticeable injuries. No scratches or bruises. He stated at the start of the shift he wanted to go outside and Staff G, LPN, took him outside. Staff K, RN, reported she did not hear an alarm going off and she did not hear any alarm when she came back in from her lunch break. She stated she took a lunch break in her car in the parking lot and did not see the resident come out of the door. On 07/25/2023 at 2:40 p.m., Resident #1 was observed in his room standing next to the bed. A wander monitoring device was observed on his right leg. He stated he was hungry when asked how he was doing. The Staffing Coordinator was in the room with the resident at this time and she stated Resident #1 was on 1:1 supervision and she was scheduled to be with him at this time. A review of the Order Summary Report with active orders as of 07/26/2023 showed the following: May go out with responsible party (ordered 03/24/2021); Monitoring wander monitoring device expiration May 2026- every night shift every 4 weeks on Wednesday for monitoring (05/12/2023); Resident is 1:1 at all times every shift for safety (07/04/2023); Snack 3 times a day between meals (06/09/2022); Wander monitoring device- check for function each day every night shift for monitoring (03/25/2021) Wander monitoring device- check every shift for placement and monitoring (03/25/2021) Atorvastatin calcium tablet 20 mg- give 1 tablet by mouth at bedtime for hyperlipidemia; Tamsulosin HCL capsule 0.4 mg- give 1 capsule by mouth daily for benign prostatic hyperplasia (10/19/2022); Tramadol HCL capsule- give 1 capsule by mouth every 8 hours as needed for pain; and Trazodone HCL tablet- give 0.5 tablet by mouth daily related to major depressive disorder and give ½ tablet at bedtime (11/30/2022). During the time from when Resident #1 was last seen to when he was returned to the facility, he should have received atorvastatin calcium, tamsulosin, tramadol, and trazodone between 7:00 p.m. 7/4/2023 and 1:45 a.m. 7/5/2023. He should have received a snack during that time. Review of the Medication Administration Record (MAR) for July 2023 showed Resident #1 did not receive these medications or the snack as ordered on 07/04/2023. A review of the Treatment Administration Record (TAR) showed 6 in the box for checking the function of the wander monitoring device every night shift for monitoring and a 6 was in the box for checking the placement of the wander monitoring device every shift for monitoring on 07/04/2023. A review of Resident #1's Nursing Progress Notes revealed the following: On 07/04/2023 at 9:10 p.m., the writer spoke with a staff member from the local hospital taking care of Resident #1. The staff member stated, Resident is pleasantly confused at the moment. On 07/05/2023 at 1:45 a.m., the resident returned to the facility from the local hospital via stretcher with three attendants. The resident was alert and stated he will try to leave every chance he gets. Resident #1 was calling staff names, threatened to knock you down, I will hit you, and telling staff to get the hell away from me. The resident was placed on 1:1 for safety at this time. On 07/05/2023 at 2:21 a.m., the patient returned from the hospital at 145 a.m., he was not happy about coming back and stated he wanted to leave again. The patient is currently on 1:1 since his return and has been displaying negative behaviors such as yelling and cursing at the staff. On 07/07/2023 at 09:00 a.m., (Resident #1) eloped from facility the evening of 07/04/2023. The resident exited the facility through the front doors and proceeded to walk down the sidewalk as he reports in an effort to go to his favorite restaurant that he once worked at. Resident #1 has consistently been taken by friends to the July 4th parade in town where he's been a yearly fixture in handing out flags. This year however, the person that checked him out of the facility to do this annual tradition was out of town on vacation. Upon further investigation by staff, including social services, the resident has consistently stated his intent was to go to the restaurant he used to work at bussing tables to get something to eat and visit and then planned to go hand out flags at the parade. The writer went to question Resident #1 regarding events at his bedside where the resident pointed to pictures on his wall of him at the restaurant in question and also handing out flags at the July 4th celebration. Interventions have included one on one companionship, take out order from a local restaurant, and there are plans in place for next July 4th to take the resident out to enjoy watching fireworks although staff is working out the details as to the safest way to provide this annual expectation to meet his needs while ensuring his safety. The resident has not since tried to leave the facility and a care plan is now in place around this annual expectation. Resident #1 has since not attempted or expressed any want to leave, staff will continue to monitor and follow. Psychiatric care is also following the resident and have conducted a thorough evaluation since the elopement. Psychiatric care will also continue to monitor and follow. An observation of the path the resident may have taken revealed from the front door he turned left heading North after leaving the facility property. A two-lane road with a speed limit of 30 mph (miles per hour) separated the facility grounds from a grassy area that lead onto an asphalt sidewalk. The sidewalk with uneven cemented surfaces, potholes and cracks followed around the lake without barriers. The unprotected lake was approximately 10 feet away from the asphalt sidewalk. The resident was found across the road from the facility in a grassy area. Resident #1's Elopement Risk assessment dated [DATE] completed by Staff C, LPN, showed No was checked for attempt to wander off the unit and positions self by exit areas. Yes was checked for having a history of wandering or elopement. No was checked for attempts to leave the building or grounds without notifying staff, the resident was not able to negotiate environment safely and has a history of substance abuse and/or substance seeking behavior, repetitive verbalizations of I'm going home, and is ambulatory including wheelchair mobility and for not accepting his current residency in the facility. Yes was checked for having a diagnosis of Dementia, Alzheimer's and is able to negotiate environment safety. The assessment showed Resident #1 was not at risk for elopement at this time. The form also revealed a section that showed If there are 'Yes' answers, but the resident is not at risk explain why. The box for the section was blank. A Change in Condition dated 07/04/2023 showed the incident location was outside. Resident #1 left the facility. Staff were notified by anonymous bystanders that the resident was by the fire training center on the ground. The resident description section revealed, I don't want to be here anymore. I'm going to [a local restaurant]. The resident was transported to a local hospital and returned to the facility on 1:45 a.m. on 07/05/2023. Review of Resident #1's care plan revealed a focus area initiated on 03/26/2021 [Resident #1] is an elopement risk, wanders throughout facility independently related to dementia, disoriented to place, impaired safety awareness, and the resident wanders aimlessly at times. Interventions included 1:1 supervision at all times (07/05/2023), assess for elopement risk (03/26/2021), distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book (03/26/2021), identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate (03/26/2021), provide structured activities: toileting, walking inside and outside, reorientation, strategies including signs, picture and memory boxes (03/26/2021), psychiatric care evaluation as indicated (07/11/2023), and wander monitoring device (electronic monitoring device)- check placement every shift and function daily (03/26/2021). A review of the psychiatric care note written by Staff R, Advanced Registered Nurse Practitioners (ARNP), with a date of service date of 07/14/2023 showed patient was seen on 07/05/2023 for a telehealth follow up. He is currently taking Trazodone HCL Tablet 25 MG by mouth once a day for major depressive disorder. Patient seen today after eloping yesterday (July 4) from facility. He is alert and pleasantly confused. Appears in no acute distress. Patient reports he intended to have a meal at his favorite local restaurant. He reports he used to work at this restaurant. He stated he was planning to return after his meal. It was reported that the patient walked approximately 7 minutes and was spotted by nearby people who were watching fireworks. He was found sitting in a chair among the people watching fireworks. He was taken to the emergency room that evening to be evaluated. He was discharged later at approximately 1 a.m. on 07/05. Patient has returned and appears in good condition. No adverse effects or injuries noted or reported. No distresses or trauma observed related to the elopement. He denies increased anxiety or depression. Staff reports he remains pleasant and complaint with care. He is currently on one to one supervision for safety monitoring. During an interview on 07/25/2023 at 2:00 p.m., Staff Q, Receptionist, stated the door alarm and the wander monitoring device alarm had the same sound. Her shift ends at 4:00 p.m. daily. They have a part-time employee that works from 4:00 p.m. to 7:00 p.m. on Monday and Tuesday and another part-time employee that works 4:00 p.m. to 7:00 p.m. on Wednesday, Thursday, and Friday. The red alarm is a screamer, the door alarm was a beep. The front door had a high pitch sound, one beep, and a continuous beep until it was turned off. It will also beep if someone holds the door open too long. You must put a code in to turn the alarm off. An interview was conducted on 07/25/2023 at 2:35 p.m. with the Maintenance Director. He reported there were 8 exit doors in the facility, and they all had keypads. Three of the doors also had a wander monitoring device alarm, the front door is one of them. Residents would have to have a code to get through the doors. The Maintenance Director demonstrated how the doors were tested with his device and showed the front door was functioning properly. The Maintenance Director tested the door with the wander monitoring device and the alarm sounded when he was at the door. He said since the elopement that Screamer (very loud) alarms were put on a set of double doors that lead to the lobby, main entrance area. He said he checked the doors daily on weekdays, and according to the Administrator, the nursing staff check the doors on the weekend. The Alarmed and Exit Doors Daily Inspections log was reviewed at that time for the months of May 2023 and June 2023. It showed the doors were checked on weekdays but not checked on the weekend. During the observation the front door alarm was set off with a wander monitoring device by the Maintenance Director. The alarm could not be heard while standing on the North unit/300 hall. This was confirmed by the Maintenance Director. During an interview on 07/25/2023 at 3:29 p.m. with the Administrator and DON, the DON reported Staff G, LPN, contacted the DON and reported Resident #1 was out of the building and she was contacted by some bystanders. The resident was found about 7 minutes away from the facility if you walked. They both came to start the investigation. They called the police, the Power of Attorney (POA), the doctor, psychiatric care, and another outside agency. Interviews were completed with staff and residents. None of the staff reported he wanted to leave the facility that day or mentioned anything about leaving the facility. He walks back and forth all day. He had asked some about going out for fresh air. They went outside and came back in. Staff K, RN, took her lunch break around 6:10 p.m. and her car was facing the door. After her break, she came back in, went to the bathroom, and went back to the unit. Two phone calls came in about a missing resident. The DON stated Staff I, CNA, heard the alarm go off but she didn't see anyone. Resident #1 definitely went out of the front door. If you hold the door for 15 seconds, the door would open. He was a pretty smart guy and can probably read. He didn't verbalize he wanted to see fireworks. Resident #1 had on the wander monitoring device at the time he left the facility. It was removed in the hospital and brought back from the hospital when he returned. They tested the same wander monitoring device when he came back, and it was still working. We put it back on with a new bracelet. The wander monitoring device had an expiration date of 04/20/2025. In-services were started immediately after the incident. Maintenance came and checked the doors, and they were working fine. They set up 30-minute checks on all alarmed doors. The alarm company came out on 07/06/2023. They added screamers to the double doors to have a second alarm, because you cannot hear the alarm at the north Unit nursing station. The receptionist leaves at 4:30 p.m. or 5:00 p.m. Once the receptionist leaves, the nurse comes over and sets the alarm. There were no screamers when Resident #1 eloped. An enunciator will be placed at north unit nurse's station, it has been ordered, so alarms can be heard there. You must put a code in to enter or exit the facility. Visitors have to ring the bell. Prior to the incident, the receptionist buzzed everyone in and out. Now the nurse comes and sets the alarms to the front door after the receptionist leaves. The receptionist announces on the intercom that she is leaving for the day. Someone in charge, usually one of the nurses comes to lock the door. The nursing supervisors are the ones that come to turn on screamers. All nurses have keys to screamers. Resident #1 was placed on 1:1. The DON and ADON evaluated all residents for elopement. They checked wander monitoring devices, monitored Resident #1, and did a whole house audit. Staffing was good. No issue with staffing on that day. Staff were educated on the elopement procedure and drills. They did a drill each shift and did them weekly after the incident. During an interview on 07/27/23 at 9:55 a.m., the Administrator and DON reported training was provided on the elopement policy/procedure/protocol prior to July 4, 2023. Elopement audits and drills were completed. On 07/27/2023 12:08 p.m., the DON reported elopement education was completed upon hire. They do not have access to elopement training and elopement drills completed due to a change in systems approximately two months ago. Alarmed and Exit Doors Daily Inspections for the months of May 2023 and June 2023 were verified. The doors were not checked on the weekend. This was confirmed by the Administrator and DON. She stated as of July, nursing staff had been checking the doors on the weekend. 2. On 7/5/23 at approximately 9:40 a.m. Resident #8 was able to exit the facility without supervision through an exit door on an uninhabited hall (600) that was equipped with a door alarm. An interview conducted with the Activity Director on 07/26/2023 at 12:47 p.m. He stated he heard the alarm go off and the 600 area being announced by staff. Everyone jumped up and started moving. Everyone was looking. Staff scattered to their areas. He saw the Maintenance Director going down the 600 hall. The Activity Director went down the 500 hall; when he got to the 500 hall exit door it was locked so he ran toward the 600 side, and he didn't see anyone. The Activity Director stated he then went back to the 500 hall and opened the exit door and saw Resident #8 closer by the dumpster, he was smiling and giggling. He wheeled Resident #8 back into the facility and took him to the nursing station. The resident got out of the door on the end of the 600 hall and went down the sidewalk that surrounds the building towards the 500 unit. During an interview on 07/26/2023 at 12:21 p.m., the Maintenance Director stated on 7/5/2023 he was headed to the morning meeting, he exited the service hall, and heard the alarm going off. He checked the enunciator, and it showed the alarm was coming from the 600 hall. The exit door was open on the end of the 600 hall. He went outside and immediately ran to the front of the building, because there was more danger in the front of the building than the rear. He didn't see anyone. He then came in and headed back to the 600 hall and saw Resident #8 from the window sitting outside. Two other staff members were heading out to get him. Within two minutes they had him back inside. The Maintenance Director went back down the 600 hall, reset the doors and silenced the alarms. He was the first one to respond to the alarm. He immediately looked to see what hall the alarm was coming from. After the incident happened, they put a rope across the hall, caution signs, and wet floor signs. Resident #8 frequently pushes on the doors. He knows the door will open after 15 seconds. The resident was just sitting looking around at the trees. There's a sidewalk in the back parking lot area. Another staff member got to Resident #8 before he did. He went back to secure the doors after the resident was brought back into the facility. Observation of the outside area where the resident was found revealed an uneven cement sidewalk surface that wrapped around the facility's building connecting one entrance to the next. Adjacent to the sidewalk was approximately 5 feet of grassy terrain that led into a large area with trees, overgrown shrubs and standing water. Review of Resident 8's admission Record showed he was admitted on [DATE] with diagnoses to include muscle weakness, difficulty in walking, unspecified lack of coordination, limitation of activities due to disability, other lack of coordination, history of falling, age related cognitive decline, age related physical decline, unspecified dementia, unspecified severity without behavioral disturbance, psychiatric disturbance, mood disorder, anxiety, unspecified cataract, and Alzheimer's Disease. A review of the quarterly MDS with an ARD/target date of 05/16/2023 revealed Resident #8 had a BIMS score of 00 out of 15 indicating severe cognitive impairment. Section G Functional Status of the MDS showed the resident needed extensive assistance with two plus persons physical assist with bed mobility and transfers and needed supervision with one-person physical assist for locomotion on and off the unit. Resident #8 needed extensive assistance with one-person physical assist for dressing and personal hygiene. He needed supervision with setup help only for eating and he was total dependent with two plus persons physical assist for toilet use. Section P Restraints and Alarms revealed Resident #8 used a wander monitoring device daily. An observation and interview were conducted on 7/24/2023 at 10:05 a.m. of Resident #8 on 1:1 with CNA, Staff O. Resident #8 was observed to be dressed in day clothes, sitting in his wheelchair in front of an exit door at the end of the 400 hallway. Staff O, CNA stated she was on 1:1 with him because around 07/05/2023, he went past the nurses' station and pushed on the exit door to the 600 hall and was found outside by the dumpsters. She stated he always pushes on the doors. He used to be a lawyer and he thinks his car was parked in the parking lot and he says he had to go to work. Since he was admitted he has pretty much always pushed on the doors. You see he is sitting in front of this door, and I told him 'You can't push on the doors okay' and he told me 'Well yeah if I keep pushing on it the door will open, you see the sign.' A sign was observed on the door with the words Push Until Alarm Sounds Door Can Be Opened In 15 Seconds. The resident was observed to have a wander guard on his left ankle under his sock. A review of the Order Summary Report with active orders as of 07/26/2023 showed the following: 1:1 close observation every shift for safety (ordered 07/05/2023); May go out with responsible party (10/10/2021); Monitoring wander monitoring device expiration May 2026- every night shift every 4 weeks on Wednesday for monitoring (05/17/2023); (Company name) Hospice for diagnosis of metabolic encephalopathy (02/11/2022); Wander monitoring device- check for function each day every night shift for monitoring (07/29/2022); Wander monitoring device- place wander monitoring device on wheelchair (08/04/2022); and Wander monitoring device- check every shift for placement and monitoring (07/29/2022). A review of the Treatment Administration Record (TAR) for July 2023 showed that the function and placement of the wander monitoring device was checked every shift according to orders. A review of Resident #8's Nursing Progress Notes revealed the following: On 07/05/2023 at 9:40 a.m., the patient was found on the sidewalk next to the building after exiting out of the 600-hall door. The alarm was sounding and when staff investigated, they found the patient in his wheelchair on the sidewalk. The patient was frequently sitting at the doors down the halls and needed frequent redirection. Patient was subsequently put on 1 to 1 observation. The patient was alert to self which is normal. On 07/05/2023 at 1:00 p.m., Resident #8 eloped from the southside unit he resides on at approximately 9:30 a.m. Resident #8 was located at 9:42 a.m. Witness interviews indicate that he did not verbalize any desire to exit the building nor show any exit seeking behaviors toward staff. Resident interviews were performed, all of which stated they were unaware he'd eloped and did not visually observe him in the hall that morning as they were still in their rooms at the time. Staff interviews revealed Resident #8 was not observed entering the currently unoccupied 600 hall. The Maintenance Director observed the[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of medical records, facility policy and procedure review, and interviews with facility staff, the facility failed to provide supervision and identify hazards to prevent an unwitnessed exit from the facility for two (Resident #1 and Resident #8) of three residents sampled as high-risk for elopement. Resident #1 was a long-term care resident who was confused, at risk for elopement, known to wander, and had a wander monitoring device on at the time of his elopement. Resident #1 was able to exit the facility unsupervised through the front door which was equipped with a door alarm, a wander monitoring device alarm system and a sign with the words Push Until Alarm Sounds Door Can Be Opened In 15 Seconds. Resident #8 was a long-term resident who was confused, at risk for elopement, a known wanderer, known to push on doors, known to be exit seeking, and had a wander monitoring device on at the time of his unsupervised exit from the facility. Resident #8 was unsteady on his feet, had a history of falling, and age-related cognitive decline. On 07/05/2023 at approximately 9:40 a.m., Resident #8 was able to exit the facility without supervision through an exit door at the end of an uninhabited unit (the 600 hall). The door had an alarm and a sign with the words Push Until Alarm Sounds Door Can Be Opened In 15 Seconds. Resident #8 was located on 07/05/2023 at approximately 9:42 a.m. on the sidewalk that wraps around the building and escorted back into the building unharmed. Nursing Elopement prevention policies were not followed regarding supervision of wandering residents and checking thoroughly for a resident elopement after an alarm is heard and before turning off the alarm. These failures created a situation that resulted in the likelihood for serious injury and/or death to Resident #1 and Resident #8 and resulted in the determination of Immediate Jeopardy on 07/04/2023. The findings of Immediate Jeopardy were determined to be removed on 07/27/2023 and the severity and scope was reduced to a E after verification of removal of Immediate Jeopardy. Findings included: Review of the facility floor plan showed a North Unit consisting of a nurse's station and the 100, 200 and 300 halls, and a South Unit consisting of a nurse's station and the 400, 500 and 600 halls. The front lobby with a reception area and the main entrance is in the middle of the two units. The facility main entrance is across a two-land road from Lake [NAME] a 2,272 acre Fish Management Area with a maximum depth of 10 feet. According to https://myfwc.com/fishing/[NAME]/sites-forecasts/sw/lake-[NAME] Review of weather history in the Lakeland during the two-day period 7/4/2023 to 7/5/2023 revealed: July 4, 2023, and July 5, 2023, Max temp: 97 degrees Fahrenheit. Minimum temp: 80 degrees (wunderground.com) An interview was conducted with Staff I, CNA, on 07/25/2023 at 1:51 p.m. She stated she was doing patient care and heard the alarm going off at the front door. She was working on the South unit/400 hall. She said it was not a wander monitoring device alarm, it was just the door alarm going off. No other staff came out to see why the alarm was going off. She said she went to the door, looked out of the glass window, turned the alarm off, and went back to the unit because she did not see anyone. A receptionist was not at the desk at this time. When Staff I, CNA, went back to the unit the phone rang at the nurse's station and she answered it. It was a man who said he was down the street from the facility and believed one of the residents had gotten out. She ran called for the nurse on her South Unit/400 hall. The person that called said Resident #1 had collapsed. She got in her car and went down the street. She went to the park and came back around and didn't see him, so she came back to the facility. She decided to go one more time and observed the nurses were down with Resident #1, so she came back. Staff G, Licensed Practical Nurse (LPN), was one of the nurses and she was not sure who the other nurse was. Resident #1 was found across the street from the fire station training center near the lake. She saw people were taking videos. Resident #1 was sitting on a lawn chair with a whole lot of people around. She said they had enough staff that day. Resident #1 walks around and he had a wander monitoring device on. Normally, a resident can get to where the receptionist sits in the front lobby, and the wander guard alarm would sound, and someone would have to input a code to turn it off. When they found him, he was transported to the hospital, and she didn't see him until a couple of days later. When Administration interviewed her about the incident, she told them she didn't hear the wander monitoring device sound going off at the front door. Staff I, CNA, stated you can hear the alarm sounding on South/400 unit, but you cannot hear the alarm sounding on the North Unit /300 hall and this is where Resident #1's room was located. Review of Resident #1's admission Record showed he was admitted to the facility on [DATE] with diagnoses that included unsteadiness on feet, age related physical debility, limitation of activities due to disability, history of falling, age related cognitive decline, difficulty in walking, muscle weakness, unspecified lack of expected normal physiological development in childhood, and major depressive disorder. Staff G, LPN, was one of the nurses that found Resident #1 by the lake. During an interview on 7/25/2023 at 3:05 p.m., Staff G, LPN, confirmed she worked on the day of the incident. At 3:30 p.m., Resident #1 was walking around. He was not happy. He usually says I love you to everybody and was very friendly. He said he was not ok on this day and wanted to go outside, so she took him outside. The wander monitoring device was on at the time. She took him outside from 3:30 p.m. to 4:45 p.m. and they sat out on the front porch. Staff G, LPN, stayed with him the entire time they were outside. The wander monitoring device alarm went off when he was near the front door prior to them going outside. Staff G, LPN, told Resident #1 to step back so she could put the code in, and then she was able to open the door. Other residents were outside. At 4:45 p.m., everyone came in to get ready for dinner. Around 7:10 p.m., the nurse assigned to Resident #1 said they found a patient by the lake, and they said it was Resident #1. She and that nurse ran to the car, and they rode together. Resident #1 was found by the lake right before the fire station training center on the opposite side of the street. He was sitting in a lawn chair near where people were fishing in the lake. Staff G, LPN, stated she was the first one to get out of the car. He had written on a piece of paper that Resident #1 was looking for a former coworker that he used to work with. Every 4th of July, she comes to get him, and she didn't come this time. He kept saying he wanted to go to a local restaurant to see the former coworker. She stayed until 911 came. Resident #1 came back the same night. Staff G, LPN, stated she didn't know how he got out. She helped with admissions, she was not assigned to residents, and there were plenty of staff on duty. When she came back to the facility after EMS took Resident #1, they did a head count and got statements from everyone in the building. She called everyone to let them know what was going on, including the Director of Nursing (DON) and the Administrator. The last time she saw him was around 4:45 p.m. She did not remember if there was a sidewalk. Around 7:00 p.m., she was on the North unit and did not hear the alarm go off. Staff K, Registered Nurse (RN), was the nurse assigned to Resident #1 on the day of the elopement. During a telephone interview on 07/26/2023 at 9:49 a.m., Staff K, RN, confirmed Resident #1 was assigned to her on the day of the elopement. She saw him as she was completing medication pass and saw him in his room eating around 6:00 p.m. Ten minutes after coming back from her lunch break, she received a call from a lady stating she may have one of her patients up the road. She asked the staff to check for all patients. Resident #1 was the only patient they couldn't locate. She asked her if he was Resident #1 and she said yes. Staff K, RN, drove about 2 minutes up the road and observed Resident #1 sitting in a chair. The lady that called was there and another guy out there was extremely aggressive so she couldn't assess him. There were no noticeable injuries. No scratches or bruises. He stated at the start of the shift he wanted to go outside and Staff G, LPN, took him outside. Staff K, RN, reported she did not hear an alarm going off and she did not hear any alarm when she came back in from her lunch break. She stated she took a lunch break in her car in the parking lot and did not see the resident come out of the door. A review of the Order Summary Report with active orders as of 07/26/2023 showed the following: May go out with responsible party (ordered 03/24/2021); Monitoring wander monitoring device expiration May 2026- every night shift every 4 weeks on Wednesday for monitoring (05/12/2023); Resident is 1:1 at all times every shift for safety (07/04/2023); Snack 3 times a day between meals (06/09/2022); Wander monitoring device- check for function each day every night shift for monitoring (03/25/2021) Wander monitoring device- check every shift for placement and monitoring (03/25/2021) Atorvastatin calcium tablet 20 mg- give 1 tablet by mouth at bedtime for hyperlipidemia; Tamsulosin HCL capsule 0.4 mg- give 1 capsule by mouth daily for benign prostatic hyperplasia (10/19/2022); Tramadol HCL capsule- give 1 capsule by mouth every 8 hours as needed for pain; and Trazodone HCL tablet- give 0.5 tablet by mouth daily related to major depressive disorder and give ½ tablet at bedtime (11/30/2022). During the time from when Resident #1 was last seen to when he was returned to the facility, he should have received atorvastatin calcium, tamsulosin, tramadol, and trazodone between 7:00 p.m. 7/4/2023 and 1:45 a.m. 7/5/2023. He should have received a snack during that time. Review of the Medication Administration Record (MAR) for July 2023 showed Resident #1 did not receive these medications or the snack as ordered on 07/04/2023. A review of the Treatment Administration Record (TAR) showed 6 in the box for checking the function of the wander monitoring device every night shift for monitoring and a 6 was in the box for checking the placement of the wander monitoring device every shift for monitoring on 07/04/2023. A review of Resident #1's Nursing Progress Notes revealed the following: On 07/04/2023 at 9:10 p.m., the writer spoke with a staff member from the local hospital taking care of Resident #1. The staff member stated, Resident is pleasantly confused at the moment. On 07/07/2023 at 09:00 a.m., (Resident #1) eloped from facility the evening of 07/04/2023. The resident exited the facility through the front doors and proceeded to walk down the sidewalk as he reports in an effort to go to his favorite restaurant that he once worked at. Resident #1 has consistently been taken by friends to the July 4th parade in town where he's been a yearly fixture in handing out flags. This year however, the person that checked him out of the facility to do this annual tradition was out of town on vacation. Upon further investigation by staff, including social services, the resident has consistently stated his intent was to go to the restaurant he used to work at bussing tables to get something to eat and visit and then planned to go hand out flags at the parade. The writer went to question Resident #1 regarding events at his bedside where the resident pointed to pictures on his wall of him at the restaurant in question and also handing out flags at the July 4th celebration. Interventions have included one on one companionship, take out order from a local restaurant, and there are plans in place for next July 4th to take the resident out to enjoy watching fireworks although staff is working out the details as to the safest way to provide this annual expectation to meet his needs while ensuring his safety. The resident has not since tried to leave the facility and a care plan is now in place around this annual expectation. An observation of the path the resident may have taken revealed from the front door he turned left heading North after leaving the facility property. A two-lane road with a speed limit of 30 mph (miles per hour) separated the facility grounds from a grassy area that lead onto an asphalt sidewalk. The sidewalk with uneven cemented surfaces, potholes and cracks followed around the lake without barriers. The unprotected lake was approximately 10 feet away from the asphalt sidewalk. The resident was found across the road from the facility in a grassy area. Resident #1's Elopement Risk assessment dated [DATE] completed by Staff C, LPN, showed No was checked for attempt to wander off the unit and positions self by exit areas. Yes was checked for having a history of wandering or elopement. No was checked for attempts to leave the building or grounds without notifying staff, the resident was not able to negotiate environment safely and has a history of substance abuse and/or substance seeking behavior, repetitive verbalizations of I'm going home, and is ambulatory including wheelchair mobility and for not accepting his current residency in the facility. Yes was checked for having a diagnosis of Dementia, Alzheimer's and is able to negotiate environment safety. The assessment showed Resident #1 was not at risk for elopement at this time. The form also revealed a section that showed If there are 'Yes' answers, but the resident is not at risk explain why. The box for the section was blank. A Change in Condition dated 07/04/2023 showed the incident location was outside. Resident #1 left the facility. Staff were notified by anonymous bystanders that the resident was by the fire training center on the ground. The resident description section revealed, I don't want to be here anymore. I'm going to [a local restaurant]. The resident was transported to a local hospital and returned to the facility on 1:45 a.m. on 07/05/2023. Review of Resident #1's care plan revealed a focus area initiated on 03/26/2021 [Resident #1] is an elopement risk, wanders throughout facility independently related to dementia, disoriented to place, impaired safety awareness, and the resident wanders aimlessly at times. Interventions included 1:1 supervision at all times (07/05/2023), assess for elopement risk (03/26/2021), distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book (03/26/2021), identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate (03/26/2021), provide structured activities: toileting, walking inside and outside, reorientation, strategies including signs, picture and memory boxes (03/26/2021), psychiatric care evaluation as indicated (07/11/2023), and wander monitoring device (electronic monitoring device)- check placement every shift and function daily (03/26/2021). Review of the care plans revealed a focus area initiated on 10/07/2022 [Resident #1] is/has potential to be verbally aggressive towards staff related to ineffective coping skills, limited impulse control inappropriate language use, refuses medications at times, history of elopement, will only allow name/id bracelet on his ankle, then takes it off when agitated, becomes agitated during 4th of July, and Memorial Day when he doesn't have someone take him out due to history of being very active handing out flags in the community. Interventions included administer medications as ordered, monitor/document for side effects and effectiveness (10/07/2022), analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document (10/07/2022), assess resident's coping skills and support systems 10/07/2022), assess resident's understanding of the situation, allow time for the resident to express self and feelings towards the situation (10/07/2022), and psychiatric care evaluation as indicated (07/11/2023. Review of Resident's #1 care plan revealed a focus area initiated on 02/17/2022 [Resident #1] has impaired cognitive function and/or impaired thought processes related to dementia diagnosis. Interventions included administer medications as ordered, monitor/document for side effects and effectiveness (02/17/2022), ask yes/no questions in order to determine the resident's needs (02/17/2022), and communicate with the resident/resident's representative/caregivers regarding resident's capabilities and needs (02/17/2022). Engage the resident in simple, structured activities that avoid overly demanding tasks (02/17/2022) and keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion (02/17/2022). Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated (02/17/2022). Review of the care plan revealed a focus area initiated on 04/05/2021 [Resident #1] is at risk for further falls related to confusion, gait/balance problems, episodes of incontinence, medication use, weakness, confusion, ambulates throughout unit wearing regular socks and refuses to have non-skid socks or tennis shoes put on for him at times. Interventions included anticipate and meet the resident's needs (04/05/2021), be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (04/05/2021), bed in low position (04/05/2021), and educate the resident and as needed the family on any individual fall reduction strategies (02/18/2022). Encourage resident to wear appropriate footwear/non-skid socks when ambulating (04/22/2021). Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (04/05/2021). Fall on 04/05/22 with ambulation, therapy evaluation, neurochecks, Xray lumbar spine, and encourage nonskid socks (04/06/2022). Medications as ordered and monitor for side effects (02/16/2022). Physical Therapy to evaluate and treat as ordered or as needed (04/05/2021). A review of the psychiatric care note written by Staff R, Advanced Registered Nurse Practitioners (ARNP), with a date of service date of 07/14/2023 showed patient was seen on 07/05/2023 for a telehealth follow up. He is currently taking Trazodone HCL Tablet 25 MG by mouth once a day for major depressive disorder. Patient seen today after eloping yesterday (July 4) from facility. He is alert and pleasantly confused. Appears in no acute distress. Patient reports he intended to have a meal at his favorite local restaurant. He reports he used to work at this restaurant. He stated he was planning to return after his meal. It was reported that the patient walked approximately 7 minutes and was spotted by nearby people who were watching fireworks. He was found sitting in a chair among the people watching fireworks. He was taken to the emergency room that evening to be evaluated. During an interview on 07/25/2023 at 2:00 p.m., Staff Q, Receptionist, stated the door alarm and the wander monitoring device alarm had the same sound. Her shift ends at 4:00 p.m. daily. The red alarm is a screamer, the door alarm was a beep. The front door had a high pitch sound, one beep, and a continuous beep until it was turned off. It will also beep if someone holds the door open too long. You must put a code in to turn the alarm off. An interview was conducted on 07/25/2023 at 2:35 p.m. with the Maintenance Director. He reported there were 8 exit doors in the facility, and they all had keypads. Three of the doors also had a wander monitoring device alarm, the front door is one of them. He said since the elopement that Screamer (very loud) alarms were put on a set of double doors that lead to the lobby, main entrance area. He said he checked the doors daily on weekdays, and according to the Administrator, the nursing staff check the doors on the weekend. The Alarmed and Exit Doors Daily Inspections log was reviewed at that time for the months of May 2023 and June 2023. It showed the doors were checked on weekdays but not checked on the weekend. During the observation the front door alarm was set off with a wander monitoring device by the Maintenance Director. The alarm could not be heard while standing on the North unit/300 hall. This was confirmed by the Maintenance Director. During an interview on 07/25/2023 at 3:29 p.m. with the Administrator and DON, the DON reported Staff G, LPN, contacted the DON and reported Resident #1 was out of the building and she was contacted by some bystanders. The resident was found about 7 minutes away from the facility if you walked. They both came to start the investigation. They called the police, the Power of Attorney (POA), the doctor, psychiatric care, and another outside agency. Interviews were completed with staff and residents. None of the staff reported he wanted to leave the facility that day or mentioned anything about leaving the facility. He walks back and forth all day. He had asked some about going out for fresh air. They went outside and came back in. Staff K, RN, took her lunch break around 6:10 p.m. and her car was facing the door. After her break, she came back in, went to the bathroom, and went back to the unit. Two phone calls came in about a missing resident. The DON stated Staff I, CNA, heard the alarm go off but she didn't see anyone. Resident #1 definitely went out of the front door. If you hold the door for 15 seconds, the door would open. He was a pretty smart guy and can probably read. He didn't verbalize he wanted to see fireworks. Resident #1 had on the wander monitoring device at the time he left the facility. They tested the same wander monitoring device when he came back, and it was still working. In-services were started immediately after the incident. Maintenance came and checked the doors, and they were working fine. They set up 30-minute checks on all alarmed doors. The alarm company came out on 07/06/2023. They added screamers to the double doors to have a second alarm, because you cannot hear the alarm at the north Unit nursing station. The receptionist leaves at 4:30 p.m. or 5:00 p.m. Once the receptionist leaves, the nurse comes over and sets the alarm. There were no screamers when Resident #1 eloped. An enunciator will be placed at north unit nurse's station, it has been ordered, so alarms can be heard there. You must put a code in to enter or exit the facility. Visitors have to ring the bell. Prior to the incident, the receptionist buzzed everyone in and out. Now the nurse comes and sets the alarms to the front door after the receptionist leaves. The receptionist announces on the intercom that she is leaving for the day. Someone in charge, usually one of the nurses comes to lock the door. The nursing supervisors are the ones that come to turn on screamers. All nurses have keys to screamers. Resident #1 was placed on 1:1. The DON and ADON evaluated all residents for elopement. They checked wander monitoring devices, monitored Resident #1, and did a whole house audit. Staffing was good. No issue with staffing on that day. Staff were educated on the elopement procedure and drills. They did a drill each shift and did them weekly after the incident. During an interview on 07/27/23 at 9:55 a.m., the Administrator and DON reported training was provided on the elopement policy/procedure/protocol prior to July 4, 2023. Elopement audits and drills were completed. On 07/27/2023 12:08 p.m., the DON reported elopement education was completed upon hire. They do not have access to elopement training and elopement drills completed due to a change in systems approximately two months ago. Alarmed and Exit Doors Daily Inspections for the months of May 2023 and June 2023 were verified. The doors were not checked on the weekend. This was confirmed by the Administrator and DON. She stated as of July, nursing staff had been checking the doors on the weekend. 2. On 7/5/23 at approximately 9:40 a.m. Resident #8 was able to exit the facility without supervision through an exit door on an uninhabited hall (600) that was equipped with a door alarm. An interview was conducted on 07/26/2023 at 12:29 p.m. with Staff M, CNA. She said on 7/5/2023 she served him breakfast around 8:00 a.m., picked up the tray, and the last time she saw him was after 9:00 a.m. He was down 400 hall next to the nurse. Staff M, CNA, stated she went into a room to provide patient care to another resident and heard the alarm going off. She looked on the board and saw the alarm was going off on the 600 hall. She looked and didn't see anything. At that time, they made an announcement to do a patient count. During an interview on 07/26/2023 at 12:11 p.m. with Staff L, LPN, she stated she was assigned to the resident that day. He likes to go back and forth. Around 9:20 a.m., she gave him medications and that was the last time she saw him. She was down the 400 hall passing medications when the alarm went off. She saw the Maintenance Guy and Housekeeping going down the 600 hall when the alarm went off. She continued finishing what she was in the middle of doing. She didn't see Resident #8 outside. After they wheeled him back in, she assessed him. He gravitated towards the doors with lights and guessed he was just going to see what was outside. He pushes on doors and jiggles the handles frequently. He had a wander monitoring device on which is why the alarm was going off. Everyone was busy, it was in the morning after breakfast. One of the CNAs took care of him before she gave him his medications. No one was on break, but everyone was busy with the residents. It was sunny and hot on that day. During an interview on 07/26/2023 at 12:37 p.m., Staff N, CNA, stated she was working on the floor on the day of the incident. She was giving a bed bath to another resident. She heard the alarm, came out of the room, and saw they were working on the doors. She saw the Maintenance Director working on the door around 9:50 a.m. She went back to finish the resident's bed bath. When she later went to nurses' station, the staff asked if she heard the alarm. She was assigned to stay with Resident #8 one on one that day at about 10:00 a.m. and she stayed with him until about 3:00 p.m. that day. An interview conducted with the Activity Director on 07/26/2023 at 12:47 p.m. He stated he heard the alarm go off and the 600 area being announced by staff. Everyone jumped up and started moving. Everyone was looking. Staff scattered to their areas. He saw the Maintenance Director going down the 600 hall. The Activity Director went down the 500 hall; when he got to the 500 hall exit door it was locked so he ran toward the 600 side, and he didn't see anyone. The Activity Director stated he then went back to the 500 hall and opened the exit door and saw Resident #8 closer by the dumpster, he was smiling and giggling. He wheeled Resident #8 back into the facility and took him to the nursing station. The resident got out of the door on the end of the 600 hall and went down the sidewalk that surrounds the building towards the 500 unit. During an interview on 07/26/2023 at 12:21 p.m., the Maintenance Director stated on 7/5/2023 he was headed to the morning meeting, he exited the service hall, and heard the alarm going off. He checked the enunciator, and it showed the alarm was coming from the 600 hall. The exit door was open on the end of the 600 hall. He went outside and immediately ran to the front of the building, because there was more danger in the front of the building than the rear. He didn't see anyone. He then came in and headed back to the 600 hall and saw Resident #8 from the window sitting outside. Two other staff members were heading out to get him. Within two minutes they had him back inside. The Maintenance Director went back down the 600 hall, reset the doors and silenced the alarms. He was the first one to respond to the alarm. He immediately looked to see what hall the alarm was coming from. After the incident happened, they put a rope across the hall, caution signs, and wet floor signs. Resident #8 frequently pushes on the doors. He knows the door will open after 15 seconds. The resident was just sitting looking around at the trees. There's a sidewalk in the back parking lot area. Another staff member got to Resident #8 before he did. He went back to secure the doors after the resident was brought back into the facility. Observation of the outside area where the resident was found revealed an uneven cement sidewalk surface that wrapped around the facility's building connecting one entrance to the next. Adjacent to the sidewalk was approximately 5 feet of grassy terrain that led into a large area with trees, overgrown shrubs and standing water. Review of Resident 8's admission Record showed he was admitted on [DATE] with diagnoses to include muscle weakness, difficulty in walking, unspecified lack of coordination, limitation of activities due to disability, other lack of coordination, history of falling, age related cognitive decline, age related physical decline, unspecified dementia, unspecified severity without behavioral disturbance, psychiatric disturbance, mood disorder, anxiety, unspecified cataract, and Alzheimer's Disease. A review of the quarterly MDS with an ARD/target date of 05/16/2023 revealed Resident #8 had a BIMS score of 00 out of 15 indicating severe cognitive impairment. Section G Functional Status of the MDS showed the resident needed extensive assistance with two plus persons physical assist with bed mobility and transfers and needed supervision with one-person physical assist for locomotion on and off the unit. Resident #8 needed extensive assistance with one-person physical assist for dressing and personal hygiene. He needed supervision with setup help only for eating and he was total dependent with two plus persons physical assist for toilet use. Section P Restraints and Alarms revealed Resident #8 used a wander monitoring device daily. An observation and interview were conducted on 7/24/2023 at 10:05 a.m. of Resident #8 on 1:1 with CNA, Staff O. Resident #8 was observed to be dressed in day clothes, sitting in his wheelchair in front of an exit door at the end of the 400 hallway. Staff O, CNA stated she was on 1:1 with him because around 07/05/2023, he went past the nurses' station and pushed on the exit door to the 600 hall and was found outside by the dumpsters. She stated he always pushes on the doors. He used to be a lawyer and he thinks his car was parked in the parking lot and he says he had to go to work. Since he was admitted he has pretty much always pushed on the doors. You see he is sitting in front of this door, and I told him 'You can't push on the doors okay' and he told me 'Well yeah if I keep pushing on it the door will open, you see the sign.' A sign was observed on the door with the words Push Until Alarm Sounds Door Can Be Opened In 15 Seconds. The resident was observed to have a wander guard on his left ankle under his sock. A review of the Order Summary Report with active orders as of 07/26/2023 showed the following: 1:1 close observation every shift for safety (ordered 07/05/2023); May go out with responsible party (10/10/2021); Monitoring wander monitoring device expiration May 2026- every night shift every 4 weeks on Wednesday for monitoring (05/17/2023); (Company name) Hospice for diagnosis of metabolic encephalopathy