**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Risk Manager, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, the facility failed to protect the resident's right to be free from neglect by not ensuring one (#1) of 58 residents at risk for elopement, was provided with supervision and services related to the resident's known cognitive deficits and history of wandering before admission to the facility. The facility staff failed to ensure the safety of Resident #1; between approximately 2:45 PM on 11/27/2023 and 5:30 PM on 11/27/2023, Resident #1 ambulated from the dementia care unit, followed behind a staff member through a door equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked) and into an outdoor enclosed porch area. Resident #1 opened a wooden gate in the outdoor enclosed porch area, which was left unlatched and unlocked by staff, and walked into an enclosed courtyard. Resident #1 walked into the courtyard and exited the facility grounds unsupervised and without staff knowledge through a vinyl fence door equipped with an electromagnetic locking device, which was left propped open by staff. Resident #1 walked approximately 0.8 miles on a sidewalk along a 6 lane highway to a bus stop. The facility failed to take action to prevent the resident from exiting the secured dementia care unit by not providing supervision for the resident, not ensuring doors were properly closed to prevent the resident from following behind them as they exited the secured dementia care unit, and not accounting for the resident for approximately 1 hour and 45 minutes. Resident #1 was discovered by facility staff on 11/27/2023 at approximately 5:30 PM at a bus stop, sitting on a bench. Resident #1 was returned to the facility by facility staff at approximately 5:40 PM. The failure created a situation that resulted in a likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 11/27/2023. The findings of Immediate Jeopardy were determined to be corrected on 12/5/2023. Findings included: A review of Resident #1's Situation, Background, Assessment, and Recommendation (SBAR) Communication and Progress Note dated 11/27/2023 at 9:28 PM revealed the following under the section titled Nursing Notes: [Resident #1] was noted missing from the unit. The unit was searched without success. Code silver [was] paged and all departments came to assist. [Local police department] was called to assist as well. Outside perimeter of the facility was searched and resident was located at a nearby establishment. [Resident #1] denies pain or discomfort. No new skin issues noted. VSS (vital signs stable). New order for [electronic elopement device] place[d] on resident and enhanced monitoring. A telephone interview was conducted on 12/19/2023 at 10:40 AM with Resident #1's responsible party (RP). The RP stated Resident #1 was initially admitted to the facility for a short term respite stay of 5 days and required placement on the dementia care unit due to his history of dementia and poor short term memory. The resident had a 5-day respite stay at the facility sometime in October, then again in November. The RP also stated Resident #1 required assistance at home with finding the bedroom and the bathroom and the doors in the house were deadbolted due to the resident wanting to exit the house and stating he needed to go to work. The RP stated Resident #1 had poor safety awareness and would often walk in the middle of the parking lot when they would go to the store together and required frequent redirection and reorientation to his surroundings. The RP stated on 11/27/2023 a staff member from the facility arrived at her house and told her Resident #1 was missing from the facility. The staff member asked if the resident was at the house and the RP told her Resident #1 was not at the house. The RP drove to the facility shortly after the interaction and spoke with local law enforcement at the facility. The RP stated Resident #1 was found around 5:30 PM by facility staff and was brought back to the facility. The RP also stated Resident #1 had an electronic elopement device placed on his body and was provided with increased supervision until he was discharged on 12/1/2023. A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral atherosclerosis, vascular dementia, severe, without behavioral disturbance, and depression. Resident #1 was discharged home on [DATE]. Resident #1 was readmitted to the facility on [DATE] and was discharged home on [DATE]. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 11/24/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form also revealed under Section E: Medical Condition, primary discharge diagnoses of cerebral atherosclerosis and dementia. The transfer form revealed under Section G: Patient Risk Alerts, Resident #1 was at risk for elopement. A review of Resident #1's physician's orders revealed the following: - An order dated 11/27/2023 for an electronic elopement device to the right ankle for safety. - An order dated 11/27/2023 to verify placement of the electronic elopement device to the resident's right ankle every shift for safety. - An order dated 11/27/2023 to verify functioning of the electronic elopement device to the resident's right ankle every shift for safety. A review of Resident #1's Pre-admission Care Needs assessment, dated 11/25/2023, revealed under the section titled Mental Status, Resident #1 was confused and an Elopement Risk. The assessment also revealed, under the section titled Behavior Patterns Resident #1 had a history of elopement. A review of Resident #1's Pre/Post admission Elopement Risk Evaluation, dated 11/25/2023, revealed Resident #1 had a history of wandering or elopement, exit seeking behavior, confusion/dementia, and a resident or family home nearby. A review of the facility policy titled Risk Management/Nursing Policies - Elopement Risk, with no effective date, revealed under the section titled Policy an elopement risk evaluation is completed as a part of screening upon admission. All residents will be evaluated for elopement risk upon admission, quarterly, and with a change in condition. The policy also stated under the section titled Procedure if the resident is identified as an elopement risk based on the evaluation, a care plan will be developed to reduce elopement risk. Facility staff will provide supervision and engage the resident as needed to minimize wandering or exit seeking behavior according to the plan of care. A review of Resident #1's baseline care plan, dated 11/26/2023, revealed Resident #1 was an elopement risk with a goal for Resident #1 to remain in a safe, supervised, and supportive environment. Interventions included to initiate elopement risk protocol, involve in activities, and redirect and/or distract as needed. A review of Resident #1's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/27/2023 revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 4, which indicated severely impaired cognition. A review of Resident #1's Progress Notes dated 10/21/2023 at 12:14 PM and authored by Staff F, Licensed Practical Nurse (LPN) and Unit Manager (UM), [Resident #1] has expressed the desire to leave on multiple occasions and is constantly looking for an exit. Redirected without much success. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%20severe%20injury%20and%20death.&text=The%20persistent%20wandering%20behavior%20and,fractures%2C%20and%20accidents%20in%20PwD. A review of the facility policy titled Abuse, Neglect, Exploitation, & Misappropriation, with no effective date, revealed under the section titled Policy it is the policy of this facility to take appropriate steps to prevent abuse, neglect, exploitation, and misappropriation and the occurrence of an injury of unknown source, and to ensure all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Services, Director, and the Director of Nursing. The policy defines neglect as .the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of or should be aware of goods and services that a resident requires, but the facility fails to provide them to the resident resulting in or may result in physical harm. An observation was conducted on 12/18/2023 at 11:54 AM of the facility's dementia care unit. A doorbell was observed on the left wall outside of the entrance to the unit with a small gold colored sign underneath, which stated For entrance to the dementia unit, please ring this bell and then step to the door. A nurse at the station will press the key pad to let you in. Thanks for your help as we ensure the safety of our residents. A small contact alarm (an alarm with a magnetic piece and a sensor body that adhere to doors which activate when separated from their sensors and the sensor's magnetic field is broken) was observed on the entrance door of the unit, which sounded an audible alarm when opened by staff. The facility's Nursing Home Administrator (NHA) entered the hallway to silence the alarm after entering the unit. Facility staff were observed at the unit nurse's station, which is positioned next to the unit entrance. A small, enclosed patio was observed in the back of the unit, separated by a glass door exiting to the outside. The door was observed to be locked with an electromagnetic locking device and a red colored contact alarm was observed on the door. The Director of Nursing (DON) and Risk Manager (RM) were observed on the dementia care unit. The DON stated the contact alarm can be disengaged using a key to position the alarm from on to off and keys are kept by the nursing staff on the unit. The DON opened the magnetically locked door using a keypad to the left side of the door. Upon opening the door, the contact alarm engaged, and an audible alarming sound was heard. The alarm was disengaged by nursing staff and reengaged after exiting the unit to the enclosed porch. The outdoor porch was observed to be enclosed with a vinyl white lattice fence and a large wooden door leading out to a courtyard behind the unit. The wooden gate was observed to be latched with a metal latching device and locked with a small padlock. A white sign was observed on the wooden door, which stated gate to remain locked when not in use. A key box with a numbered combination lock was observed mounted to a post next to the wooden door. The RM entered the combination for the key box, which opened the box and revealed a key for the lock on the wooden gate. The RM unlocked the lock and unlatched the wooden door, leading to a large courtyard area behind the dementia care unit. The courtyard was observed enclosed by a white vinyl fence approximately 8 feet tall. Several exit signs were observed along the vinyl fence with signs pointing to an exit door, which lead to a small parking area, a sidewalk, and 4 lane street outside of the facility grounds. The RM stated the fence door is secured with an electromagnetic locking device and can be opened with the keypad. The keypad was moved from the inside of the courtyard to the outside of the courtyard, so staff do not have to go through the dementia care unit to gain access to the courtyard behind the dementia care unit. An interview was conducted on 12/18/2023 at 1:13 PM with the NHA, DON, and RM. The RM stated on 11/27/2023 around 4:30 PM, Resident #1 was not able to be located on the dementia care unit. Staff E, Certified Nursing Assistant (CNA) was working as Eagle Eye staff on the unit for the 3 PM to 11 PM shift and reported to Staff F, LPN UM she was not able to locate Resident #1 on the unit. The RM stated Eagle Eye staff are assigned to the dementia care unit to ensure the safety of the residents on the unit by visualizing the location of the resident every 15 minutes for the duration of their shift. The RM stated per Staff E, CNA's statement, Staff E, CNA noticed around 3:45 PM on 11/27/2023 Resident #1 was not located on the unit and began searching for the resident on the unit. After reporting the missing resident to Staff F, LPN UM, the dementia care unit was searched by the CNA staff and nursing staff on the unit. After not being able to locate Resident #1 on the unit, staff called a code silver, which is the code to indicate a missing resident from the facility, between 4:40 and 4:45 PM. The DON stated she reported to the dementia care unit to coordinate the code and several staff began to search for Resident #1 both inside the facility and outside of the facility as assigned by the DON. The DON also informed local law enforcement around 5:05 PM of Resident #1 missing from the facility. The DON assigned Staff F, LPN UM to search around the local shopping mall area and drove to Resident #1's house since it was near the facility. The DON was on the phone with Staff F, LPN UM when she arrived at Resident #1's house and Resident #1's RP answered the door. Staff F, LPN UM informed the RP Resident #1 was missing from the facility and the RP stated Resident #1 was not at the house. Staff F, LPN UM continued to search the local area for Resident #1 and located the resident at a bus stop sitting on a bench around 5:30 PM. Resident #1 was brought back to the facility by Staff F, LPN UM and did not have any injuries. Resident #1 was wearing grey colored khaki pants, a grey short sleeved shirt, a blue jacket, and black shoes when he arrived back to the facility. The RM stated Resident #1 was placed on one to one supervision and an electronic elopement device was applied to the resident's right ankle. The RM stated Resident #1 did not have an electronic elopement device previously because he was housed on the locked dementia care unit. Resident #1 had one to one supervision until his scheduled discharge on [DATE]. The following day on 11/28/2023, the RM, NHA, and maintenance staff did walking rounds on dementia care unit to assess how Resident #1 eloped from the facility. The RM stated the wooden gate for the enclosed porch outside of the dementia care unit was observed to be open and unlocked. The RM also stated their investigation revealed a correlation between the time Resident #1 eloped and the time outside lawn workers performed lawn care for the courtyard behind the dementia care unit, which was typically on Mondays between 3:00 PM and 3:30 PM. The RM stated per interview with Staff G, Maintenance, the staff member went through the dementia care unit around 3:15 PM to the back courtyard area and through the locked glass door. Staff G, Maintenance unlocked the wooden gate to the enclosed porch behind the dementia care unit and left it open due to the not being able to lock the door from the outside. Staff G, Maintenance opened the white vinyl gate to allow lawn care workers into the courtyard behind the dementia care unit and left the door propped open for approximately 30 minutes. The RM stated the investigation revealed Resident #1 followed Staff G, Maintenance off the unit and onto the enclosed porch without the staff member's knowledge, before exiting the porch and exiting the courtyard to the sidewalk outside of the facility. The RM stated since the elopement occurred, the facility removed the button behind the nurse's station on the dementia care unit which allowed nursing staff to open the door to the unit. Nursing staff must enter a code on the keypad to deactivate the magnetic lock on the door to allow visitors and staff to exit the unit. A contact alarm was added to the exit doors on the unit, which were previously located inside of the unit. This was implemented to ensure staff turn around to deactivate the alarm, which will further ensure no resident is trailing behind them when they exit the unit. The RM stated contact alarms, or stop alarms, were added to the exit doors on the dementia care unit leading out to the enclosed patio and courtyard behind the unit. The DON stated all residents in the facility were re-evaluated for elopement risk and those residents determined at risk for elopement will have an electronic elopement device, including those residents on the dementia care unit. The DON also stated facility staff have been educated on the proper procedure for shift-to-shift walking rounds and staff must visualize the resident at the time of their report, which is also verified by the nurse. The DON stated all codes for the doors in the facility equipped with an electromagnetic lock were changed to ensure no residents have access to the codes. A review of the facility policy titled Risk Management - Missing Resident and Elopement, with no effective date, revealed under the section titled Policy elopement occurs when a resident who needs supervision leaves a safe area without supervision. If any resident should leave the premises at any time without following the facility procedure for voluntary leave, the missing resident/elopement procedure should begin immediately. The policy also revealed under the section titled Procedure it is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as possible. An interview was conducted on 12/18/2023 at 2:03 PM with Staff F, LPN UM, who was Resident #1's assigned nurse for the 7 AM to 7 PM shift on 11/27/2023. Staff F, LPN UM stated she was Resident #1's assigned nurse on 11/27/2023 for the 7:00 AM to 7:00 PM shift. Staff F, LPN UM also stated Resident #1 often expressed he wanted to go home, told staff his brother was waiting outside for him, and asked staff how he could get out of the facility, but was easily re-directed by staff on the dementia care unit. Staff F, LPN UM stated Resident #1 was an elopement risk before being admitted to the facility and his RP placed several locks on the doors of his home to prevent him from eloping from the house. Staff F, LPN UM stated prior to Resident #1's elopement, she saw the resident between 2:15 PM and 2:30 PM by the unit nurse's station walking in the unit halls. Staff F, LPN UM also stated around 4:00 PM, Staff E, CNA and Staff H, CNA told her Resident #1 was missing from the unit and the staff members already searched the unit for the resident. Staff F, LPN UM and the dementia care unit staff searched the unit one more time for Resident #1, including the courtyard and activity areas, without success. Staff F, LPN UM called a code silver and other facility staff reported to the unit to assist in locating Resident #1. Facility staff searched throughout the facility and surrounding areas. Staff F, LPN UM stated she went toward Resident #1's home because he previously stated he wanted to go home, and the resident lived close to the facility. Staff F, LPN UM arrived at Resident #1's home and spoke with the RP, who stated the resident was not at the house. Staff F, LPN UM informed the RP Resident #1 was missing from the facility and local law enforcement was aware. After leaving Resident #1's home, Staff F, LPN UM got into her car and searched areas closer to the facility grounds. Staff F, LPN UM found Resident #1 sitting at a bus stop in front of a local restaurant. Staff F, LPN UM took Resident #1 by the hand and assisted him into her vehicle before driving him back to the facility. Resident #1 was assessed and had no injuries because of the elopement. Resident #1 was taken by staff to the unit dining room for dinner. Resident #1 was placed on one to one supervision until he was discharged on 12/1/2023. Staff F, LPN UM stated the CNA staff were not conducting shift to shift reporting properly and they have since reinforced the requirement of conducting a head count of the residents before and after each shift. An interview was conducted on 12/18/2023 at 2:33 PM with Staff C, CNA, who was Resident #1's assigned CNA on 11/27/2023 during the 7 AM to 3 PM shift. Staff C, CNA stated 11/27/2023 was the first day she was assigned care for Resident #1, and she was not very familiar with his behaviors. Staff C, CNA also stated Resident #1 had expressed a desire to leave during the 7 AM to 3 PM shift because his brother was waiting for him by the back door. Resident #1 was also pushing on the door but was easily re-directed to another area of the unit. Staff C, CNA stated she informed the Eagle Eye staff of Resident #1's attempts and desires to leave the unit but did not inform the nurse on duty, Staff F, LPN UM. Staff C, CNA stated the last time she saw Resident #1 on the unit on 11/27/2023 was around 3:00 PM while he was walking back and forth through the unit hallways. Staff C, CNA stated upon ending her shift, she gave a verbal report to Staff I, CNA for the 3 PM to 11 PM shift but did walking rounds to ensure all the assigned residents were present on the unit. Staff C, CNA also stated she had not been working as a CNA for very long and she was not aware they needed to visually check on the residents as part of her shift to shift rounds and she did not visualize the residents before leaving the unit around 3:35 PM. Staff C, CNA stated she did not include Resident #1's desire to leave the unit or attempts to open the doors to the unit in her report to Staff I, CNA and only stated to keep an eye on him. Staff C, CNA stated they must complete a form during their shift to shift rounds to verify the presence of the residents on the unit and verify placement of any electronic elopement devices on the residents, which is a process they did not have in place prior to Resident #1's elopement. An interview was conducted on 12/18/2023 at 3:23 PM with Staff E, CNA and Staff J, CNA. Staff J, CNA stated she worked as an Eagle Eye on the dementia care unit on 11/27/2023 during the 7 AM to 3 PM shift. Staff J, CNA also stated the Eagle Eye's role is to check every resident on the unit every 15 minutes to ensure the resident is safe and care needs are met. Staff J, CNA stated Resident #1 would normally wander around the unit hallways throughout the day and at one point told her he needed to leave because his brother was waiting for him outside. Resident #1 was easily re-directed by staff. Staff J, CNA stated she last saw Resident #1 on the unit around 2:45 PM while the resident was wandering the unit hallways. Staff E, CNA relieved Staff J, CNA for the 3 PM to 11 PM shift. Staff H, CNA was also supposed to work as an Eagle Eye for the 3 PM to 11 PM shift but was about 30 minutes late for her shift, leaving only Staff E, CNA. Staff E, CNA stated on 11/27/2023 she was assigned the opposite side of the hallway and Staff H, CNA was assigned the other side of the hallway where Resident #1 resided. Staff E, CNA also stated she conducted a report with Staff J, CNA, but did not conduct a head count or visualize all the residents on the unit as part of her shift to shift report. Staff E, CNA stated when she came on the unit around 3 PM, she conducted safety rounds on her assigned residents, which took about 10 or 15 minutes. Staff E, CNA then conducted rounds on the side of the hall Resident #1 was on and did not see the resident on the unit. Staff E, CNA stated a Bingo activity was being conducted on another unit of the facility and she assumed Resident #1 was at the activity, but she did not verify Resident #1 was at the activity. Staff E, CNA continued to look for Resident #1 on the unit until Staff H, CNA came to the unit around 3:30 PM and assisted in locating Resident #1. Staff E, CNA stated around 3:30 or 4 PM, she went to another unit where the Bingo activity was taking place to see if Resident #1 was at the activity. After verifying Resident #1 was not at the activity, Staff E, CNA informed Staff F, LPN UM around 4:00 PM, Resident #1 was missing. Staff F, LPN UM called a code silver and facility staff searched around the facility and facility ground attempting to find Resident #1. Staff E, CNA stated she searched the entire outside perimeter of the facility but was not able to locate Resident #1. Resident #1 was located by Staff F, LPN UM and was placed on one to one supervision upon his return. Staff E, CNA and Staff J, CNA were not able to state why they did not perform a head count of the residents on the dementia care unit during their shift to shift report. A review of the facility procedure titled Eagle Eye Observation Program, with no effective date, revealed there will be a CNA observer for the whole unit on 7:00 AM to 3:00 PM, 2 CNA observers, one for each hallway on 3:00 PM to 11:00 PM, and one CNA observer for the whole unit for the 11 PM to 7 AM shift. The procedure also revealed during those periods, the staff member will be responsible for the following monitoring: - Walk the halls, checking each room and common areas to include the solarium. This will occur throughout the eight-hour shift every 15 minutes. - During this time the staff members will be observing the following potential occurrences to promote proactive intervention and ensures resident safety: Preventing unusual occurrences, assist residents with activities, prevent residents from falling, prevent conflict between residents, redirects residents out of another resident's room, check each room for patient needs every 15 minutes, and prevent potential elopement. - Any unusual situation or significant change that this staff member observes will be immediately reported to the resident's assigned nurse. A telephone interview was conducted on 12/19/2023 at 9:15 AM with Staff I, CNA, who was Resident #1's assigned CNA for the 3 PM to 11 PM shift on 11/27/2023. Staff I, CNA stated she arrived at the dementia care unit on 11/27/2023 around 3:00 PM and received a verbal report from Staff C, CNA. Staff I, CNA assisted Staff C, CNA with changing another resident in the unit shower room and continued to check on other resident's in her assignment. Staff I, CNA stated she had never seen Resident #1 before and did not know to look for him on the unit because she did not know he was a resident of the facility. Staff I, CNA stated Staff E, CNA asked her where Resident #1 was and she replied, who's that? Staff I, CNA stated Staff E, CNA informed Staff F, LPN UM Resident #1 was missing from the facility and a code silver was called. Staff I, CNA stated she looked at a photo to see what Resident #1 looked like and began to assist in searching for him throughout the facility. Staff I, CNA stated Resident #1 was brought back to the facility around 5:40 PM and was brought into the facility dining room for dinner. A telephone interview was attempted on 12/19/2023 at 9:36 AM with Staff H, CNA. The phone call was not answered, and a message was left for a return call. Staff H, CNA did not return the phone call. A telephone interview was attempted on 12/19/2023 at 11:53 AM with Staff G, Maintenance. The phone call was not answered, and a message was left for a return call. Staff G, Maintenance did not return the phone call. A telephone interview was conducted on 12/19/2023 at 4:20 PM with the facility's Medical Director (MD). The MD stated Resident #1 was at the facility for a short term respite stay and resided on the dementia care unit. The MD also stated Resident #1 was not well known by the facility staff because he was only there for a short time, and he was informed of Resident #1's elopement on 11/27/2023 by the RM. The MD stated he was not very familiar with Resident #1 but did discuss the resident's elopement with the Interdisciplinary Team (IDT) to discuss elopement prevention, keeping track of the resident head count more frequently, and having every resident always accounted for. Facility's immediate actions to remove the Immediate Jeopardy included: - Full body sweep and evaluation for injury on Resident #1, completed on 11/27/2023 upon return to the facility. - CNA's assigned to resident for 7:00 AM - 5:30 PM on 11/27/2023 were suspended 11/27/2023. - Completed new elopement evaluations on all residents starting with Resident #1, update care plans and care guide as needed, completed on 11/28/2023. - All staff working on the dementia care unit on 11/27/23 from 7:00 AM to 5:30 PM were interviewed on 11/30/2023. - Complete elopement drills on each shift one to include the weekend and then twice a month on rotating shifts and including the weekend. Elopement drills were completed on 11/28/2023, 11/30/2023, and 12/3/2023. - Have all doors and alarm system devices were checked for functioning. Batteries to all alarm systems checked and a system of routine changing was put into place to prevent battery issues. On 11/27/2023 the NHA, Maintenance, and RM verified all doors were functioning as they should. Locks were replaced on the dementia care unit dining room, key entry, and key exit. Alarms on the dementia care unit doors removed from inside of the unit and placed on the outside of the unit. The door latch release behind the unit nurse's station was removed. Red exit door alarms placed on all exit doors for added notification. Completed on 11/28/2023. - 100% of all staff were educated on elopement response expectations, process/responsibilities, and reporting. Education completed on 12/5/2023. - Competency for all nurses on checking wander management device functioning. Education was conducted on responsibility to apply, notify, and care plan when evaluating residents who are at risk. Completed 12/15/2023. - 100% of all nursing staff were educated on walking rounds for report from shift to shift and rounding on their assigned residents at least every 2 hours. Completed 12/5/2023. - &nb[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Risk Manager, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, facility failed to ensure one resident (#1) of 58 residents at risk for elopement, was provided with supervision and services related to the resident's known cognitive deficits and history of wandering before admission to the facility. The facility staff failed to ensure the safety of Resident #1; between approximately 2:45 PM on 11/27/2023 and 5:30 PM on 11/27/2023, Resident #1 ambulated from the dementia care unit, followed behind a staff member through a door equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked) and into an outdoor enclosed porch area. Resident #1 opened a wooden gate in the outdoor enclosed porch area, which was left unlatched and unlocked by staff, and walked into an enclosed courtyard. Resident #1 walked into the courtyard and exited the facility grounds unsupervised and without staff knowledge through a vinyl fence door equipped with an electromagnetic locking device, which was left propped open by staff. Resident #1 walked approximately 0.8 miles on a sidewalk along a 6-lane highway to a bus stop. The facility failed to take action to prevent the resident from exiting the secured dementia care unit by not providing supervision for the resident, not ensuring doors were properly closed to prevent the resident from following behind them as they exited the secured dementia care unit, and not accounting for the resident for approximately 1 hour and 45 minutes. Resident #1 was discovered by facility staff on 11/27/2023 at approximately 5:30 PM at a bus stop, sitting on a bench. Resident #1 was returned to the facility by facility staff at approximately 5:40 PM. The failure created a situation that resulted in a likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 11/27/2023. The findings of Immediate Jeopardy were determined to be corrected on 12/5/2023. Findings included: A review of Resident #1's Situation, Background, Assessment, and Recommendation (SBAR) Communication and Progress Note dated 11/27/2023 at 9:28 PM revealed the following under the section titled Nursing Notes: [Resident #1] was noted missing from the unit. The unit was searched without success. Code silver [was] paged and all departments came to assist. [Local police department] was called to assist as well. Outside perimeter of the facility was searched and resident was located at a nearby establishment. [Resident #1] denies pain or discomfort. No new skin issues noted. VSS (vital signs stable). New order for [electronic elopement device] place[d] on resident and enhanced monitoring. A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral atherosclerosis, vascular dementia, severe, without behavioral disturbance, and depression. Resident #1 was discharged home on [DATE]. Resident #1 was readmitted to the facility on [DATE] and was discharged home on [DATE]. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 11/24/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form also revealed under Section E: Medical Condition, primary discharge diagnoses of cerebral atherosclerosis and dementia. The transfer form revealed under Section G: Patient Risk Alerts, Resident #1 was at risk for elopement. A review of Resident #1's physician's orders revealed the following: - An order dated 11/27/2023 for an electronic elopement device to the right ankle for safety. - An order dated 11/27/2023 to verify placement of the electronic elopement device to the resident's right ankle every shift for safety. - An order dated 11/27/2023 to verify functioning of the electronic elopement device to the resident's right ankle every shift for safety. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%20severe%20injury%20and%20death.&text=The%20persistent%20wandering%20behavior%20and,fractures%2C%20and%20accidents%20in%20PwD. A review of Resident #1's baseline care plan, dated 11/26/2023, revealed Resident #1 was an elopement risk with a goal for Resident #1 to remain in a safe, supervised, and supportive environment. Interventions included to initiate elopement risk protocol, involve in activities, and redirect and/or distract as needed. A review of Resident #1's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/27/2023 revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 4, which indicated severely impaired cognition. An observation was conducted on 12/18/2023 at 11:54 AM of the facility's dementia care unit. A doorbell was observed on the left wall outside of the entrance to the unit with a small gold colored sign underneath, which stated For entrance to the dementia unit, please ring this bell and then step to the door. A nurse at the station will press the keypad to let you in. Thanks for your help as we ensure the safety of our residents. A small contact alarm (an alarm with a magnetic piece and a sensor body that adhere to doors which activate when separated from their sensors and the sensor's magnetic field is broken) was observed on the entrance door of the unit, which sounded an audible alarm when opened by staff. The facility's Nursing Home Administrator (NHA) entered the hallway to silence the alarm after entering the unit. Facility staff were observed at the unit nurse's station, which is positioned next to the unit entrance. A small, enclosed patio was observed in the back of the unit, separated by a glass door exiting to the outside. The door was observed to be locked with an electromagnetic locking device and a red colored contact alarm was observed on the door. The Director of Nursing (DON) and Risk Manager (RM) were observed in the dementia care unit. The DON stated the contact alarm can be disengaged using a key to position the alarm from on to off and keys are kept by the nursing staff on the unit. The DON opened the magnetically locked door using a keypad to the left side of the door. Upon opening the door, the contact alarm engaged, and an audible alarming sound was heard. The alarm was disengaged by nursing staff and reengaged after exiting the unit to the enclosed porch. The outdoor porch was observed to be enclosed with a vinyl white lattice fence and a large wooden door leading out to a courtyard behind the unit. The wooden gate was observed to be latched with a metal latching device and locked with a small padlock. A white sign was observed on the wooden door, which stated gate to remain locked when not in use. A key box with a numbered combination lock was observed mounted to a post next to the wooden door. The RM entered the combination for the key box, which opened the box and revealed a key for the lock on the wooden gate. The RM unlocked the lock and unlatched the wooden door, leading to a large courtyard area behind the dementia care unit. The courtyard was observed enclosed by a white vinyl fence approximately 8 feet tall. Several exit signs were observed along the vinyl fence with signs pointing to an exit door, which lead to a small parking area, a sidewalk, and 4 lane street outside of the facility grounds. The RM stated the fence door is secured with an electromagnetic locking device and can be opened with the keypad. The keypad was moved from the inside of the courtyard to the outside of the courtyard, so staff do not have to go through the dementia care unit to gain access to the courtyard behind the dementia care unit. An interview was conducted on 12/18/2023 at 1:13 PM with the NHA, DON, and RM. The RM stated on 11/27/2023 around 4:30 PM, Resident #1 was not able to be located on the dementia care unit. Staff E, Certified Nursing Assistant (CNA) was working as Eagle Eye staff on the unit for the 3 PM to 11 PM shift and reported to Staff F, LPN UM she was not able to locate Resident #1 on the unit. The RM stated Eagle Eye staff are assigned to the dementia care unit to ensure the safety of the residents on the unit by visualizing the location of the resident every 15 minutes for the duration of their shift. The RM stated per Staff E, CNA's statement, Staff E, CNA noticed around 3:45 PM on 11/27/2023 Resident #1 was not located on the unit and began searching for the resident on the unit. After reporting the missing resident to Staff F, LPN UM, the dementia care unit was searched by the CNA staff and nursing staff on the unit. After not being able to locate Resident #1 on the unit, staff called a code silver, which is the code to indicate a missing resident from the facility, between 4:40 and 4:45 PM. The DON stated she reported to the dementia care unit to coordinate the code and several staff began to search for Resident #1 both inside the facility and outside of the facility, as assigned by the DON. The DON also informed local law enforcement around 5:05 PM of Resident #1 missing from the facility. The DON assigned Staff F, LPN UM to search around the local shopping mall area and drove to Resident #1's house since it was near the facility. The DON was on the phone with Staff F, LPN UM when she arrived at Resident #1's house and Resident #1's RP answered the door. Staff F, LPN UM informed the RP Resident #1 was missing from the facility and the RP stated Resident #1 was not at the house. Staff F, LPN UM continued to search the local area for Resident #1 and located the resident at a bus stop sitting on a bench around 5:30 PM. Resident #1 was brought back to the facility by Staff F, LPN UM and did not have any injuries. Resident #1 was wearing grey colored khaki pants, a grey short sleeved shirt, a blue jacket, and black shoes when he arrived back to the facility. The RM stated Resident #1 was placed on one-to-one supervision and an electronic elopement device was applied to the resident's right ankle. The RM stated Resident #1 did not have an electronic elopement device previously because he was housed on the locked dementia care unit. Resident #1 had one to one supervision until his scheduled discharge on [DATE]. The following day on 11/28/2023, the RM, NHA, and maintenance staff did walking rounds on dementia care unit to assess how Resident #1 eloped from the facility. The RM stated the wooden gate for the enclosed porch outside of the dementia care unit was observed to be open and unlocked. The RM also stated their investigation revealed a correlation between the time Resident #1 eloped and the time outside lawn workers performed lawn care for the courtyard behind the dementia care unit, which was typically on Mondays between 3:00 PM and 3:30 PM. The RM stated per interview with Staff G, Maintenance, the staff member went through the dementia care unit around 3:15 PM to the back courtyard area and through the locked glass door. Staff G, Maintenance unlocked the wooden gate to the enclosed porch behind the dementia care unit and left it open due to not being able to lock the door from the outside. Staff G, Maintenance opened the white vinyl gate to allow lawn care workers into the courtyard behind the dementia care unit and left the door propped open for approximately 30 minutes. The RM stated the investigation revealed Resident #1 followed Staff G, Maintenance off the unit and onto the enclosed porch without the staff member's knowledge, before exiting the porch and exiting the courtyard to the sidewalk outside of the facility. The RM stated since the elopement occurred, the facility removed the button behind the nurse's station on the dementia care unit which allowed nursing staff to open the door to the unit. Nursing staff must enter a code on the keypad to deactivate the magnetic lock on the door to allow visitors and staff to exit the unit. A contact alarm was added to the exit doors on the unit, which were previously located inside of the unit. This was implemented to ensure staff turn around to deactivate the alarm, which will further ensure no resident is trailing behind them when they exit the unit. The RM stated contact alarms, or stop alarms, were added to the exit doors on the dementia care unit leading out to the enclosed patio and courtyard behind the unit. The DON stated all residents in the facility were re-evaluated for elopement risk and those residents determined at risk for elopement will have an electronic elopement device, including those residents on the dementia care unit. The DON also stated facility staff have been educated on the proper procedure for shift-to-shift walking rounds and staff must visualize the resident at the time of their report, which is also verified by the nurse. The DON stated all codes for the doors in the facility equipped with an electromagnetic lock were changed to ensure no residents have access to the codes. A review of the facility policy titled Risk Management/Nursing Policies - Elopement Risk, with no effective date, revealed under the section titled Policy an elopement risk evaluation is completed as a part of screening upon admission. All residents will be evaluated for elopement risk upon admission, quarterly, and with a change in condition. The policy also stated under the section titled Procedure if the resident is identified as an elopement risk based on the evaluation, a care plan will be developed to reduce elopement risk. Facility staff will provide supervision and engage the resident as needed to minimize wandering or exit seeking behavior according to the plan of care. A review of Resident #1's Pre-admission Care Needs assessment, dated 11/25/2023, revealed under the section titled Mental Status, Resident #1 was confused and an Elopement Risk. The assessment also revealed, under the section titled Behavior Patterns Resident #1 had a history of elopement. A review of Resident #1's Pre/Post admission Elopement Risk Evaluation, dated 11/25/2023, revealed Resident #1 had a history of wandering or elopement, exit seeking behavior, confusion/dementia, and a resident or family home nearby. A review of Resident #1's Progress Notes dated 10/21/2023 at 12:14 PM and authored by Staff F, Licensed Practical Nurse (LPN) and Unit Manager (UM), [Resident #1] has expressed the desire to leave on multiple occasions and was constantly looking for an exit. Redirected without much success. An interview was conducted on 12/18/2023 at 2:03 PM with Staff F, LPN UM, who was Resident #1's assigned nurse for the 7 AM to 7 PM shift on 11/27/2023. Staff F, LPN UM stated she was Resident #1's assigned nurse on 11/27/2023 for the 7:00 AM to 7:00 PM shift. Staff F, LPN UM also stated Resident #1 often expressed he wanted to go home, told staff his brother was waiting outside for him, and asked staff how he could get out of the facility, but was easily re-directed by staff on the dementia care unit. Staff F, LPN UM stated Resident #1 was an elopement risk before being admitted to the facility and his RP placed several locks on the doors of his home to prevent him from eloping from the house. Staff F, LPN UM stated prior to Resident #1's elopement, she saw the resident between 2:15 PM and 2:30 PM by the unit nurse's station walking in the unit halls. Staff F, LPN UM also stated around 4:00 PM, Staff E, CNA and Staff H, CNA told her Resident #1 was missing from the unit and the staff members already searched the unit for the resident. Staff F, LPN UM and the dementia care unit staff searched the unit one more time for Resident #1, including the courtyard and activity areas, without success. Staff F, LPN UM called a code silver and other facility staff reported to the unit to assist in locating Resident #1. Facility staff searched throughout the facility and surrounding areas. Staff F, LPN UM stated she went toward Resident #1's home because he previously stated he wanted to go home, and the resident lived close to the facility. Staff F, LPN UM arrived at Resident #1's home and spoke with the RP, who stated the resident was not at the house. Staff F, LPN UM informed the RP Resident #1 was missing from the facility and local law enforcement was aware. After leaving Resident #1's home, Staff F, LPN UM got into her car and searched areas closer to the facility grounds. Staff F, LPN UM found Resident #1 sitting at a bus stop in front of a local restaurant. Staff F, LPN UM took Resident #1 by the hand and assisted him into her vehicle before driving him back to the facility. Resident #1 was assessed and had no injuries because of the elopement. Resident #1 was taken by staff to the unit dining room for dinner. Resident #1 was placed on one-to-one supervision until he was discharged on 12/1/2023. Staff F, LPN UM stated the CNA staff were not conducting shift to shift reporting properly and they have since reinforced the requirement of conducting a head count of the residents before and after each shift. An interview was conducted on 12/18/2023 at 2:33 PM with Staff C, CNA, who was Resident #1's assigned CNA on 11/27/2023 during the 7 AM to 3 PM shift. Staff C, CNA stated 11/27/2023 was the first day she was assigned care for Resident #1, and she was not very familiar with his behaviors. Staff C, CNA also stated Resident #1 had expressed a desire to leave during the 7 AM to 3 PM shift because his brother was waiting for him by the back door. Resident #1 was also pushing on the door but was easily re-directed to another area of the unit. Staff C, CNA stated she informed the Eagle Eye staff of Resident #1's attempts and desires to leave the unit but did not inform the nurse on duty, Staff F, LPN UM. Staff C, CNA stated the last time she saw Resident #1 on the unit on 11/27/2023 was around 3:00 PM while he was walking back and forth through the unit hallways. Staff C, CNA stated upon ending her shift, she gave a verbal report to Staff I, CNA for the 3 PM to 11 PM shift but did walking rounds to ensure all the assigned residents were present on the unit. Staff C, CNA also stated she had not been working as a CNA for very long and she was not aware they needed to visually check on the residents as part of her shift to shift rounds and she did not visualize the residents before leaving the unit around 3:35 PM. Staff C, CNA stated she did not include Resident #1's desire to leave the unit or attempts to open the doors to the unit in her report to Staff I, CNA and only stated to keep an eye on him. Staff C, CNA stated they must complete a form during their shift-to-shift rounds to verify the presence of the residents on the unit and verify placement of any electronic elopement devices on the residents, which is a process they did not have in place prior to Resident #1's elopement. A review of the facility policy titled Risk Management - Missing Resident and Elopement, with no effective date, revealed under the section titled Policy elopement occurs when a resident who needs supervision leaves a safe area without supervision. If any resident should leave the premises at any time without following the facility procedure for voluntary leave, the missing resident/elopement procedure should begin immediately. The policy also revealed under the section titled Procedure it is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as possible. An interview was conducted on 12/18/2023 at 3:23 PM with Staff E, CNA and Staff J, CNA. Staff J, CNA stated she worked as an Eagle Eye on the dementia care unit on 11/27/2023 during the 7 AM to 3 PM shift. Staff J, CNA also stated the Eagle Eye's role is to check every resident on the unit every 15 minutes to ensure the resident is safe and care needs are met. Staff J, CNA stated Resident #1 would normally wander around the unit hallways throughout the day and at one point told her he needed to leave because his brother was waiting for him outside. Resident #1 was easily re-directed by staff. Staff J, CNA stated she last saw Resident #1 on the unit around 2:45 PM while the resident was wandering the unit hallways. Staff E, CNA relieved Staff J, CNA for the 3 PM to 11 PM shift. Staff H, CNA was also supposed to work as an Eagle Eye for the 3 PM to 11 PM shift but was about 30 minutes late for her shift, leaving only Staff E, CNA. Staff E, CNA stated on 11/27/2023 she was assigned the opposite side of the hallway and Staff H, CNA was assigned the other side of the hallway where Resident #1 resided. Staff E, CNA also stated she conducted a report with Staff J, CNA, but did not conduct a head count or visualize all the residents on the unit as part of her shift-to-shift report. Staff E, CNA stated when she came on the unit around 3 PM, she conducted safety rounds on her assigned residents, which took about 10 or 15 minutes. Staff E, CNA then conducted rounds on the side of the hall Resident #1 was on and did not see the resident on the unit. Staff E, CNA stated a Bingo activity was being conducted on another unit of the facility and she assumed Resident #1 was at the activity, but she did not verify Resident #1 was at the activity. Staff E, CNA continued to look for Resident #1 on the unit until Staff H, CNA came to the unit around 3:30 PM and assisted in locating Resident #1. Staff E, CNA stated around 3:30 or 4 PM, she went to another unit where the Bingo activity was taking place to see if Resident #1 was at the activity. After verifying Resident #1 was not at the activity, Staff E, CNA informed Staff F, LPN UM around 4:00 PM, Resident #1 was missing. Staff F, LPN UM called a code silver and facility staff searched around the facility and facility ground attempting to find Resident #1. Staff E, CNA stated she searched the entire outside perimeter of the facility but was not able to locate Resident #1. Resident #1 was located by Staff F, LPN UM and was placed on one-to-one supervision upon his return. Staff E, CNA and Staff J, CNA were not able to state why they did not perform a head count of the residents on the dementia care unit during their shift-to-shift report. A review of the facility procedure titled Eagle Eye Observation Program, with no effective date, revealed there will be a CNA observer for the whole unit on 7:00 AM to 3:00 PM, 2 CNA observers, one for each hallway on 3:00 PM to 11:00 PM, and one CNA observer for the whole unit for the 11 PM to 7 AM shift. The procedure also revealed during those periods, the staff member will be responsible for the following monitoring: - Walk the halls, checking each room and common areas to include the solarium. This will occur throughout the eight-hour shift every 15 minutes. - During this time the staff members will be observing the following potential occurrences to promote proactive intervention and ensures resident safety: Preventing unusual occurrences, assist residents with activities, prevent residents from falling, prevent conflict between residents, redirects residents out of another resident's room, check each room for patient needs every 15 minutes, and prevent potential elopement. - Any unusual situation or significant change that this staff member observes will be immediately reported to the resident's assigned nurse. A telephone interview was conducted on 12/19/2023 at 9:15 AM with Staff I, CNA, who was Resident #1's assigned CNA for the 3 PM to 11 PM shift on 11/27/2023. Staff I, CNA stated she arrived at the dementia care unit on 11/27/2023 around 3:00 PM and received a verbal report from Staff C, CNA. Staff I, CNA assisted Staff C, CNA with changing another resident in the unit shower room and continued to check on other residents in her assignment. Staff I, CNA stated she had never seen Resident #1 before and did not know to look for him on the unit because she did not know he was a resident of the facility. Staff I, CNA stated Staff E, CNA asked her where Resident #1 was and she replied, who's that? Staff I, CNA stated Staff E, CNA informed Staff F, LPN UM Resident #1 was missing from the facility and a code silver was called. Staff I, CNA stated she looked at a photo to see what Resident #1 looked like and began to assist in searching for him throughout the facility. Staff I, CNA stated Resident #1 was brought back to the facility around 5:40 PM and was brought into the facility dining room for dinner. A telephone interview was attempted on 12/19/2023 at 9:36 AM with Staff H, CNA. The phone call was not answered, and a message was left for a return call. Staff H, CNA did not return the phone call. A telephone interview was conducted on 12/19/2023 at 10:40 AM with Resident #1's responsible party (RP). The RP stated Resident #1 was initially admitted to the facility for a short-term respite stay of 5 days and required placement on the dementia care unit due to his history of dementia and poor short-term memory. The resident had a 5-day respite stay at the facility sometime in October, then again in November. The RP also stated Resident #1 required assistance at home with finding the bedroom and the bathroom and the doors in the house were deadbolted due to the resident wanting to exit the house and stating he needed to go to work. The RP stated Resident #1 had poor safety awareness and would often walk in the middle of the parking lot when they would go to the store together and required frequent redirection and reorientation to his surroundings. The RP stated on 11/27/2023 a staff member from the facility arrived at her house and told her Resident #1 was missing from the facility. The staff member asked if the resident was at the house and the RP told her Resident #1 was not at the house. The RP drove to the facility shortly after the interaction and spoke with local law enforcement at the facility. The RP stated Resident #1 was found around 5:30 PM by facility staff and was brought back to the facility. The RP also stated Resident #1 had an electronic elopement device placed on his body and was provided with increased supervision until he was discharged on 12/1/2023. A telephone interview was attempted on 12/19/2023 at 11:53 AM with Staff G, Maintenance. The phone call was not answered, and a message was left for a return call. Staff G, Maintenance did not return the phone call. A telephone interview was conducted on 12/19/2023 at 4:20 PM with the facility's Medical Director (MD). The MD stated Resident #1 was at the facility for a short-term respite stay and resided on the dementia care unit. The MD also stated Resident #1 was not well known by the facility staff because he was only there for a short time, and he was informed of Resident #1's elopement on 11/27/2023 by the RM. The MD stated he was not very familiar with Resident #1 but did discuss the resident's elopement with the Interdisciplinary Team (IDT) to discuss elopement prevention, keeping track of the resident head count more frequently, and having every resident always accounted for. Facility's immediate actions to remove the Immediate Jeopardy included: - Full body sweep and evaluation for injury on Resident #1, completed on 11/27/2023 upon return to the facility. - CNAs assigned to resident for 7:00 AM - 5:30 PM on 11/27/2023 were suspended 11/27/2023. - Completed new elopement evaluations on all residents starting with Resident #1, update care plans and care guide as needed, completed on 11/28/2023. - All staff working on the dementia care unit on 11/27/23 from 7:00 AM to 5:30 PM were interviewed on 11/30/2023. - Complete elopement drills on each shift one to include the weekend and then twice a month on rotating shifts and including the weekend. Elopement drills were completed on 11/28/2023, 11/30/2023, and 12/3/2023. - Have all doors and alarm system devices were checked for functioning. Batteries to all alarm systems checked and a system of routine changing was put into place to prevent battery issues. On 11/27/2023 the NHA, Maintenance, and RM verified all doors were functioning as they should. Locks were replaced on the dementia care unit dining room, key entry, and key exit. Alarms on the dementia care unit doors removed from inside of the unit and placed on the outside of the unit. The door latch release behind the unit nurse's station was removed. Red exit door alarms placed on all exit doors for added notification. Completed on 11/28/2023. - 100% of all staff were educated on elopement response expectations, process/responsibilities, and reporting. Education completed on 12/5/2023. - Competency for all nurses on checking wander management device functioning. Education was conducted on responsibility to apply, notify, and care plan when evaluating residents who are at risk. Completed 12/15/2023. - 100% of all nursing staff were educated on walking rounds for report from shift to shift and rounding on their assigned residents at least every 2 hours. Completed 12/5/2023. - 100% of nurses were educated on completing the elopement evaluation and putting interventions into place. If a resident is cognitively impaired, staff should attempt to attain information from the family related to the elopement evaluation. Completed on 11/30/2023. - Nurse management or designee audited shift to shift walking reports being completed randomly between each shift one time a week. Audits began 11/28/2023, and were completed on 11/30/2023, 12/4/2023, 12/5/2023, 12/6/2023, 12/8/2023, 12/12/2023, 12/14/2023, 12/15/2023, and 12/18/2023. - All elopement books were audited for accuracy and maintenance on 11/28/2023. Verification of the facility's removal actions was conducted by the survey team on 12/20/2023. Review of facility education was conducted. Staff roster provided by NHA and DON. 306 total staff members, 1 on administrative leave. 305 total staff members were educated related to abuse, neglect, and exploitation, el[TRUNCATED]