**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's staff and interdisciplinary team (IDT) neglected to identify, communicate, and provide necessary care and services to ensure the safety of a resident who wandered; neglected to respond to a missing resident in a timely and efficient manner; and failed to recognize and address an unsecured area as an environmental hazard to prevent a vulnerable, cognitively impaired resident from exiting the facility, for 1 of 4 residents reviewed for elopement, out of a total sample of 32 residents, (#25). These failures contributed to the elopement of resident #25 and placed her at risk for serious injury/impairment/death. While resident #25 was out of the facility unsupervised, there was a likelihood she could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On [DATE] at approximately 8:30 AM, resident #25 left the [NAME] Wing dining room and walked away from the unit. Along the way, the resident informed another resident's private caregiver that her ride did not show up, so she would walk home. Facility staff did not notice the resident as she wandered along the hallway or redirect her when she opened a door that led to the courtyard. The resident crossed the courtyard, opened the latch on an unlocked gate, and walked away from the property at approximately 8:38 AM. Resident #25 headed towards the heavily trafficked road in front of the facility, flagged down a passing car, and asked the driver to take her to the high school. The unknown person drove the resident to a high school located over three miles away, left her there, then called 911 to request a wellness check due to concerns about the resident's cognitive status. Meanwhile, at the facility, the private caregiver informed a staff member that resident #25 verbalized her intent to leave and was no longer present in the vicinity of the [NAME] Wing. The staff member disregarded the information and did not alert nursing staff or attempt to locate the resident. Resident #25's assigned nurse discovered she was missing at approximately 9:15 AM and staff initiated a search of the building and its surroundings. The facility was not aware of resident #25's whereabouts until approximately 10:00 AM when law enforcement contacted the resident's son, who retrieved his mother from the high school and returned her to the facility. The facility's failure to implement policies and procedures to prevent neglect, maintain a secure environment, and respond appropriately to a report regarding a missing resident placed all residents who wandered and/or had access to the courtyard at risk. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F607, F641, F656, F689, and F835. Review of the medical record revealed resident #25 was an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, dementia, insomnia, and anxiety. Resident #25's admission Wandering/Elopement Risk Assessment dated [DATE], revealed she was cognitively impaired, independently ambulatory, and verbalized her intent to leave the facility. The assessment form included a recommendation to initiate a care plan to address the identified risk factors for elopement; however, the document showed no care plan was developed at that time. Review of the facility's policy and procedure Wandering and Elopements (undated) revealed the facility would identify residents at risk for unsafe wandering. The document read, If identified to be at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of resident #25's medical record from [DATE] to [DATE] revealed nursing notes that described the resident as confused, wandering, and requiring frequent redirection. Three days after admission, a Daily Skilled Note dated [DATE] indicated nursing staff deemed it necessary to place an electronic monitoring device on the resident to address her behaviors. The medical record revealed resident #25's behaviors escalated over the next two days. A Daily Skilled Note dated [DATE] revealed the resident was anxious and confused as she wandered throughout the facility. She repeatedly verbalized her intent to leave and successfully managed to open an emergency exit door. On [DATE], resident #25's assigned nurse noted she continuously wandered around the unit and informed staff she wanted to leave the facility and go home. A Clinical Note dated [DATE], two weeks after the electronic monitoring device was placed, revealed resident #25 eloped from the facility. The Minimum Data Set (MDS) admission assessment with assessment reference date of [DATE] revealed resident #25 was admitted to the facility from the community. Her Brief Interview for Mental Status Score was 4 out of 10 which indicated severe cognitive impairment. In conflict with nursing progress notes, the MDS assessment showed the resident had no behavioral symptoms and did not wander or use a wander alarm. The document indicated it was very important to the resident to have her family involved in discussions regarding her care. Review of the medical record revealed resident #25 had a care plan for elopement risk related to exit seeking behavior initiated on [DATE] at the time her electronic monitoring device was placed. The care plan goal was the resident would not have any successful elopement attempts. The interventions developed on [DATE] were to update elopement manuals with the resident's information, encourage activities of choice, and check the placement and function of her left ankle electronic monitoring device. The care plan did not incorporate any person-centered approaches that reflected IDT collaboration and input from the resident's family. In addition, the document did not provide instructions for direct care staff regarding effective approaches to address the resident's wandering and exit-seeking behaviors. On [DATE] at 1:21 PM, the MDS Coordinator stated she attended daily clinical meetings with other members of the IDT. She explained the team discussed new admissions, new physician orders, incidents, and any other issues that affected residents. The MDS Coordinator stated the IDT would develop appropriate care plans and interventions to meet residents' needs based on the discussions. She stated in addition to the IDT process, a care plan meeting was held with each resident and/or a representative two to three weeks after admission, to identify any additional areas of concern or necessary services. The MDS Coordinator stated resident #25's care plan meeting was not held prior to her elopement. She validated the resident's elopement care plan with basic interventions were created on [DATE], the day she had the electronic monitoring device placed. The MDS Coordinator acknowledged the care plan did not show evidence of review or revisions by the IDT prior to her elopement to ensure the resident received care and services for her escalating behaviors. In interviews on [DATE] at 1:30 PM and [DATE] at 9:49 AM, the Director of Nursing (DON) confirmed resident #25 had an electronic monitoring device applied on her fourth day in the facility as she was ambulatory and wandered. The DON confirmed the facility's IDT process included daily meetings to review residents' status, changes in condition, and care needs. She said, I was not aware of [the resident's] nighttime agitation and wandering. The DON acknowledged the IDT process therefore did not effectively identify or address the care and services required for resident #25. She confirmed resident #25 eloped from the facility on [DATE] by accessing the courtyard. She stated the resident wore an electronic monitoring device but there were no sensors at either the door to the courtyard or the gate. The DON explained the gate had a latch, but was never locked, and resident #25 quickly opened it and left the premises. The DON stated the incident investigation indicated another resident's private caregiver notified an Activity Department staff member that the resident stated she was leaving the facility. The DON explained the staff member did not inform anyone or initiate a search for the resident, but resumed her regular activities. The DON stated when the resident's assigned nurse noted she was missing at approximately 9:15 AM, all staff stopped what they were doing and searched the premises. She stated the facility followed policies and procedures by notifying the resident's family and law enforcement. The DON recalled resident #25's son and daughter arrived soon after being called, and she thought the Administrator notified law enforcement within 20 to 30 minutes after the resident was discovered to be missing. The facility was not able to show law enforcement had been notified by the Administrator. When asked what the facility's policy indicated regarding timeframe for notification of law enforcement, she explained there was no specific time period, and staff were to complete a search of the premises including the nine-story independent living facility next door first. The DON said, I believe the policy states a thorough search prior to call. She acknowledged while the cognitively impaired resident was outside the facility, she faced many potential safety hazards. The DON listed dangers that included a busy road, unleveled ground, traffic from the nearby neighborhood and schools, a construction site, woods, and a swimming pool. She stated a deputy sheriff responded to a call from dispatch regarding a wellness check request made by a concerned citizen who had picked up resident #25 at an unknown location and dropped her off at a high school. The DON stated the resident's son received a call from the deputy at approximately 10:00 AM, left to retrieve his mother, and the deputy followed them back to the facility. She recalled the deputy instructed her if the facility was ever again unable to find a resident, staff should call for assistance immediately. Review of the facility's Procedures for an Elopement/Missing Resident (undated) revealed instructions to check the sign out log for evidence of authorized leave of absence, and then make a thorough search of the building and premises. The document indicated if the resident was not located, staff would notify the Administrator, DON, Risk Manager, the resident's representative, the attending physician, and law enforcement before continuing .an extensive search of the surrounding area. The attached document, Elopement Drill Instructions (undated) revealed details regarding assigned locations to be searched by designated staff. The search included all areas of the facility, including the Assisted Living Facility. Two maintenance staff were directed to .walk the entire perimeter of the entire campus, going in opposite directions. The document did not reference the nearby eleven-story independent living facility, nor instruct staff to delay law enforcement notification until that building was searched. Review of the staff assignment sheet for Monday [DATE], noted resident #25's assigned Certified Nursing Assistant (CNA) for the 7:00 AM to 3:00 PM shift was CNA L. However, on [DATE] at 2:57 PM, CNA L stated she did not work on [DATE] and heard about resident #25's elopement on the following day when she returned to work. CNA L recalled someone told her CNA G was assigned to care for resident #25. On [DATE] at 3:04 PM, CNA G explained she usually worked on the 3:00 PM to 11:00 PM shift and on occasion, she would pick up a 7:00 AM to 3:00 PM shift, but usually arrived at 8:30 AM. CNA G recalled on [DATE] she was seated in the [NAME] Wing dining room assisting a resident with breakfast and saw resident #25 eating at another table. CNA G said. I am not sure I was on [resident #25's] hallway that morning. She was finishing up breakfast and next thing they said they did not see her, and we started to look for her. CNA G could not recall how many CNAs were assigned to the unit on that shift, and when asked who monitored her assigned residents from the start of the shift at 7:00 AM until 8:30 AM when she arrived, she said, Everybody gives an eye on the team until I get here. CNA G did not recall any interaction with resident #25 prior to seeing her in the dining room and could not state with certainty that she was actually assigned to the resident on the morning she eloped from the facility. On [DATE] at approximately 6:00 PM, the Staffing Coordinator provided a revised staff assignment sheet dated [DATE] which had been corrected to show CNA L did not work, and CNA G was assigned to care for resident #25. In response to multiple requests, the facility was unable to provide timeclock punch times for all CNAs who worked on the [NAME] Wing on [DATE] on the day shift. The facility provided a Payroll Punch Variance Form for CNA G. The form indicated CNA G worked from 7:00 AM to 7:15 PM, and in the comment section she wrote, No time clock. When asked to clarify the discrepancy between her earlier statement and the variance form, CNA G stated she forgot she started the day shift at 7:00 AM on [DATE]. On [DATE] at 8:47 AM, the private caregiver explained she worked in the facility six days weekly and was familiar with many of the residents, including resident #25. She stated the resident was usually confused and described her as kind of antsy on the morning she eloped. The private caregiver said, I saw her walking past the door.That day she looked like she was on a mission. She recalled resident #25 told her she had to get a ride or walk home and then headed towards the front lobby. The private caregiver stated she was worried the resident would try to go out the front door so after a while, she walked to the lobby to check on the resident's location. She stated resident #25 was not in the lobby, and the receptionist was on the telephone. She recalled Activity Aide K was working at a board in the lobby and she told her resident #25 said she was going home. The private caregiver stated Activity Aide K denied seeing the resident and continued working at the board. The private caregiver stated she then walked towards the therapy gym and on the way she asked two or three other staff members if they had seen the resident. She recalled she eventually heard an overhead page Code Purple which she was told meant there was a missing resident. On [DATE] at 2:39 PM, Activity Aide K recalled the morning resident #25 eloped. She confirmed she was in the lobby posting the activity calendar and decorating the notice board. She confirmed the private caregiver approached her and told her resident #25 was confused and said she wanted to go home. Activity Aide K said, I am doing my stuff and I did not see her. I don't know where she went through. She had confusion at times and often says she wants to home. I didn't really pay attention and I continued on doing what I was doing. Activity Aide K stated she did not report the information to the nurse as she had to finish decorating the activity board. On [DATE] at 12:40 PM, during a tour of the facility with the Maintenance Supervisor, he explained there were sensors for the electronic monitoring system at the front lobby door and the double doors in the hallway that led to the therapy gym. He explained alarms sounded when the sensors were triggered but the doors did not lock, so a resident with an electronic monitoring device could walk through the doors unimpeded. Demonstration of the electronic monitoring system revealed the alarms sounded only at the keypad at a low volume. He stated there were doors on two separate hallways that led into the courtyard, but neither had a sensor to alert staff if residents with monitoring devices exited the building. The Maintenance Supervisor explained prior to resident #25's elopement, residents, visitors, and staff had unlimited access to the courtyard. He verified the gate at the far end of the courtyard had a vertical pull latch that was never locked. On [DATE] at 2:02 PM, the Social Services Director (SSD) confirmed resident #25 was confused, alert to self only, and regularly wandered around the facility searching for her deceased mother and father. The SSD explained the resident was admitted to the facility for long-term care as she was no longer safe living in the community and required 24-hour care. The SSD verified she participated in discussions about residents during daily IDT meetings and was also responsible for completion of MDS assessment sections related to cognitive status and behavioral symptoms such as wandering. She acknowledged the MDS assessment did not accurately show resident #25's status and exit-seeking behaviors, and her elopement care plan did not reflect details of the care and services to be provided by the facility. On [DATE] at 10:41 AM, in a telephone interview with resident #25's daughter, she confirmed on the day of admission, the DON asked if her mother wandered. The daughter said, I told her she had gotten out twice when she had a urinary tract infection. She would unlock the gate by sticking her hand through it. The daughter explained her mother left her house and walked to a neighbor's house and had to be brought back home. She stated the family even had to block the front door to prevent her mother from getting out. Resident #25's daughter reiterated the facility was aware of her mother's wandering, agitation, and desire to leave. She explained during the weeks that preceded the elopement, the facility called several times to inform her that her mother was agitated and verbalized wanting to leave and go somewhere. The facility's policy and procedure Abuse Neglect Exploitation Mistreatment and Misappropriation of Property dated [DATE] revealed it was the policy of the facility to protect its residents from neglect. The document defined 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. The Facility Assessment Tool dated [DATE], revealed the facility was able to care for residents with impaired cognition, depression, anxiety disorder, behaviors that required interventions, Alzheimer's Disease, and dementia. The document indicated the facility would provide person-centered care by preventing abuse and neglect and identify hazards and risks for residents. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE], resident #25 eloped from the facility at approximately 8:39 AM. The facility initiated a search, and the resident was not found on the premises. She was located by law enforcement and returned to the facility at approximately 10:14 AM. On return, the resident was immediately assessed by the Nurse Practitioner, noted to have no injuries or abnormalities, and was placed on one-to-one supervision. *On [DATE], the facility obtained an estimate to add magnet/code alarms to the doors that did not currently have electronic monitoring system sensors/alarms in place. The installation date was scheduled for [DATE]. *On [DATE] at approximately 10:30 AM, a staff member was placed at both emergency exits without electronic monitoring system alarms for 24 hours. *As of [DATE] at approximately 6:00 PM, all the doors in the facility that did not have the electronic monitoring system alarm were armed with an emergency screamer alarm with a key override. The alarms were checked every two hours to ensure they were in place and functioned. All electronic monitoring devices are checked every shift for placement and functioning. All residents, regardless of cognitive status will have a staff member accompany them when spending time in the courtyard. Every two hours the courtyard gate is checked to ensure that it remains locked. *On [DATE], the Staff Development Coordinator initiated an in-service to cover Abuse, Neglect, and Reporting Abuse and/or Neglect; and notification to management if a resident begins to seek an exit or express a desire to leave the facility. In-services were also conducted covering the elopement policy, procedure, and prevention. A total of 97% of the staff were in-serviced by [DATE]. *On [DATE], an emergency Quality Assurance and Performance Improvement (QAPI) committee meeting was held to address the identified non-compliance. *As of [DATE], the DON sends the Corporate Nursing team the projected staffing hours every morning to ensure adequate staff was scheduled to care for the residents. *On [DATE], the Corporate Nurse Consultant assessed the knowledge of the management team regarding abuse, neglect, elopement, risk management, and reporting specific incidents to specific agencies. The Corporate Nurse Consultant educated the management team on Elopement Prevention, Risk Management, Adverse Incidents, and Reporting. *On [DATE], the Corporate Nurse Consultant gave instruction on how to conduct, and reviewed the Standards of Care Meeting with the interdisciplinary team. In this weekly meeting, run by the DON, all residents who are potentially at risk for any type of decline, have recently had a change in condition, or been involved in any type of incident are discussed to ensure their needs are anticipated and being met. *As of [DATE], the Nurse Management Team assesses the residents in the facility and completes an acuity report. This report breaks down specific needs and explains how many residents in the facility require that specific type of care. The Corporate team, and the management team utilize the weekly acuity report in conjunction with the daily staffing hours to ensure there is adequate staff in relation to the acuity of the residents. *On [DATE], the Corporate Nurse Consultant observed the care of residents provided by all direct care staff throughout the facility for all shifts. The Corporate Nurse Consultant spoke with multiple direct care staff to ensure they were able to adequately care for the current residents. *On [DATE], the Corporate Nurse Consultant visited multiple patient rooms, spoke with them about the care they received, and reviewed multiple charts to assess whether resident's needs were being met. *As of [DATE], safety checks were conducted on each resident at risk for elopement. *On [DATE], the QAPI committee held an emergency meeting on [DATE] to address the identified noncompliance with F600. *On [DATE], all cognitively intact residents were interviewed by the management team and asked the following questions: a) Have you ever been treated in a way that you feel was abusive by the staff? b) Have you felt neglected by any member of the staff? c) Has anyone spoken to you in way that was verbally abusive? d) Do you feel safe in this facility? e) Do you feel there is adequate staff here at all times to meet your needs? *On [DATE], a questionnaire was initiated for staff in the facility, asking the following: a) Have you been educated on Abuse, and Neglect? b) If you have been, approximately when was the last time? c) Do you feel that you are knowledgeable about what is expected of you here at work? d) Do you feel that you have everything you need to provide the care that is required of you? e) Do you feel that all the residents are appropriate for this environment and that their needs can be met by the staff? f) Do you feel that there is adequate staff present during all shifts to meet the resident's need? *On [DATE], responses to the above questions were reviewed with no findings of any residents who felt neglected by the staff. All staff members reported they were recently educated on neglect and abuse and could meet the needs of the residents in their care. *As of [DATE], all residents regardless of their cognitive status will have a staff member accompany them into the courtyard. Review of Courtyard Gate Lock Check forms from [DATE] to [DATE] revealed staff completed gate checks with varying frequencies, between every two hours to every six hours. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on the topics listed above. On [DATE], interviews were conducted with five Licensed Practical Nurses, three CNAs, one Personal Care Attendant, two Rehab staff, one Activities staff, one maintenance staff and one housekeeper. All verbalized understanding of the education provided. The resident sample was expanded to include three additional residents who were at risk for elopement. Observations, interviews, and record reviews revealed no concerns for residents #11, #12, and #19 related to neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring of the status and activities of a vulnerable, cognitively impaired resident to prevent unsupervised exit from the facility through an unmonitored courtyard for 1 of 4 residents reviewed for elopement, out of a total sample of 32 residents, (#25). This failure contributed to the elopement of resident #25 and placed her at risk for serious injury/impairment/death. While resident #25 was out of the facility unsupervised, there was a likelihood she could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On [DATE] at approximately 8:30 AM, resident #25 left the [NAME] Wing dining room and walked away from the unit. Along the way, the resident informed another resident's private caregiver that her ride did not show up, so she would walk home. Facility staff did not notice the resident as she wandered along the hallway or redirect her when she opened a door that led to the courtyard. The resident crossed the courtyard, opened the latch on an unlocked gate, and walked away from the property at approximately 8:38 AM. Resident #25 headed towards the heavily trafficked road in front of the facility, flagged down a passing car, and asked the driver to take her to the high school. The unknown person drove the resident to a high school located over three miles away, left her there, then called 911 to request a wellness check due to concerns about the resident's cognitive status. Meanwhile, at the facility, the private caregiver informed a staff member that resident #25 verbalized her intent to leave and was no longer present in the vicinity of the [NAME] Wing. The staff member disregarded the information and did not alert nursing staff or attempt to locate the resident. Resident #25's assigned nurse discovered she was missing at approximately 9:15 AM and staff initiated a search of the building and its surroundings. The facility was not aware of resident #25's whereabouts until approximately 10:00 AM when law enforcement contacted the resident's son, who retrieved his mother from the high school and returned her to the facility. The facility's failure to provide the appropriate level of supervision and frequency of monitoring for a resident with known exit-seeking behavior contributed to resident #25's elopement and placed all residents who wandered at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on [DATE] and was removed on [DATE]. Findings: Cross reference F600, F607, F641, F656, and F835. Review of the medical record revealed resident #25 was an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, dementia, insomnia, and anxiety. Review of a Wandering/Elopement Risk Assessment dated [DATE], revealed on admission, nursing staff identified resident #25 was at risk for elopement as she was cognitively impaired, independently ambulatory, and verbalized her intent to leave the facility. Although the assessment form included a recommendation to initiate an elopement care plan to address the identified risk factors for elopement, the admission nurse did not follow the instruction, and resident #25's plan of care did not include approaches to ensure her safety. Review of the facility's policy and procedure Wandering and Elopements (undated) revealed the facility would identify residents at risk for unsafe wandering. The document read, If identified to be at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of resident #25's medical record revealed a physician's order dated [DATE] that read, May go on leave with responsible party. An order dated [DATE] indicated the resident could be treated by a psychologist, and an order dated [DATE] read, Electronic monitoring device to alert staff of residents risk for exit seeking behavior, check placement on left ankle [every shift]. Resident #25 had a care plan for elopement risk related to exit seeking behavior initiated on [DATE] at the time her electronic monitoring device was placed. The care plan goal was the resident would not have any successful elopement attempts. The interventions developed on [DATE] were to update elopement manuals with the resident's information, encourage activities of choice, and check placement and function of her left ankle electronic monitoring device. The care plan did not specify the level of supervision or frequency of monitoring required, nor provide instructions on approaches to ensure the resident's safety during periods of heightened behaviors. Review of a Daily Skilled Note dated [DATE] revealed the resident was anxious and confused as she wandered throughout the facility, repeatedly verbalized her intent to leave, and successfully managed to open an emergency exit door. Review of the medical record revealed neither the progress notes nor the elopement care plan reflected additional, effective nursing interventions related to verbalization of intent to elope and the actual elopement attempt. The medical record did not show involvement of nursing management or the determination that resident #25 required increased supervision or more frequent monitoring when wandering or exit-seeking. The following day, on [DATE], resident #25's assigned nurse noted she continuously wandered around the unit and informed staff she wanted to leave the facility to go home. Review of a clinical nursing note dated [DATE] revealed resident #25's assigned nurse, Registered Nurse (RN) F, observed the resident in the [NAME] Wing dining room at approximately 8:30 AM that morning. The note indicated RN F discovered the resident was missing approximately 30 to 45 minutes later, and a search of the facility was initiated. The document revealed resident #25 was found away from the facility, and she was retrieved and returned to her room at about 10:30 AM. The elopement care plan was revised on [DATE], after the resident's elopement, to show she required one-to-one supervision. Review of resident #25's Physical Therapy Plan of Treatment for Rehabilitation dated [DATE] revealed the resident exhibited decreased safety awareness, decreased bilateral lower extremity strength, and impaired overall mobility. The evaluation indicated resident #25 was at increased risk of falls and injury due to decreased awareness of her physical limitations. A Speech Therapy Plan of Treatment for Rehabilitation dated [DATE] revealed the reason for the referral was long-term care placement .due to increasing confusion from Alzheimer's disease resulting in a functional decline in cognitive skills, safety awareness. On [DATE] at 12:13 PM, Speech Therapist O validated resident #25 did not have the reasoning ability to function in the community. She explained the resident would not be safe unsupervised, whether in the facility, at home or outside the facility. Speech Therapist O said, If she was discharged home, our recommendation would be 24-hour care. Review of a Psychiatric Evaluation Note dated [DATE] revealed facility staff informed the Psychiatric Nurse Practitioner that resident #25 was confused, wandered the hallways, and was an elopement risk. A Brief Interview for Mental Status exam resulted in a score of five, which indicated severe cognitive impairment. A Psychiatric Subsequent Note dated [DATE] revealed clinical staff reported the resident continued with confusion and anxiety and paced the halls. During the visit, the resident reported the year was 1958, and the practitioner noted the resident had disorganized thought process and loose associations. Review of a Sheriff's Office Case Report revealed a Deputy Sheriff responded to a report of a suspicious person at a local high school on [DATE] at 9:15 AM. The document indicated the involved party was resident #25 who was described as confused and disoriented. The Deputy Sheriff wrote, She advised she needed to get to school, or she would be late for class. She was convinced that she was a student in school. The report revealed resident #25 was initially seen by a citizen in the area of a nearby middle school and she solicited a ride to the high school. The report indicated the citizen was concerned and called law enforcement to report the encounter. The Deputy Sheriff noted he was able to contact resident #25's son by telephone, and the son explained his mother had severe dementia and was a resident of the facility. The document revealed the resident's son arrived on scene to transport his mother back to the facility. On [DATE] at 9:35 AM, in a telephone interview, the Deputy Sheriff confirmed he received the initial call for service on [DATE] at 9:15 AM, and responded to the local high school. He stated he learned resident #25 left the facility and walked along the main road in front of the facility and was picked up by a citizen. The Deputy Sheriff stated when he questioned resident #25, she thought she was in Ohio, but was able to provide her name and he was eventually able to find telephone contact information for her son. The deputy stated the son came to the high school to collect his mother and he followed them back to the facility. He stated facility administration informed him new owners had taken over that morning so there was a lot of activity. He said, I confirmed that the Director of Nursing (DON) was there from the previous administration. In the end, I expressed to them there was too much reliance on technology, and it cannot supersede human supervision. He explained although resident #25 wore an electronic monitoring device, it was not a foolproof intervention. The Deputy Sheriff stated there was a pool at the Independent Living facility next door which could be a danger to a confused, wandering resident. He explained he informed the DON that memory care services required a secure facility and adequate supervision. When informed resident #25 had verbalized her intent to leave the facility for weeks and even on the morning she eloped, the Deputy Sheriff said, I told them there are major issues. A predictable event is preventable. On [DATE] at 1:09 PM, in a telephone interview, resident #25's son stated he was aware his mother eloped from the facility on [DATE]. He said, All I know is she got out and wandered up the road. She got three miles away. They picked her up by the high school. He explained his mother lived in her own home prior to admission to the facility in [DATE]. The son stated the family decided to place her at the facility as there was no one at home to supervise her during the day and she also suffered extreme anxiety when left alone. The son confirmed his mother had wandered to a neighbor's home in the past. On [DATE] at 1:30 PM, the DON confirmed resident #25 eloped from the facility on [DATE] and was found by law enforcement at a local high school. The DON explained although resident #25 had an electronic monitoring device, there was no sensor with an alarm at the exit door to the courtyard and the gate was not locked. She stated the resident was last seen in the [NAME] Wing dining room by multiple Certified Nursing Assistants (CNAs) and another resident's private caregiver at about 8:30 AM. The DON stated resident #25 left the dining room, informed the private caregiver she was leaving the facility, and the private caregiver shared that information with Activity Aide K. The DON acknowledged Activity Aide K did not act on the report and returned to her duties. Review of staff statements with the DON revealed none of the CNAs on the [NAME] Wing were aware resident #25 left the unit until the assigned nurse noticed she was missing approximately 30 to 45 minutes later. The DON stated the facility notified the resident's family that their mother was missing and when the son arrived he was upset, asked how it happened, and said, This is why we brought her here. On [DATE] at 3:04 PM, CNA G stated on the day resident #25 eloped she last saw her in the [NAME] Wing dining room at approximately 8:30 AM. CNA G did not recall if she was assigned to care for the resident that day and she was not aware resident #25 was missing until an overhead page alerted all staff to search for her. CNA G recalled when resident #25 was returned to the facility, her jeans were wet, almost to her knees. She said, If she went through the ditch, that's probably why. We had rain a few days. On [DATE] at 2:02 PM and 3:30 PM, the Social Services Director (SSD) confirmed resident #25 was confused, had memory deficit, and often wandered throughout the facility searching for her deceased mother and father. The SSD explained the resident was admitted for long-term care and would not be safe in the community without 24-hour care. She said, Once we accept new residents we have to meet their needs. On [DATE] at 1:11 PM, the Maintenance Supervisor described resident #25's elopement route. He stated security camera footage showed the resident pushed on the [NAME] Wing hallway exit doors to the courtyard, followed the path to the far end of the courtyard, unlatched the gate and walked away, out of camera range. The Maintenance Supervisor demonstrated how resident #25 would have easily been able to reach through the bars on the gate and release the latch located at waist-level. He stated the elopement occurred a few days after a hurricane brought between nine and fourteen inches of rainfall to the area. The Maintenance Supervisor said, There was a lot of standing water for a while. He stated water in the [NAME] in front of the facility was above ankle-deep, and there was a deeper drainage ditch and culvert on the opposite side of the street. Review of the area map revealed resident #25 walked away from the facility towards the south, and followed the heavily trafficked, major thoroughfare for approximately 0.5 miles until she arrived at the middle school. There was no sidewalk on that side of the road, and she would have crossed a driveway, passed a heavily wooded area, and walked through standing water of unknown depths along the uneven terrain. The resident was picked up by a citizen who drove her approximately 3.5 miles to the high school which was located near a major intersection and a six-lane highway (retrieved on [DATE] from www.google.com/maps). On [DATE] at 5:20 PM, RN F stated she was resident #25's assigned nurse on the day she eloped. She recalled she saw the resident eating breakfast and approximately 30 to 45 minutes later she realized the resident was nowhere to be found. RN F stated the resident would often ask about the location of the front door or where she could get a taxi or the bus. She explained staff would try to redirect her, but that strategy was not usually very effective. RN F explained the electronic monitoring device was in place to prevent elopement and was checked by nurses every shift. She stated she had not yet checked the resident's device when she eloped. RN F said, I knew she had to be watched, absolutely. On [DATE] at 9:49 AM, the DON stated resident #25's family did not inform the facility she had exit-seeking behavior prior to admission. However, she acknowledged within four days of admission, the facility identified the resident was at risk for elopement and placed an electronic monitoring device, an intervention to promote her safety. The DON was informed the medical record included frequent nursing documentation after placement of the device related to the resident's behaviors such as wandering, exit-seeking, and verbalizing her intent to leave the facility. She stated she was not aware of the extent and impact of resident #25's behaviors, especially the nighttime agitation and wandering, and acknowledged the care plan did not show additional interventions including increased supervision were discussed by nursing management. On [DATE] at 10:41 AM, in a telephone interview, resident #25's daughter stated on the day of admission, she informed the DON her mother had wandered away from home on two occasions in the past. She stated her mother was definitely not safe during the period she was out of the facility unsupervised. She said, It was days after the hurricane and there was water ankle-deep to waist-deep outside the facility. The daughter recalled when her mother was found she wore canvas slip-on shoes with low-cut socks, and her jeans were wet to the knees. She stated she was concerned as her mother could not swim. On return to the facility, the daughter noted and informed staff that her mother had a loose ankle bracelet. The resident's daughter recalled her mother informed her she had been trying to remove the device the previous day. The Facility Assessment Tool dated [DATE] revealed the facility was able to care for residents with impaired cognition, Alzheimer's Disease, dementia, depression, anxiety, and behaviors that required interventions. The document indicated staff received mandatory dementia management training and were competent in caring for residents Alzheimer's Disease and other dementias. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE], resident #25 eloped from the facility through the courtyard gate at approximately 8:39 AM. The facility initiated a search, and the resident was not found on the premises. She was located by law enforcement and returned to the facility at approximately 10:14 AM. On return, the resident was immediately assessed by the Nurse Practitioner, and there were no injuries or abnormalities. Resident #25 was immediately placed on one-to-one supervision. *On [DATE], the facility completed a facility-wide re-assessment of each resident's risk for elopement. All residents deemed to be at risk were provided with an electronic monitoring device to alert staff of resident's risk of exit seeking. The residents deemed to be at risk for elopement had care plans updated to reflect this assessment. No additional residents were determined to have exit seeking behaviors or made statements in reference to leaving facility. All residents deemed to be at risk for elopement, receive safety checks every 15 minutes to ensure they are safely in the facility. * As of [DATE], upon admission, all residents will be assessed to determine their elopement risk. Residents identified to be at risk for elopement will be provided with an electronic monitoring device, and an elopement risk care plan, and will receive safety checks every 15 minutes to ensure that they are still safely in the facility. *On [DATE], the facility obtained an estimate to add magnet/code alarms to the doors that did not currently have electronic monitoring system sensors/alarms in place. The installation date was scheduled for [DATE]. *On [DATE] at approximately 10:30 AM, a staff member was placed at both emergency exits without electronic monitoring system alarms for 24 hours. *As of [DATE] at approximately 6:00 PM, all the doors in the facility that did not have the electronic monitoring system alarm were armed with an emergency screamer alarm with a key override. The alarms were checked every two hours to ensure they were in place and functioned. All electronic monitoring devices are checked every shift for placement and functioning. All residents, regardless of cognitive status will have a staff member accompany them when spending time in the courtyard. Every two hours the courtyard gate is checked to ensure that it remains locked. *On [DATE], the Staff Development Coordinator initiated an in-service to cover elopement prevention, electronic monitoring alarm system, screamer alarm system, courtyard supervision, monitoring of residents who are at risk for elopement; and notifying management of residents who are exit-seeking, and those that express a desire to leave the facility. A total of 97% of the staff were in-serviced by [DATE]. *On [DATE], an emergency Quality Assurance and Performance Improvement (QAPI) committee meeting was held to address the identified non-compliance. * As of [DATE], safety checks are conducted on each resident at risk for elopement. *On [DATE], the QAPI committee held an emergency meeting on [DATE] to address the identified noncompliance with F689. Review of Courtyard Gate Lock Check forms from [DATE] to [DATE] revealed staff completed gate checks with varying frequencies, between every two hours to six hours. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on the topics listed above. On [DATE], interviews were conducted with five LPNs, three CNAs, one Personal Care Attendant, two Rehab staff, one Activities staff, one maintenance staff and one housekeeper. All verbalized understanding of the education provided. The resident sample was expanded to include three additional residents who were at risk for elopement. Observations, interviews, and record reviews revealed no concerns for residents #11, #12, and #19 related to supervision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's administration failed to effectively utilize its resources to mitigate vulnerabilities in the electronic wander monitoring system; failed to maintain a secure environment to prohibit unauthorized entry and egress through the courtyard; and failed to oversee the implementation of policies and procedures and interdisciplinary team (IDT) processes to ensure the safety of 5 of 5 physically and/or cognitively impaired residents identified to be at risk for elopement, of a total sample of 32 residents, (#11, #12, #14, #19 & #25). These failures contributed to the elopement of resident #25 and placed her at risk for serious injury/impairment/death. While resident #25 was out of the facility unsupervised, there was likelihood she could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On 10/03/22 at approximately 8:30 AM, resident #25 left the [NAME] Wing dining room and walked away from the unit. Along the way, the resident informed another resident's private caregiver that her ride did not show up, so she would walk home. Facility staff did not notice the resident as she wandered along the hallway or redirect her when she opened a door that led to the courtyard. The resident crossed the courtyard, opened the latch on an unlocked gate, and walked away from the property at approximately 8:38 AM. Resident #25 headed towards the heavily trafficked road in front of the facility, flagged down a passing car, and asked the driver to take her to the high school. The unknown person drove the resident to a high school located over three miles away, left her there, then called 911 to request a wellness check due to concerns about the resident's cognitive status. Meanwhile, at the facility, the private caregiver informed a staff member that resident #25 verbalized her intent to leave and was no longer present in the vicinity of the [NAME] Wing. The staff member disregarded the information and did not alert nursing staff or attempt to locate the resident and instead, returned to her duties. Resident #25's assigned nurse discovered she was missing at approximately 9:15 AM and staff initiated a search of the building and its surroundings. The facility was not aware of resident #25's whereabouts until approximately 10:00 AM when law enforcement contacted the resident's son, who retrieved his mother from the high school and returned her to the facility. The facility's failure to maintain a safe and secure environment and implement policies and procedures to prevent neglect and elopement placed all residents who wandered and/or had access to the courtyard at risk. This failure resulted in Immediate Jeopardy starting on 10/03/22. The Immediate Jeopardy was removed on 11/09/22. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F600, F607, F641, F656, and F689. Review of the medical record revealed resident #25 was an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, dementia, insomnia, and anxiety. On 11/07/22 at 1:30 PM, the facility's Administrator and Director of Nursing (DON) confirmed resident #25 eloped from the facility on 10/03/22. The DON stated the incident investigation identified the root cause as a weak link in facility security related to the absence of electronic monitoring system sensors at the courtyard doors and an unlocked gate. The Administrator and DON could not provide documentation of an investigation with a focus on identification and prohibition of Neglect according to regulatory requirements and facility policy and procedure. The Administrator acknowledged the facility took actions to secure the courtyard after the elopement occurred. On 11/09/22 at 12:21 PM, the Administrator explained he did not have access to the reporting system required for submission of investigations related to allegations of abuse and neglect although he was the facility's designated Risk Manager. Review of the facility's policy and procedure Abuse Prevention Program revised in July 2020, indicated the facility would identify and assess all possible incidents of abuse, neglect, or mistreatment. The document revealed the Administrator was responsible for overall implementation of the policies and procedures that prohibited neglect. Review of the facility's policy and procedure for Wandering and Elopements revised in December 2020 revealed the facility would identify residents who were at risk for wandering and elopement and develop appropriate strategies and interventions to maintain safety. Review of the facility's policy and procedure Care Plans, Comprehensive Person-Centered revised in November 2020 revealed the Interdisciplinary Team (IDT) was responsible for review and revision of residents' care plans when the desired outcome is not met. On 11/09/22 at 9:49 AM, the DON stated she was not made aware of the concerns related to resident #25's continuous, escalating wandering and exit-seeking behaviors in IDT meetings. The DON confirmed the IDT conducted daily meetings and group huddle meetings prior to the resident's elopement. She validated the IDT discussion process was not as effective as it should have been. On 11/09/22 at 11:33 AM, the Medical Records staff stated she attended daily IDT meetings during which orders and incidents were reviewed. She confirmed information related to issues such as placement of resident #25's electronic monitoring device, her increased behaviors, and elopement attempts should be discussed. When asked about the effectiveness of IDT meeting discussions, the Medical Records staff said, Sometimes there are lots of side conversations. On 11/07/22 at 2:08 PM, the Administrator retraced the resident's elopement route through the courtyard. He acknowledged prior to the event; the facility's administration was aware there were no sensors for the electronic monitoring system at the courtyard doors to alert staff that residents with these devices had exited the building. Observation of the exterior exit gate revealed standing A-frame sign boards that measured approximately three feet from the ground on both sides of the gate. The signs had instructions regarding not using the gate for entry or egress. The Administrator moved the signs and unlatched the gate. He stated the gate was never locked as it was a fire exit, but the new security system would enable the gate to be locked and automatically open if the fire alarm triggered. The Administrator acknowledged the gate remained an unsecured point of entry and exit. On 11/08/22 at 12:40 PM, the Maintenance Supervisor demonstrated and acknowledged weaknesses in the facility's electronic monitoring system included protected doors did not lock to prevent exit when the alarm was triggered; alarms sounded from the keypads and were not audible in other areas of the facility such as nurses' stations; and the system was not installed at the doors that led to the courtyard. The Maintenance Supervisor explained he had been on staff for over seven years, and during that time the courtyard doors never had alarms, and the gate was always unlocked. He confirmed prior to resident #25's elopement, residents, visitors, and staff had unlimited access to the courtyard. Review of the medical records revealed concerns related to placement of electronic monitoring devices on wheelchairs rather than on the residents' extremities. Resident #11 had a physician's order dated 7/25/22 for an electronic monitoring device to his wheelchair. Resident #12 had a physician's order dated 9/20/22 for an electronic monitoring device to be attached to his wheelchair and resident #19 had an order dated 9/19/19 for a device on her wheelchair. On 11/08/22 at approximately 5:30 PM, the Administrator, DON, and Corporate Nurse were informed that review of physician orders revealed some residents had electronic monitoring devices placed on their extremities and others had the devices placed on their wheelchairs. They were unaware of any manufacturer's recommendations regarding placement of the monitoring devices. Review of the electronic monitoring system manufacturer's instructions revealed the device was to be worn on either the wrist or ankle. The User Guide read, The range, accuracy, function, and performance. of the device may be affected by factors including metal objects in the vicinity and placement of the device. On 11/09/22 at 4:14 PM, the Staff Development Coordinator (SDC) stated she had been on staff for almost six years and was never made aware of the manufacturer's recommendations regarding placement of electronic monitoring devices. The SDC stated after the administrative team was questioned about the different locations of residents' devices, they reviewed the manufacturer's manual and discovered the device must be placed on the resident and not on wheelchairs. On 11/09/22 at 4:23 PM, the Administrator stated the facility's Quality Assurance and Performance Improvement (QAPI) committee met once monthly to review of quality measures, grievances and customer service issues, Resident Council meeting minutes, and other key indicators. The Administrator stated in addition to the monthly QAPI meetings, the IDT reviewed issues that impacted resident care and services including changes in resident status in daily morning meetings and huddle meetings. He explained the QAPI committee also received information from employees by way of concerns reported to a supervisor or in town hall meetings, staff meetings and departmental meetings. The Administrator stated prior to resident #25's elopement, the facility's administration was aware the courtyard gate was unlocked, and that the electronic monitoring system did not trigger doors to lock in response to wandering and elopement attempts. He explained, No [resident] had gone in and out of the back gate until that resident left. The Administrator confirmed the IDT, administrative team, and QAPI committee had not identified concerns related to person-centered care plans. The Facility Assessment Tool dated 11/19/21, revealed the facility would provide person-centered care by identifying hazards and risks for residents. The assessment listed physical environment and building needs but did not include the electronic monitoring system or the courtyard fencing and gate. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/03/22, resident #25 eloped from the facility through the courtyard gate at approximately 8:39 AM. The facility initiated a search, and the resident was not found on the premises. She was located by law enforcement and returned to the facility at approximately 10:14 AM. On return, the resident was immediately assessed by the Nurse Practitioner, and there were no injuries or abnormalities. Resident #25 was immediately placed on one-to-one supervision. *On 10/03/22, the facility obtained an estimate to add magnet/code alarms to the doors that did not currently have electronic monitoring system sensors/alarms in place. The installation date was scheduled for 11/10/22. *On 10/04/22, the Nurse Consultant of Education educated the management team on Elopement Prevention, Risk Management, and Adverse Incidents. *As of 10/03/22, upon admission, all residents will be assessed to determine their elopement risk. Residents identified to be at risk for elopement will be provided with an electronic monitoring device, and an elopement risk care plan. *On 10/03/22, the DON conducted an Elopement drill to obtain a baseline and assess for weakness in following the protocol. *As of 10/03/22, elopement drills will be conducted monthly on a different shift each month. Each shift will have an elopement drill at least once every quarter. * On 10/04/22, an Emergency QAPI committee meeting was held to address the identified non-compliance. *On 10/18/22, another elopement drill was conducted to assess improvement after education. *On 11/08/22, the user manual for the Wander guard system was reviewed to ensure that all components are being utilized as intended. *On 11/08/22, the QAPI committee held an emergency meeting to address the identified noncompliance with F835. Review of in-service attendance sheets revealed management staff signatures to reflect participation in education on the topics listed above, and staff signatures for participation in elopement drills. The resident sample was expanded to include three additional residents who were at risk for elopement. Observations, interviews, and record reviews were conducted for residents #11, #12, and #19 revealed concerns related to placement of their electronic monitoring devices.