**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed and interviews, the facility failed to provide adequate supervision to ensure residents' safety for one out of 3 sampled residents (Resident #1). As evidenced by, on 03/30/2025 Resident #1 left the facility undetected at approximately 12:45 PM, boarded a city bus and was found 8 hours later by law enforcement. The resident was located 5.2 miles away from the facility. The areas where the facility and where the resident was located are in high traffic areas and there were cross streets which could lead to the increased risk of the resident being hit by an automobile, falling, or being assaulted and/or being robbed based on his vulnerability and cognitive impairment. According to website, Accuweather.com on 03/30/2025 the temperature ranged between 72 degrees Fahrenheit (F) to 86 degrees (F) with scattered showers. It was determined that this deficient practice posed an Immediate Jeopardy (IJ) situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) started on 03/30/2025 and was determined to be Past Noncompliance effective 04/06/2025 based on the corrective actions implemented by the facility. The findings included: Observation on 04/07/2025 at 3:34 PM, revealed Resident#1 in his room watching television and responded to his name. A wander alert system bracelet was observed on his right wrist. On 04/08/2025 at 8:40 AM, Resident #1 was standing in the hallway beside his room. Resident # 1 was asked about leaving the facility he laughed and stated, me again never and laughed. On 04/09/2025 at 10:20 AM, Resident #1 was speaking with the surveyors and staff alternating in English and Spanish; Resident #1 was asked how he left the facility that Sunday; he responded in Spanish, bus dosciendos (meaning bus 215). Clinical record review revealed, Resident #1 was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Acute respiratory failure Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], the Cognitive section documented a Brief Interview of Mental Status (BIMS) score of 4 out of 15 meaning, Resident #1 had severe cognitive impairment. The Functional status section revealed, Resident #1 requires assistance with all Activities of Daily Living (ADLs) and for Bowel and Bladder status the resident is incontinent of Bladder. Record review revealed a Health Status Note dated 03/30/2025 time stamped 13:50 (1:50 PM); The note text documented: Approximately around 12:45 PM CNA (Certified Nursing Assistant) alerted the nurse the resident's lunch tray was in the room and the resident was not there. The Nurse began searching for the resident in the unit and a facility search was done. The Nurse notified the supervisor and other floors. Review of the Health Status Note dated 3/30/2025 and timestamped 14:00 (2:00 PM) indicated the Note Text documented: The Nurse alerted the supervisor at 13:09 (1:09 PM) that she went to serve the residents lunch, and he was not seen. A complete facility search was done including facility grounds. A Code [NAME] (Code when a resident is missing) was called. Law enforcement was notified, the guardian was called, and the residents MD (Medical Doctor) notified. A voicemail message was left for the guardian. 911 was called and the call was transferred to the non-emergency number. Review of Health Status Note created by Staff CC, RN 3- 11 nurse dated 3/30/2025 and timestamped 15:30 (3:30 PM), the Note Text documented: The shift report was received and the outgoing nurse informed [3-11 nurse] that the resident was not at the facility and that they had begun a search process following established protocols. Review of Health Status Note dated 3/30/2025 at 22:25 (10:25 PM) by the Nursing Supervisor indicated: Two police officers came to facility and met with the staff. They did an internal and external facility search and provided a case number. All area hospitals were called and staff visited two area hospital emergency rooms. The Guardianship Program was called, and the emergency guardianship number was called, and message was left. A Police Detective [name and badge] from [local law enforcement] located resident and called the facility to inform the facility that resident was found. Staff from the facility were dispatched to pick up the resident. Upon arriving, a complete nursing assessment was conducted .There were no neurological deficits noted as compared to the previous assessments, bruises observed to right knee [Physician Assistant] notified. A Psych consult was done, the resident was placed on 1:1 and monitoring was initiated. A message was left for Guardian Program. The resident was given shower, and a warm dinner was served. Close monitoring maintained. During an interview on 04/07/25 at 6:54 PM, the [NAME] President of Clinical Services revealed, there were a lot of visitors that Sunday who were signing in and out and the resident may have followed one of the visitors that were leaving. At lunch time when the CNAs went to place his lunch, they realized he was gone. After the incident occurred, all residents in the facility were screened, and wander management system bracelets were ordered and put in place for the residents that triggered for an elopement risk. During an interview on 04/07/2025 at 7:49 PM, Staff K, Registered Nurse (RN) and 3-11 shift Supervisor that was on duty at the time of the incident revealed: When I came, they told me about the elopement, and I went in my car and searched with the police outside and did a deep search. The police told us if they found him, they would call. [local area law enforcement] called a little after 8:00 PM and the resident was returned to the facility. The resident was okay, we did a full assessment and the resident he was okay. During an interview on 04/07/2025 at 7:55 PM, Staff CC, RN from 3-11 shift stated: When I arrived the off going nurse told me they were searching for the resident around 8:00 PM. The supervisor told me the resident was found, and the supervisor [Staff DD, an RN and 7-3 shift supervisor] took him back to the facility and I did a complete assessment. He was confused, he had no injuries, just a bruise on his right knee and he was fine. We put the [wander alert system] bracelet on his wrist and started at 1:1 staff monitoring and he is doing better. During an interview on 04/08/25 at 8:41 AM, Staff BB, Licensed Practical Nurse (LPN) revealed, He is alert and oriented to his name, but he is confused. He did not show any behaviors that he wanted to leave. That day at around 12:45 PM, I was doing Accu checks, it was lunch time, and the CNAs told me when they were passing trays at around 12:45 PM he was not in his room, so I told everybody, and we all started looking for him and we did Code Green. Everybody started looking for the resident and I printed face sheets so that everybody could identify the resident. After that the Administrator was in the building. We searched inside and out, and some staff went to look in the parking lot and, in their cars, also around the neighborhood while the Administrator and the Supervisor handled the rest. He did not miss any medications on my shift. I was in the building until he came back. He was talking in Spanish; he had a bruise on his right knee but looked fine. The nurse on duty did the assessment and I was there. He did not miss any medications on my shift. During an interview on 04/08/2025 at 9:05 AM, Staff AA, the CNA that was assigned to Resident # 1 on the date of the incident stated: That day in the morning after breakfast I gave him a shower in the morning at around 11:05 AM; I put him back in the room and I told him sit there while I went to take care of two other residents. He usually stays in his room and watch TV(Television). When I went back after I finished with the other two residents, I did not see him in the room and went to pass the lunch trays. He was not in the room for his lunch tray. At around 12:49 PM I told the nurse he was not in his room. We continued to search everywhere in the facility and outside. It was also raining at the time. The nurse called and told DON (Director of Nursing), ADON (Assistant Director of Nursing) and the Administrator to let them know what happened and they came right away. We continued to search, and they called the police and hospitals after all this time. The [ADON] told me I could go home before it got too dark. I told the oncoming CNA. I talked to the police when I was at the facility. I have no idea how he left the facility because usually after I give him a shower he walks to his room. The following day he was okay. During an interview on 04/09/2025 at 10:58 AM, the Director of Nursing (DON) stated, I was out of town and received a call at approximately 1:00 PM from the facility telling me that the resident was missing, and they were looking for the resident. The Administrator called law enforcement and reported the resident was missing. I could not go with them to find the resident. I arrived in the building between 7:00 or 8:00 PM and [law enforcement] called and reported the resident was found. The DON revealed, Resident #1 was picked up by a staff member and returned to the facility and was smiling when he returned. The doctor was called, and labs and x-rays were ordered and all came back normal. He had a psych evaluation on 03/31/2025 and medications were reviewed. The resident was placed on 1:1 monitoring, we placed a [wander alert system] bracelet on his wrist and the resident was compliant with the 1:1 monitoring and additional interventions. The DON revealed steps implemented to prevent reoccurrence that included but were not limited to trainings, all resident received an elopement assessment, the codes on all doors and elevators were checked, the main entrance, the entrance for all staff, the additional doors with codes between the lobby and unit. Started 24-hour front desk coverage. Maintenance staff checked all the exit doors that day and will continue to check. During an interview on 04/09/2025 at 11:10 AM, the Maintenance Director revealed wander alert system on doors are being checked every day and all doors and keypads are checked daily. The Maintenance Director reported, I check the doors Monday to Friday and the maintenance staff checks them on Saturday and Sunday. I installed a door between the lobby to the floor and added keypads on all the doors to go in and out of the facility and the offices. I also check the code for the elevator to make sure it is working. The Maintenance Director revealed he and all his staff received elopement and abuse training. The facility took the following actions to address the elopement incident and to prevent any additional residents from suffering an adverse outcome. (Completion Date: 4/2/2025) 1. On 3/30/2021, the nurses completed a head count using the facility's census to ensure no other residents were missing. The nursing supervisor verified the count, confirming that no other residents were missing. On 3/31/2025, the resident was reevaluated by the psychiatrist and new orders were received. On 3/31/2025, reeducation regarding the prevention of elopement was initiated for the 7-3 staff by the Director of Nurses (DON). By 4/2/2025, all nursing staff on all shifts received education from the Staff Development, Director of Nursing (DON), or their designees regarding residents who exhibit exit-seeking behavior, the risk of elopement, and the need for adequate supervision to ensure resident safety. This education aimed to prevent serious injury, harm, impairment, or death. Any staff on leave were to receive education on their next scheduled workday. By 4/2/2025, the Unit Managers, supervisors, and/or designee(s) and/or MDS Coordinator(s) re-evaluated residents at risk for elopement by completing a new elopement risk screening form. By 4/2/2025, the MDS Coordinator and/or designee reviewed and updated the care plans of the residents at risk for elopement to reflect the current elopement risk. By 4/2/2025, Nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee(s). Any staff on leave will receive education prior to returning to their shift. A Root Cause analysis was completed using the Five Whys to develop new approaches to prevent reoccurrence. The Facility conducted an AdHoc Quality Assurance Meeting on 3-31-2025 to review the Performance Improvement Plan ensuring proper interventions are put in place. The facility conducted an elopement drill every shift X 3 days, then weekly X 4 weeks, then monthly X 3 Months. 2. Facility Actions to Prevent Occurrence/Recurrence: Staff were re-educated on the Elopement and wandering, exit seeking resident policy. The staff will follow the policy to ensure safety measures are implemented. By 4/2/2025 the DON, ADON, and designee completed elopement risk screening on active residents and reviewed their plan of care to ensure appropriate interventions are in place, and the plan of care was updated to reflect the evaluation and modification of interventions that are in place. After the facility wide audit of the elopement screenings, the facility identified 4 new residents that triggered for elopement risk. Residents triggered for at risk for elopement have orders for a [wander alert system] to be put in place. Orders were obtained from the physician for psych reevaluation for residents triggered for elopement risk. The elopement book was updated with new pictures of residents triggered for elopement risk. Elevator keypads installed on the elevators by the Elevator Company. A keypad/alarm installed at the door leading to the lobby by the alarm company. Elopement drills are done monthly on every shift. The Maintenance Director or designee to conduct Safety rounds Log to check exit door, screamer alarms and outside gates daily. Residents with new behaviors of exit seeking and wandering will be added to the elopement risk book that is kept at the nursing station and is accessible to all staff. The behaviors will be added to the resident's care plan and the [NAME]. Nursing staff will communicate during the shift to shift report any resident who exhibits behaviors to leave the facility, and the safety measures put into place. The nurses and nursing supervisors will use the facility census to conduct the headcount of the residents in their respective unit during shift change and they will sign the census to validate that the count is correct, and all residents are accounted for. The CNAs will conduct rounds every two hours to ensure the residents are safe and accounted for. CNAs will report to the nurse immediately if unable to locate a resident. Facility protocols for missing residents will be used immediately to locate the residents. New admissions elopement evaluations will be reviewed during clinical meetings held Monday through Friday to ensure elopement interventions are in place for residents that are at risk and the facility guidelines are followed. Nursing Supervisors will review the new admissions elopement evaluation on the weekend for compliance. The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. Residents with new behaviors of wandering, exit seeking will be reassessed by the ADON, Unit Managers, Supervisors or designee for a risk for elopement. The DON, Administrator, ADON and/or designee will enforce disciplinary action for facility staff who fail to follow the elopement policy and procedures. New hires will receive education on wandering, elopement, and resident safety by the DON, ADON or designee(s). 3. Facility Implementation: Education Target goal is 100% By 4/2/2025, the DON and ADON reeducated a total of 268 employees on the facility's policy & procedures as it is related to elopement and residents' safety. The facility achieved 100% compliance. By 4/2/2025, a total of 232 staff members had participated in the elopement drills. Facility compliance was 86.56 percent. Dates of the Elopement Drills included: Total staff participation on 3/31/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift- 40% compliance. On 4/1/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift - 71.26 % compliance. On 4/2/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift - 86.56 % compliance. As of 4/2/2025, the total staff who participated was 232 employees, which is 86.56 % On 4/9/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift-90 employees participated (only 20 employees participated for the first time). The Total staff that participated in the elopement drill: from 3/31/2025 to 4/9/2025 is a total of 252 employees which is 94%. The facility has 16 more employees who need to participate in the elopement drills. Elopement Drills will be conducted upon their return to work. On 4/2/2025, 4/4/2025, 4/7/2025 & 4/10/2025, all elopement elements put into place were verified and the facility is 100% compliance. By 4/1/2025, after the facility wide audit of the elopement screening, the facility identified 4 new residents who triggered for elopement. On 4/7/2025 a QAPI (Quality Assurance and Performance Improvement) review for follow-up was done, all the elements were verified, and facility was 100% compliance. Quality Assurance: The facility will conduct an elopement drill weekly X 4 weeks, then monthly X 3 Months. The DON, ADON, and administrator will review weekly X 4 weeks then monthly, the clinical record of any residents with behaviors of exit seeking and wandering to ensure the facility policy and procedures are implemented and followed, and residents have remained safe at the facility. Review the findings during the monthly QAPI meeting. After completing the facility wide audit the DON, ADON/designee will conduct a weekly quality review of 10 residents on each unit weekly x 4 weeks, and then every 2 weeks x 2 months. The findings of these reviews will be reported in the next Risk Management/QA Committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring by the Regional Director of Clinical Services when completing their quality systems review. The committee reviewed the plan and determined the removal plan has been implemented effectively. Facility Compliance Rate: 100% The facility's corrective actions were verified by the survey team based on staff interviews conducted on all shifts and departments indicating all-action plans had been implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility's administration failed to ensure effective systems were in place to provide adequate supervision for one out of three sampled residents (Resident #1). As evidenced by, on 03/30/2025 Resident #1 left the facility undetected at approximately 12:45 PM, boarded a city bus and was found 8 hours later by law enforcement. The resident was located 5.2 miles away from the facility. The facility and the area that the resident was located are both in high traffic areas with cross streets which could lead to the increased risk of the resident being hit by an automobile, falling, or being assaulted and/or being robbed based on his vulnerability and cognitive impairment. According to website, Accuweather.com on 03/30/2025 the temperature ranged between 72 degrees Fahrenheit (F) to 86 degrees (F) with scattered showers. It was determined that this deficient practice posed an Immediate Jeopardy (IJ) situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) started on 03/30/2025 and was determined to be Past Noncompliance effective 04/06/2025 based on the corrective actions implemented by the facility. The findings include: Observation on 04/07/2025 at 1:20 PM, the receptionist granted access to guests entering and leaving the facility are required to sign in and out. A new door was noted with a code between the lobby area with a staff member seated at the inner hallway to grant access. The conference room assigned for the survey team also required a code to enter. Record review of the job description titled, Administrator documented: The primary purpose of this position is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern nursing facilities to ensure that the highest degree of quality care can be always provided to residents. Plan, develop, organize, implement, evaluate and direct the facility's programs and activities in accordance with guidelines issued by the governing body. Delegate a responsible staff member to act on your behalf when you are absent from the facility. Ensure that each resident receives necessary care and services to attain and maintain the highest practical physical, mental and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care .Ensure the facility and resident environment remain as free of accidents as possible and that each resident receives adequate supervision and assistive devices to prevent accidents, including identifying and analyzing hazards and risks, implementing interventions and monitoring the effectiveness of those interventions when necessary. Clinical record review revealed, Resident #1 was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Acute respiratory failure Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], the Cognitive section documented a Brief Interview of Mental Status (BIMS) score of 4 out of 15 meaning, Resident #1 had severe cognitive impairment. The Functional status section revealed, Resident #1 requires assistance with all Activities of Daily Living (ADLs) and for Bowel and Bladder status the resident is incontinent of Bladder. Record review revealed a Health Status Note dated 03/30/2025 time stamped 13:50 (1:50 PM); The note text documented: Approximately around 12:45 PM CNA (Certified Nursing Assistant) alerted the nurse the resident's lunch tray was in the room and the resident was not there. The Nurse began searching for the resident in the unit and a facility search was done. The Nurse notified the supervisor and other floors. Review of the Health Status Note dated 3/30/2025 and timestamped 14:00 (2:00 PM) indicated the Note Text documented: The Nurse alerted the supervisor at 13:09 (1:09 PM) that she went to serve the residents lunch, and he was not seen. A complete facility search was done including facility grounds. A Code [NAME] (Code when a resident is missing) was called. Law enforcement was notified, the guardian was called, and the resident's MD (Medical Doctor) was notified. A voicemail message was left for the guardian. 911 was called and the call was transferred to the non-emergency number. Review of Health Status Note dated 3/30/2025 and timestamped 15:30(3:30 PM), the Note Text documented: The shift report was received and the outgoing nurse informed me that the resident was not at the facility and that they had begun a search process following established protocols. Review of Health Status Note dated 3/30/2025 at 22:25(10:25 PM) by the Nursing Supervisor indicated: Two police officers came to facility and met with the staff. They did an internal and external facility search and provided a case number. All area hospitals were called and staff visited two area hospital emergency rooms. The Guardianship Program was called, and the emergency guardianship number was called, and message was left. A Police Detective [name and badge] from [local law enforcement] located resident and called the facility to inform the facility that resident was found. Staff from the facility were dispatched to pick up the resident. Upon arriving, a complete nursing assessment was conducted, Vital Signs were obtained. There were no neurological deficits noted as compared to the previous assessments, bruises observed to right knee . [Physician Assistant] notified. The resident was placed on 1:1 and monitoring was initiated. A message was left for the Guardianship Program. The resident was given shower, and a warm dinner was served. Close monitoring maintained. During an interview on 04/07/25 at 6:54 PM, the [NAME] President of Clinical Services revealed, there were a lot of visitors that Sunday who were signing in and out and the resident may have followed one of the visitors that were leaving. At lunch time when the CNAs went to place his lunch, they realized he was gone. After the incident occurred, all residents in the facility were screened, and wander management system bracelets were ordered and put in place for the residents that triggered for an elopement risk. During an interview on 04/07/2025 at 7:49 PM, Staff K, Registered Nurse (RN) and 3-11 shift Supervisor that was on duty at the time of the incident revealed: When I came, they told me about the elopement, and I went in my car and searched with the police outside and did a deep search. The police told us if they found him, they would call. [local area law enforcement] called a little after 8:00 PM and the resident was returned to the facility. The resident was okay, we did a full assessment and the resident he was okay. During an interview on 04/07/2025 at 7:55 PM, Staff CC, RN from 3-11 shift stated: When I arrived the off going nurse told me they were searching for the resident around 8:00 PM. The supervisor told me the resident was found, and the supervisor [Staff DD, an RN and 7-3 shift supervisor] took him back to the facility and I did a complete assessment. He was confused, he had no injuries, just a bruise on his right knee and he was fine. We put the [wander alert system] bracelet on his wrist and started at 1:1 staff monitoring and he is doing better. During an interview on 04/08/25 at 8:41 AM, Staff BB, Licensed Practical Nurse (LPN) revealed, He is alert and oriented to his name, but he is confused. He did not show any behaviors that he wanted to leave. That day at around 12:45 PM, I was doing Accu checks, it was lunch time, and the CNAs told me when they were passing trays at around 12:45 PM he was not in his room, so I told everybody, and we all started looking for him and we did Code Green. Everybody started looking for the resident and I printed face sheets so that everybody could identify the resident. After that the Administrator was in the building. We searched inside and out, and some staff went to look in the parking lot and, in their cars, also around the neighborhood while the Administrator and the Supervisor handled the rest. He did not miss any medications on my shift. I was in the building until he came back. He was talking in Spanish; he had a bruise on his right knee but looked fine. The nurse on duty did the assessment and I was there. He did not miss any medications on my shift. During an interview on 04/08/2025 at 9:05 AM, Staff AA, the CNA that was assigned to Resident # 1 on the date of the incident stated: That day in the morning after breakfast I gave him a shower in the morning at around 11:05 AM; I put him back in the room and I told him sit there while I went to take care of two other residents. He usually stays in his room and watch TV(Television). When I went back after I finished with the other two residents, I did not see him in the room and went to pass the lunch trays. He was not in the room for his lunch tray. At around 12:49 PM I told the nurse he was not in his room. We continued to search everywhere in the facility and outside. It was also raining at the time. The nurse called the Director of Nursing (DON), ADON (Assistant Director of Nursing) and the Administrator to let them know what happened and they came right away. We continued to search, and they called the police and hospitals after all this time. The [ADON] told me I could go home before it got too dark. I told the oncoming CNA. I talked to the police when I was at the facility. I have no idea how he left the facility because usually after I give him a shower he walks to his room. The following day he was okay. During an interview on 04/09/2025 at 9:28 AM, the Administrator revealed the systems implemented, the identified system failure's, the completion of the root cause analysis and efforts completed to achieve compliance. During an interview on 04/09/2025 at 10:58 AM, the Director of Nursing (DON) stated, I was out of town and received a call at approximately 1:00 PM from the facility telling me that the resident was missing, and they were looking for the resident. The Administrator called law enforcement and reported the resident was missing. I could not go with them to find the resident. I arrived in the building between 7:00 or 8:00 PM and [law enforcement] called and reported the resident was found. The DON revealed, Resident #1 was picked up by a staff member and returned to the facility and was smiling when he returned. The doctor was called, and labs and x-rays were ordered and all came back normal. He had a psych evaluation on 03/31/2025 and medications were reviewed. The resident was placed on 1:1 monitoring, we placed a [wander alert system] bracelet on his wrist and the resident was compliant with the 1:1 monitoring and additional interventions. The DON revealed steps implemented to prevent reoccurrence that included but were not limited to trainings, all resident received an elopement assessment, the codes on all doors and elevators were checked, the main entrance, the entrance for all staff, the additional doors with codes between the lobby and unit. Started 24-hour front desk coverage. Maintenance staff checked all the exit doors that day and will continue to check. During an interview on 04/09/2025 at 11:10 AM, the Maintenance Director revealed the wander alert system on all doors and keypads are checked daily. The Maintenance Director reported, I check the doors Monday to Friday and the maintenance staff checks them on Saturday and Sunday. I installed a door between the lobby to the floor and added keypads on all the doors to go in and out of the facility and the offices. I also check the code for the elevator to make sure it is working. The Maintenance Director revealed he and all his staff received elopement and abuse training. The facility took the following actions to address the elopement incident and to prevent any additional residents from suffering an adverse outcome. (Completion Date: 4/2/2025) 1. On 3/30/2021, the nurses completed a head count using the facility's census to ensure no other residents were missing. The nursing supervisor verified the count, confirming that no other residents were missing. On 3/31/2025, the resident was reevaluated by the psychiatrist and new orders were received. On 3/31/2025, reeducation regarding the prevention of elopement was initiated for the 7-3 staff by the Director of Nurses (DON). By 4/2/2025, all nursing staff on all shifts received education from the Staff Development, Director of Nursing (DON), or their designees regarding residents who exhibit exit-seeking behavior, the risk of elopement, and the need for adequate supervision to ensure resident safety. This education aimed to prevent serious injury, harm, impairment, or death. Any staff on leave were to receive education on their next scheduled workday. By 4/2/2025, the Unit Managers, supervisors, and/or designee(s) and/or MDS Coordinator(s) re-evaluated residents at risk for elopement by completing a new elopement risk screening form. By 4/2/2025, the MDS Coordinator and/or designee reviewed and updated the care plans of the residents at risk for elopement to reflect the current elopement risk. By 4/2/2025, Nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee(s). Any staff on leave will receive education prior to returning to their shift. A Root Cause analysis was completed using the Five Whys to develop new approaches to prevent reoccurrence. The Facility conducted an AdHoc Quality Assurance Meeting on 3-31-2025 to review the Performance Improvement Plan ensuring proper interventions are put in place. The facility conducted an elopement drill every shift X 3 days, then weekly X 4 weeks, then monthly X 3 Months. 2. Facility Actions to Prevent Occurrence/Recurrence: Staff were re-educated on the Elopement and wandering, residents' exit seeking policy. The staff will follow the policy to ensure safety measures are implemented. By 4/2/2025 the DON, ADON, and designee completed elopement risk screening on active residents and reviewed their plan of care to ensure appropriate interventions are in place, and the plan of care was updated to reflect the evaluation and modification of interventions that are in place. After the facility wide audit of the elopement screenings, the facility identified 4 new residents that triggered for elopement risk. Residents triggered for at risk for elopement have orders for a [wander alert system] to be put in place. Orders were obtained from the physician for psych reevaluation for residents triggered for elopement risk. The elopement book was updated with new pictures of residents triggered for elopement risk. Elevator keypads installed on the elevators by the Elevator Company. A keypad/alarm installed at the door leading to the lobby by the alarm company. Elopement drills are done monthly on every shift. The Maintenance Director or designee to conduct Safety rounds Log to check exit door, screamer alarms and outside gates daily. Residents with new behaviors of exit seeking and wandering will be added to the elopement risk book that is kept at the nursing station and is accessible to all staff. The behaviors will be added to the resident's care plan and the [NAME]. Nursing staff will communicate during the shift to shift report any resident who exhibits behaviors to leave the facility, and the safety measures put into place. The nurses and nursing supervisors will use the facility census to conduct the headcount of the residents in their respective unit during shift change and they will sign the census to validate that the count is correct, and all residents are accounted for. The CNAs will conduct rounds every two hours to ensure the residents are safe and accounted for. CNAs will report to the nurse immediately if unable to locate a resident. Facility protocols for missing residents will be used immediately to locate the residents. New admissions elopement evaluations will be reviewed during clinical meetings held Monday through Friday to ensure elopement interventions are in place for residents that are at risk and the facility guidelines are followed. Nursing Supervisors will review the new admissions elopement evaluation on the weekend for compliance. The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. Residents with new behaviors of wandering, exit seeking will be reassessed by the ADON, Unit Managers, Supervisors or designee for a risk for elopement. The DON, Administrator, ADON and/or designee will enforce disciplinary action for facility staff who fail to follow the elopement policy and procedures. New hires will receive education on wandering, elopement, and resident safety by the DON, ADON or designee(s). 3. Facility Implementation: Education Target goal is 100% By 4/2/2025, the DON and ADON reeducated a total of 268 employees on the facility's policy & procedures as it is related to elopement and residents' safety. The facility achieved 100% compliance. By 4/2/2025, a total of 232 staff members had participated in the elopement drills. Facility compliance was 86.56 percent. Dates of the Elopement Drills included: Total staff participation on 3/31/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift- 40% compliance. On 4/1/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift - 71.26 % compliance. On 4/2/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift - 86.56 % compliance. As of 4/2/2025, the total staff who participated was 232 employees, which is 86.56 % On 4/9/2025: 7-3 Shift, 3-11 Shift, 11-7 Shift-90 employees participated (only 20 employees participated for the first time). The Total staff that participated in the elopement drill: from 3/31/2025 to 4/9/2025 is a total of 252 employees which is 94%. The facility has 16 more employees who need to participate in the elopement drills. Elopement Drills will be conducted upon their return to work. On 4/2/2025, 4/4/2025, 4/7/2025 & 4/10/2025, all elopement elements put into place were verified and the facility is 100% compliance. By 4/1/2025, after the facility wide audit of the elopement screening, the facility identified 4 new residents who triggered for elopement. On 4/7/2025 a QAPI (Quality Assurance and Performance Improvement) review for follow-up was done, all the elements were verified, and facility was 100% compliance. Quality Assurance: The facility will conduct an elopement drill weekly X 4 weeks, then monthly X 3 Months. The DON, ADON, and administrator will review weekly X 4 weeks then monthly, the clinical record of any residents with behaviors of exit seeking and wandering to ensure the facility policy and procedures are implemented and followed, and residents have remained safe at the facility. Review the findings during the monthly QAPI meeting. After completing the facility wide audit the DON, ADON/designee will conduct a weekly quality review of 10 residents on each unit weekly x 4 weeks, and then every 2 weeks x 2 months. The findings of these reviews will be reported in the next Risk Management/QA Committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring by the Regional Director of Clinical Services when completing their quality systems review. The committee reviewed the plan and determined the removal plan has been implemented effectively. Facility Compliance Rate: 100% The facility's corrective actions were verified by the survey team based on observations and through staff interviews that were conducted across all shifts and departments. indicating all-action plans had been implemented.