**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, clinical record review and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 7 residents reviewed for elopement risk. (Resident #1) On 3/2/23, an elopement risk evaluation form identified Resident #1, a cognitively impaired vulnerable resident, as at risk for elopement, however, no care plan for elopement risk was initiated. Resident #1 subsequently eloped from the facility on 3/11/23 unbeknownst to staff, placing the resident at risk for serious injury, harm, or death. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of J, isolated. The facility's Administrator and the Director of Nursing were notified of the findings of Immediate Jeopardy on 4/5/23 at 4:35 PM. Immediate Jeopardy was removed on 4/6/23 at 5:00 PM and the the scope and severity of the Immediate Jeopardy deficiencies was reduced from a J level to an D level. Cross reference F689 and F867 The findings include: A record review was conducted of Resident #1, which revealed the resident was originally admitted to the facility on [DATE] with diagnoses of Dementia, Psychosis, need for assistance with personal care, Type 2 Diabetes, Difficulty in walking, and muscle weakness. On 3/2/23, an elopement risk evaluation form was completed by Staff member L, a Licensed Practical Nurse (LPN). This form identified an elopement risk score of 3.0, which indicated that the resident was at risk for elopement. Further review of the elopement risk evaluation form revealed the following directions: Complete quarterly and with significant change. If the resident is deemed at risk, a prevention protocol should be initiated immediately and documented in the care plan. The following questions were included on the form: 1. Is the resident cognitively impaired? 2. Is the resident independently mobile (ambulatory or wheelchair)? 3. Does the resident have poor decision-making skills? 4. Has the resident demonstrated exit seeking behaviors? 5. Does the resident wander oblivious to safety needs? 6. Does the resident have a history of elopement? 7. Does the resident have the ability to exit the facility? 8. Based on potential risk factors above, resident is determined to be AT RISK for elopement LPN L marked Yes to questions 1 through 8. The forms states Yes, to questions 4,5 or 6 automatically place the resident AT RISK The form further stated, If it is determined that the resident has eloped, implement care plan immediately to ensure resident's safety. Report all residents AT RISK to the Director of Clinical Services and on the 24-hour report. Review of Resident #1's care plan revealed he had the potential to be aggressive in his behavior as evidenced by aggressively moving in his wheelchair throughout the hallways. Other issues include poor impulse control, plundering his roommates' personal items, eating his roommate's food, and going into others' rooms. No care plan was initiated for his elopement risk, and no interventions were put in to place to ensure the Resident #1's safety. Further review of the record revealed that Resident #1 was discharged to the hospital on 3/2/23, with a return to the facility on 3/5/23. The elopement risk evaluation was not completed for the re-admission for 3/5/23, which resulted in a care plan not being updated for elopement risk and interventions were not put in place to ensure the resident's safety. A review of the facility's investigation revealed that Resident #1 was last seen at approximately 3:30 PM in the hallway by Staff Member B, a Certified Nursing Assistant (CNA). At approximately 4:00 PM Staff Member A, a Licensed Practical Nurse (LPN), observed Staff Member D, another CNA, standing at the therapy door exit shutting off the door alarm. LPN A clocked out for the day and exited through the therapy door. LPN A reported that, when she reached the canopy area outside the building, she noticed Resident #1 propelling himself in his manual wheelchair backwards up the East driveway exit hill. LPN A called out to Resident #1, who then rolled down the hill to LPN A. The staff member returned Resident #1 to the facility nurses' station and reported the resident being found in the parking lot to LPN M and the weekend supervisor. On 4/3/23 at approximately 3:30 PM, an interview was conducted with the Director of Clinical Services (DCS) and Staff Member K, a Care Plan Coordinator. When asked why the care plan for Resident #1 was not updated on 3/2/23, Care Plan Coordinator K responded the only reason she could think of was that she did not get to his care plan by the time the resident went out to the hospital on 3/2/23. The DCS stated that when residents are gone from the facility for over 24 hours, they are considered a re-admission upon return, with new assessments completed, including an elopement risk evaluation. The DCS stated that Resident #1 should have had an elopement risk evaluation completed upon re-admission on [DATE] and could not explain why it was not completed. The DCS further stated that, if it had been completed, it would have triggered the Minimum Data Set (MDS) and care plan to be updated and the resident would have been placed in the elopement risk binders that are kept on each nurses station and the receptionist's desk at the front entrance to alert staff regarding residents who are considered elopement risks. When asked if the care plan for Resident #1 would have changed upon re-admission, Care Plan Coordinator K stated it would not have changed much unless there was a significant change in condition. Care Plan Coordinator K confirmed that the elopement risk evaluation on 3/2/23 with a score of 3.0, when the previous elopement risk evaluation dated 8/13/21 was score was a 0 (which is not considered a risk for elopement), should have triggered the care plan to have been updated. Both the DCS and Care Plan Coordinator K confirmed that Resident #1's care plan was not updated for elopement risk until 3/12/23, which is the day after the resident had exited the building into the parking lot. A review was conducted of the Policy and Procedure titled N-1031, Subject: Elopement/Wandering Risk Guidelines (effective date of 9/21/2016 last revised 8/01/2020), which stated, Overview: To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions. Process: Patient/Residents to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change in condition, and elopement event using the risk tool. If a patient/resident is identified as being at risk complete an Elopement Risk Alert and obtain a photograph. Initiate individualized interventions based on Patient/Residents' at risk. Document individualized interventions in the patient/resident Care Plan and [NAME]. Review of the Policies and Procedures document name N-1015, Subject: Plans of Care (effective date 11/30/2014 last revised 9/25/2017) revealed, Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record. Procedure: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. Develop and implement an individualized Person-Centered baseline plan of care within 48 hours of admission. Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA (Omnibus Reconciliation Act) MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial well-being. Under Note: The resident plan of care encompasses many documents that are part of the resident's clinical record including, but not limited to, structured care plan documents, MARS (Medication Administration Records), TARS (Treatment Administration Records), physician orders, flow records, and/or legal documents that would drive the plan of care for the individual resident. The Immediate Jeopardy was removed onsite on 04/06/2023 after receipt of an acceptable removal plan and verification of corrective actions. On 04/06/2023 at approximately 5:03 PM, the removal plan was verified after staff interviews to determine knowledge of elopement policy, education on the importance of completing the elopement risk evaluation on admissions and re-admissions, physician notification of change in condition with emphasis on new or increased behaviors of wandering or exit seeking and the importance of developing a care plan and implementing interventions to include the appropriate level of supervision at the time of the residents change in behavior. Interviews were conducted with 20 staff members representing all 3 shifts. All responded with confirmation of training and were able to verbalize when assessments are to be completed as well as the updating of the care plan with implementation of appropriate interventions. The training sign-in sheet was verified, along with the documentation of training covered. On 3/11/23, Resident #1's elopement evaluation and care plan were reviewed and updated. The Director of Clinical Services, Assistant Director of Clinical Services, MDS/care plan coordinators and Executive Director were educated by the Regional Director of Clinical Services on 4/04/2023 regarding the process to review admission and readmission charts for accuracy of elopement evaluations and responsibility to provide appropriate interventions and supervision for residents with wandering and exit seeking behaviors through the care planning process. On 4/6/2023, review of the education was verified, the sign-in sheet for training and the documentation of training covered were also verified. On 4/6/23, an interview with the MDS RN coordinator verified the education training. Immediately post event on 3/11/23, the facility reviewed 100% of resident records to verify current elopement assessments and care plans developed as indicated. The removal plan documented this was updated on 4/5/23 with a review of current residents admitted or readmitted since 3/11/23 to ensure an elopement risk assessment was completed and appropriate care plan interventions were in place for those at risk for elopement. Six residents were identified as not having an assessment. The survey team verified that elopement assessments were completed. The facility added a new section to the morning clinical meeting checklist to verify completion and accuracy of elopement evaluation and the development of a care plan with implementation of appropriate interventions, verified on 4/6/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, resident interview, responsible party interview, clinical record review and policy review, the facility failed to provide adequate supervision of a vulnerable resident and identify the resident as an elopement risk due to exit seeking and wandering behaviors for 1 of 7 residents sampled for accidents and supervision. (Resident #1) On 3/11/23, Resident #1, a cognitively impaired vulnerable resident, was able to exit the facility unbeknownst to staff. A facility staff member responded to a door alarm, looked out the window instead of exiting the facility and checking the surrounding grounds, shut the alarm off when no residents were observed, and returned to work. Resident #1 was able to propel himself in his wheelchair approximately 245 feet from the exit door. The resident was found by another staff member who had clocked out at approximately 4:00 PM for the day and noted the resident propelling himself backward in his wheelchair up the east exit, which is approximately at a 45 degree slope and only 32 feet from a major 2-lane highway, and 528 feet downhill to a major 4-lane highway intersection. This failure allowed the resident, who had a documented diagnosis of dementia to exit the facility into the parking lot, placing the resident at risk for serious injury, harm, abduction, or death. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of J, isolated. The facility's Administrator and the Director of Nursing were notified of the findings of Immediate Jeopardy on 4/5/23 at 4:35 PM. Immediate Jeopardy was removed on 4/6/23 at 5:00 PM and the scope and severity of the Immediate Jeopardy deficiencies was reduced from a J level to a D level. Cross reference F656 and F867 The findings include: A record review was conducted of Resident #1, which revealed the resident was originally admitted to the facility on [DATE] with diagnoses of Dementia, Psychosis, need for assistance with personal care, Type 2 Diabetes, Difficulty in walking, and muscle weakness. On 3/2/23, an elopement risk evaluation form was completed by Staff member L, a Licensed Practical Nurse (LPN). This form identified an elopement risk score of 3.0, which indicates that the resident was at risk for elopement. Further review of the elopement risk evaluation form revealed the following directions: Complete quarterly and with significant change. If the resident is deemed at risk, a prevention protocol should be initiated immediately and documented in the care plan. The following questions were included on the form: 1. Is the resident cognitively impaired? 2. Is the resident independently mobile (ambulatory or wheelchair)? 3. Does the resident have poor decision-making skills? 4. Has the resident demonstrated exit seeking behaviors? 5. Does the resident wander oblivious to safety needs? 6. Does the resident have a history of elopement? 7. Does the resident have the ability to exit the facility? 8. Based on potential risk factors above, resident is determined to be AT RISK for elopement Staff L marked Yes to questions 1 through 8. The forms stated Yes, to questions 4,5 or 6 automatically place the resident AT RISK The form further stated, If it is determined that the resident has eloped, implement care plan immediately to ensure resident's safety. Report all residents AT RISK to the Director of Clinical Services and on the 24-hour report. A review of Resident #1's care plan revealed he had the potential to be aggressive in his behavior as evidenced by aggressively moving in his wheelchair throughout the hallways. His care plan also identified poor impulse control, stealing his roommates' personal items, eating his roommate's food, and going into others' rooms uninvited. No care plan was initiated for elopement risk, and no interventions were put in to place to ensure the residents' safety. A further review of the clinical record revealed that Resident #1 was discharged to the hospital on 3/2/23, with a return to the facility on 3/5/23. The elopement risk evaluation was not completed for the re-admission for 3/5/23, which resulted in a care plan not being updated for elopement risk and interventions were not put in place to ensure the resident's safety. A review of the resident's most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely impaired for daily decision making (worsened from moderately impaired on both the 2/24/23 discharge assessment and the 12/9/22 quarterly MDS Assessment). His balance was not steady, and he required extensive assistance with dressing, toilet use and personal hygiene. His prior MDS on 2/22/23 revealed he was independent with toilet use and required limited assistance with dressing. The MDS identified the diagnosis of non-Alzheimer's dementia and psychotic disorder. An interview with Resident #1 on 4/3/23 at 11:15 AM found Resident #1 up and dressed and sitting in a wheelchair on the memory care (Serenity) unit. Resident #1 stated that he wanted to go home. In an interview on 4/5/23 at 9:35 AM, Resident #1's Responsible Party stated that Resident #1 is an outside person and he likes to be outside more than inside. A review of the facility's investigation revealed that Resident #1 was last seen on 3/11/23 at approximately 3:30 PM in the hallway by Staff Member B, a Certified Nursing Assistant (CNA). At approximately 4:00 PM, Staff Member A, a Licensed Practical Nurse (LPN) observed Staff Member D, another CNA, standing at the therapy door exit shutting off the door alarm. LPN A clocked out for the day and exited through the same therapy door. LPN A reported that when she reached the outside canopy area, she noticed Resident #1 propelling himself in his manual wheelchair backwards up the driveway exit hill. LPN A called out to Resident #1, who then rolled down the hill to LPN A. The staff member returned Resident #1 to the facility nurses' station and reported to Staff Member M, an LPN and weekend supervisor, of the resident being found in the parking lot. CNA D was suspended pending investigation on 3/11/23, and later terminated by the facility on 3/20/23. On 4/3/23 at approximately 2:53 PM, a telephone interview was conducted with former CNA D who stated that she went down to the private hall with another CNA to give the shift report. CNA D stated that she heard the alarm but assumed that someone else would answer it, but when she returned back toward the nurses station, the alarm was still going off. CNA D further stated that she went to the therapy door exit, looked out the window but did not see anything, so she turned the alarm off and returned to work. CNA D stated she did not exit the facility and check the surrounding grounds, and denied having any training on elopement prior to 3/11/23. She stated that, if she did have training during her orientation, she did not remember doing so, until the Administrator re-educated her on elopement procedure after the incident. On 4/3/23 at approximately 3:30 PM, an interview was conducted with the Director of Clinical Services (DCS) and Staff Member K, a Care Plan Coordinator. When asked why the care plan for Resident #1 was not updated on 3/2/23, Care Plan Coordinator K responded the only reason she could think of was that she did not get to his care plan by the time the resident went out to the hospital on 3/2/23. The DCS stated that when residents are gone from the facility for over 24 hours, they are considered a re-admission upon return, with new assessments completed, including an elopement risk evaluation. The DCS stated that Resident #1 should have had an elopement risk evaluation completed upon re-admission on [DATE] and could not explain why it was not completed. The DCS further stated that, if it had been completed, it would have triggered the MDS and care plan to be updated and the resident would have been placed in the elopement risk binders that are kept on each nurses station and the receptionist's desk at the front entrance to alert staff regarding residents who are considered elopement risks. When asked if the care plan for Resident #1 would have changed upon re-admission, Care Plan Coordinator K stated it would not have changed much unless there was a significant change in condition. Care Plan Coordinator K confirmed that the elopement risk evaluation on 3/2/23 with a score of 3.0, when the previous elopement risk evaluation dated 8/13/21 was score was a 0 (which is not considered a risk for elopement), should have triggered the care plan to have been updated. Both the DCS and Care Plan Coordinator K confirmed that Resident #1's care plan was not updated for elopement risk until 3/12/23, which is the day after the resident had exited the building into the parking lot. On 4/4/23 at approximately 8:40 AM, an observation was made with the Maintenance Director and the Administrator in the parking lot for station 1, where LPN A located the resident after he exited. The Maintenance Director measured with tape-measure the distance from the area the resident was located to the Therapy Exit door, which measured approximately 245 feet. On 4/4/23 at approximately 9:58 AM, an interview was conducted with LPN A who stated that right after shift change she stayed over to complete her charting on nurses' station 2. She remembered hearing a faint beeping noise while completing her charting. LPN A stated she went to clock out for the day and noticed CNA D at the therapy door exit inputting the code to shut the alarm off. LPN A stated at this point she was not aware that a resident had exited the facility. LPN A stated she clocked out for the day at approximately 4:00 PM and exited out of the facility through the Therapy Exit door after inputting the code. When she reached the canopy area while walking to her car, she looked up and noticed Resident #1 propelling himself backwards up the hill of the east parking lot exit. She stated she called out to him by name and he lifted his feet up and let go of the wheels with his hands and proceeded to roll back toward her down the driveway hill. LPN A further stated that she took off running toward the resident and caught him at the base of the hill right where the first cars were parked to slow him down. LPN A went on to state that she returned the resident into the facility through the laundry room exit door and notified the Weekend Nurse Supervisor. LPN A identified the exact area where she found Resident #1 in the parking lot, and an observation was made in the presence of LPN A and the Administrator that the resident was located approximately 32 feet via measuring tape from a busy 2-lane highway with a speed limit of 30 miles per hour. LPN A further stated that Resident #1 would wander around the facility in his wheelchair and would try and go out to the courtyard to smoke even when the door was locked, but she had not observed him trying to exit the facility. On 4/4/23 at approximately 5:30 PM, an interview was conducted with the DCS. The DCS stated that Resident #1 would not have been able to sustain himself outside of the facility without supervision. The DCS also stated that they were unable to locate the last elopement drill conducted prior to the event, stating that it was the previous Assistant Director of Clinical Services' responsibility, and they have had some difficulties locating her documents since she quit without notice. On 4/5/23 at approximately 9:00 AM, a follow-up interview was conducted with the DCS. She stated that they were able to elopement find training conducted in an all staff meeting on 11/30/22 that included the policy and procedure but were still unable to locate any documentation of any drills conducted prior to the 3/11/23 incident. A review was conducted of the Policy and Procedure titled N-1031, Subject: Elopement/Wandering Risk Guidelines (effective date of 9/21/2016 last revised 8/01/2020), which stated, Overview: To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions. Process: Patient/Residents to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change in condition, and elopement event using the risk tool. If a patient/resident is identified as being at risk complete an Elopement Risk Alert and obtain a photograph. Initiate individualized interventions based on Patient/Residents' at risk. Document individualized interventions in the patient/resident Care Plan and [NAME]. Review of the Policies and Procedures document name N-1015, Subject: Plans of Care (effective date 11/30/2014 last revised 9/25/2017) revealed, Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record. Procedure: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. Develop and implement an individualized Person-Centered baseline plan of care within 48 hours of admission. Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA [Omnibus Reconciliation Act] MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial well-being. Under Note: The resident plan of care encompasses many documents that are part of the resident's clinical record including, but not limited to, structured care plan documents, MARS (Medication Administration Records), TARS (Treatment Administration Records), physician orders, flow records, and/or legal documents that would drive the plan of care for the individual resident. The Immediate Jeopardy was removed onsite on 04/06/2023 after receipt of an acceptable removal plan and verification of corrective actions. On 04/06/2023 at approximately 5:03 PM, the removal plan was verified after staff interviews to determine knowledge of elopement policy, education on the importance of completing the elopement risk evaluation on admissions and re-admissions, physician notification of change in condition with emphasis on new or increased behaviors of wandering or exit seeking and the importance of developing a care plan and implementing interventions to include the appropriate level of supervision at the time of the residents change in behavior. Interviews were conducted with 20 staff members representing all 3 shifts. All responded with confirmation of training and were able to verbalize when assessments are to be completed as well as the updating of the care plan with implementation of appropriate interventions. The training sign-in sheet was verified, along with the documentation of training covered. The removal plan indicated resident #1 was placed on 1:1 observation on the day of occurrence, 3/11/23. Resident #1 was subsequently moved to the memory care secure unit, and the observation level was reduced to every 15 minute safety checks. The survey team verified that the 15 minute checks were being conducted through observation, review of logs and interviews with staff on the Serenity Unit. The Director of Clinical Services, Assistant Director of Clinical Services, MDS/care plan coordinators and Executive Director were educated by the Regional Director of Clinical Services on 4/04/2023 regarding the process to review admission and readmission charts for accuracy of elopement evaluations and responsibility to provide appropriate interventions and supervision for residents with wandering and exit seeking behaviors through the care planning process. On 4/6/2023, review of the education was verified, the sign-in sheet for training and the documentation of training covered were also verified. On 4/6/23, an interview with the MDS RN coordinator verified the education training. The facility added a new section to the morning clinical meeting checklist to verify completion and accuracy of elopement evaluation and the development of a care plan with implementation of appropriate interventions, verified on 4/6/2023. The survey team verified that all exit doors were secure and safety features and alarms functioning properly as documented in the removal plan. Immediately post event on 3/11/23, the facility reviewed 100% of resident records to verify current elopement assessments. The removal plan documented this was updated on 4/5/23 with a review of current residents admitted or readmitted since 3/11/23 to ensure an elopement risk assessment was completed and appropriate care plan interventions were in place for those at risk for elopement. Six residents were identified as not having an assessment. The survey team verified that elopement assessments were completed. The removal plan documented that by 4/6/23, 97 out of 136 employees had participated in an elopement drill post event. Elopement drills will continue every shift weekly until 100% of all staff have participated with 9 unplanned drills conducted as of 4/6/23. The survey team verified elopement drills via staff interview and documentation.

Based on staff interviews, clinical record review, review of the quality assurance performance improvement plan, and policy review, the facility failed to implement their corrective action plan for monitoring of new admissions and re-admissions for elopement risk assessments for 6 of 20 residents reviewed. (Residents #6, 9, 12, 14, 19, and 20). On 3/11/23, Resident #1, a cognitively impaired vulnerable resident, was able to exit the facility unbeknownst to staff. The facility developed an implemented an immediate corrective action plan which included reviewing 100% of new admissions to ensure a complete and accurate elopement assessment and interventions initiated as indicated. On 4/3/23, the survey team identified 6 residents admitted after 3/11/23 whom had not had an elopement risk assessment completed since admission. This situation resulted in a finding of Immediate Jeopardy at a scope and severity of J, isolated. The facility's Administrator and the Director of Nursing were notified of the findings of Immediate Jeopardy on 4/5/23 at 4:35 PM. Immediate Jeopardy was removed on 4/6/23 at 5:00 PM and the scope and severity of the Immediate Jeopardy deficiencies was reduced from a J level to an D level. Cross reference F689 and F656 The findings include: A review was conducted of the facility Quality Assurance Performance Improvement (QAPI) plan which revealed under Plan: Director of Clinical Services (DCS) that the agency will conduct Quality Monitoring of newly admitted residents exhibiting exit seeking behaviors daily in clinical meetings weekly for 4 weeks. A review of the Risk Management Quality Improvement Data Collection Form revealed that the DCS failed to ensure that all readmitted residents received an updated elopement risk assessment upon re-admission. The Risk Management/Quality Improvement Data Collection Form, dated 3/28/23, revealed that Residents #6, 9, 12, 14, 19, and 20 had all been discharged and readmitted to the facility but none of them received a new elopement risk evaluation upon re-admission. On 4/4/23, an interview was conducted with the DCS at approximately 1:00 PM. The DCS stated she ran a report from Point Click Care (the facility's Electronic Medical Records software application) and was able to generate a list of residents that triggered as elopement risk and that is what she used for the weekly monitoring of all the current residents at risk for elopement. The daily monitoring is for new or re-admissions that have been gone for over 24 hours. The surveyor asked the DCS, If the assessment for elopement risk was not completed on return, then how do you know if the resident had a change in condition and are now at risk for elopement? The DCS replied, I cannot know for sure unless it was redone. A review was conducted of the document titled Policies and Procedures document subject: Quality Assurance Performance Improvement Program (QAPI) Document name: PI-215, (Effective date 11/30/2014, last revised 10/24/2022). The policy states The center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. Procedure: 1. The center's QAPI program is an on-going comprehensive review of care and services provided to residents. Including but not limited to a. Medical Care, b. Clinical care, j. Admissions, l. Medical Records. 2. Important functional areas may include but are not limited to b. admission process, c. Resident assessment, d. Quality of care, e. Quality of Life, f. Potential Adverse Events. 3. Review of activities may include but not limited to: b. Incident/accident reports, d. Interdisciplinary care planning, f. Environment of care/safety, i. Staff orientation, in-service and competence. Under Leadership: The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to: a.) implementation, d.) Ensures performance indicators, resident and staff input and other information is used to prioritize problems and opportunities. e.) Ensures corrective actions are implemented to address identified problems in systems. f.) Evaluates the effectiveness of actions. g.) Establishes expectations for safety, quality, rights and choice and respect. Under Data Collection Systems and Monitoring: The center will collect and monitor data from different departments reflecting its performance. 8. The center will identify data sources and timeframe for collection. Data sources may include but are not limited to: a.) Direct observation tools. b.) Audit tools g.) Quality measures. 9. The center will develop a schedule for routine data collection. Under Performance indicators: The center will establish performance indicators for data collected. 10. The center will utilize performance indicator to establish goals, identify opportunities for improvement, and evaluate progress towards goals. Under Identifying Quality Deficiencies and Corrective Action: The center will monitor department performance systems to identify issues or adverse events. 15. If a quality deficiency is identified, the committee will oversee the development of corrective action(s). 16. The center may choose the method of corrective action i.e., Plan, Do, Study, Act or Performance Improvement Project. The Immediate Jeopardy was removed onsite on 04/06/2023 after receipt of an acceptable removal plan and verification of corrective actions. On 04/06/2023 at approximately 5:03 PM, the removal plan was verified after staff interviews to determine knowledge of elopement policy, education on the importance of completing the elopement risk evaluation on admissions and re-admissions, physician notification of change in condition with emphasis on new or increased behaviors of wandering or exit seeking and the importance of developing a care plan and implementing interventions to include the appropriate level of supervision at the time of the residents change in behavior. Interviews were conducted with 20 staff members representing all 3 shifts. All responded with confirmation of training and were able to verbalize when assessments are to be completed as well as the updating of the care plan with implementation of appropriate interventions. The training sign-in sheet was verified, along with the documentation of training covered. The Director of Clinical Services, Assistant Director of Clinical Services, MDS/care plan coordinators and Executive Director were educated by Regional Director of Clinical Services on 4/04/2023 regarding the process to review admission and readmission charts for accuracy of elopement evaluations and responsibility to provide appropriate interventions and supervision for residents with wandering and exit seeking behaviors through the care planning process. On 4/6/2023, review of the education was verified. On 4/6/23, an interview with the MDS Registered Nurse coordinator verified the education training. The facility added a new section to the morning clinical meeting checklist to verify completion and accuracy of elopement evaluation and the development of a care plan with implementation of appropriate interventions, verified on 4/6/2023. On 4/6/23, staff re-education was verified via 20 staff interviews conducted and review of education sign in sheet that staff nurses were educated on 4/4/23 regarding the accuracy of elopement evaluations and the importance of providing appropriate supervision for residents with wandering or exit seeking behaviors. It was verified via interviews and review of the in-service dated 4/6/23 that QAPI committee training provided by the ED was conducted on 4/6/23. Inservice training for the ED and DCS on QAPI policy and procedures was verified via record review 4/6/23. Immediately post event on 3/11/23, the facility reviewed 100% of resident records to verify current elopement assessments and care plans developed as indicated. The removal plan documented this was updated on 4/5/23 with a review of current residents admitted or readmitted since 3/11/23 to ensure an elopement risk assessment was completed and appropriate care plan interventions were in place for those at risk for elopement. Six residents were identified as not having an assessment. The survey team verified that elopement assessments were completed.