**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, record and policy review, the facility failed to protect the resident's right to be free from neglect when it failed to provide supervision to protect resident safety as evidenced by disregarding the procedure to prevent the resident from eloping, failed to search for the missing resident timely, and failed to provide essential medications, for 1 of 3 sampled residents (Resident #1). The deficient practice allowed Resident #1 to exit the facility undetected on 06/18/25 at 8:26 PM. There were 111 residents in the facility at the time of the survey. The facility's Administrator was notified of Immediate Jeopardy on 06/25/25 at 4:09 PM. The immediate jeopardy was removed at the time of the facility exit on 06/26/25. Cross reference to F689. The findings included: Review of the facility's policy titled, Abuse and Neglect Prohibition revised 8/2023, documented, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, exploitation, and misappropriation of property. Neglect means failure to provide good and services necessary to avoid physical harm, mental anguish, or mental illness. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Speech and Language Deficits Following Other Nontraumatic Intracranial Hemorrhage, Schizophrenia, and Traumatic Subarachnoid Hemorrhage. Resident #1 was readmitted to the facility on [DATE] post hospitalization for a fall with tibial fracture. He ambulated without assistance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 that indicated the resident was cognitively intact. On 06/19/25, the resident's BIMS score was 15 that indicated the resident was cognitively intact. Review of a psychiatry note dated 06/19/25 revealed the resident had a speech impairment that can make communication challenging, but he is alert to person, place and time. Resident #1 had an elopement risk screen completed on 12/06/24 with an elopement risk screen score of 2, which indicated the resident was at elopement risk. An alert bracelet was applied to the resident's left ankle and a care plan was developed. The goal of the care plan was to maintain safety. At the time of elopement, the alert bracelet was worn on his left ankle. The alert bracelet alarms when the resident is near a door that has a sensor on it. The door automatically locks. A staff member can use a secure code to bypass the system. The video of the elopement event was viewed by the surveyor. The video had no sound. The video noted that on 06/18/25 at 8:09 PM, the pharmacy courier entered the exterior door of the facility which was unlocked. Once inside, the courier rang the doorbell of the inside interior door and waited until 8:11 PM for someone to open the door. When no one came to answer the doorbell, he pushed the inside interior door open at 8:11 PM. This is a fire door and when pushed for 15 seconds, the door will unlock, the alarm will sound, and it will disarm the bracelet alert system. He entered the facility at 8:11:41 PM. At that time, Resident #1 was in the courtyard walking around. At 8:26:12 PM, the courier left the building through the front door. At 8:26:17 PM, Resident #1 walked out the front door. No staff were observed by the door until the Maintenance Director reset the alarm at 8:36 PM. At the time of the elopement, there were 5 nurses and 11 certified nursing assistants working in the facility. When the front door alarmed, no staff initially responded to the alarm. It was alarmed for 25 minutes and was turned off by the Maintenance Director. The surveyor heard the alarm volume at the current sound level on 06/23/25 at 10:30 AM, then asked for the sound to be heard at the level it was at the time of the elopement, and it was at softer level at that time. The facility is shaped as a square. An observation was conducted on 06/19/25 at 10:00 AM of Resident #1's room. Resident #1's room was located on the west, front side of the facility. There is a west front unit, a nurse's station, and a west back unit. A hallway joins the west back to the east back unit. There is an east back unit, a nurse's station, and then an east front unit. A hallway joins the east front to the west front and the front door is in the middle of the joined hallway. The courtyard is opposite of the front door. In an interview with the Maintenance Director at 3:10 PM on 06/23/25, he stated he was working in the back section of the facility, and when he walked through the facility before he left for the evening, he noticed the annunciator and buzzer sounding and a light which told what door it was (this was located at the nurse's station). The front door was unlocked, and the alarm was beeping. He punched in the pass code which is on the side of the door, to reset it. He stated that the alarm stays beeping until it is reset. Staff A, Registered Nurse (RN), who worked the 3-11 shift, stated in a phone interview on 06/23/25 at 12:30 PM that she was aware of the alarm at the time the Maintenance Director turned it off. She worked the 3PM-11PM shift that day (06/18/25) in the 200 unit (east side). She heard the alarm on 06/18/25 around 8:00 PM. When she stepped out of one of the residents' rooms on the east side, the Maintenance Director was approaching the same direction to the door. Because he was going to the door, she did not. He disarmed it. Prior to the alarm going off, she saw the pharmacy courier and she got the medications from him. She does not know how he got into the building. He gave the medications to the east wing first, then the west wing. She did not see him after that. She did not say anything to anyone about hearing the alarm. A review was conducted of a witness statement from Staff E, Certified Nursing Assistant (CNA), who was assigned to Resident #1 on the 3PM-11PM shift on 06/18/25. The statement revealed she saw him in bed at approximately 7:45-8 PM. Around 9:30 PM, she rounded again, and the resident was not in the room. It was not strange since he is always walking. She did not hear any alarm. She continued to do the care to residents until it was time to leave (11PM). A telephone interview was conducted with Staff F, CNA on 06/23/25 at 1:25 PM. He was revealed he worked the 3PM-11PM shift. He was helping another CNA change the roommate of Resident #1 around 9:00 PM on 06/18/25. At 8:00 PM, he saw Resident #1 on the courtyard bench. The resident always goes into the courtyard. Staff F stated he left the facility around 11:15 PM and did not know Resident #1 was missing. A telephone interview was conducted on 06/23/25 at 1:36 PM, with Staff C, CNA on 11PM-7AM shift. She was working with Resident #1's roommate when she first came into the facility at 10:32 PM. She is not sure if Resident #1 was in bed at the time. During the second round, she reported to Staff B, the resident's assigned nurse, that Resident #1 was not in bed (she rounds every 2 hours, but she did not know the exact time). They looked in all the rooms for him and outside the building. A telephone interview was conducted with Staff B, Licensed Practical Nurse (LPN), on 06/23/25 at 12:15 PM. She stated she was the night nurse taking care of Resident #1 on 06/18/25 on the 11:00 PM-7:00 AM shift. She stated at 11:00 PM, she thought she saw the resident in bed but later found out he was not. She did not make any other observations at that time. At about 12:15 AM, she went back to the unit. When she went into Resident #1's room to check on him, she noticed he was not in bed. It did not alarm her because he is easy to redirect and comes to the nursing station during the night. She stated that she was going to check on where he was, but another room put the call-light on and needed assistance. Then, she forgot to look for Resident #1. About 30 minutes later, Staff C, CNA, came to her and asked if Resident #1 was watching television. Staff B then realized she didn't see him in his bed. Everyone started looking for him. She and Staff D, RN, who was working the 11PM-7AM shift on the east back area of the facility, went outside to search the perimeter but did not find him. She stated that around 1:45 AM, Code Silver was called. Per the facility's guideline titled Emergency Color-Code Guide, Code Silver is designated for elopements in the facility. Code Silver + room number denotes that a resident cannot be located. This code immediately initiates a center-wide search. Review of the facility's policy titled Resident Elopement revised 8/2023, documented when a resident is unable to be located on the premises, staff will: Determine if the resident is out on an authorized leave or pass. If not: Notify the Administrator and the Director of Nursing Services. Conduct a thorough search of the center and premises.The facility staff did not inform the Administrator of the missing resident for over 2 hours after staff realized the resident was missing. A telephone interview was conducted on 06/23/25 at 1:40 PM, with Staff D, RN, who worked the 11PM-7AM on the east back hall. He stated around 3:00 AM, he was charting and was notified that Resident #1 was missing. He started searching all the bathrooms but did not find him. Then he started looking outside. Another nurse called the Administrator and Director of Nurses (DON) and he continued searching. He and Staff B went by car to see if they could locate him. In an interview with the Administrator, who is also the Risk Manager, on 06/23/25 at 10:00 AM, she stated she was notified of the elopement on 06/19/25 at approximately 3:30 AM. She immediately made her way to the facility and called the Port Saint [NAME] police and DCF (Department of Children and Families) to notify them of the elopement. Resident #1 was returned to the facility on [DATE] at approximately 8:30 AM by the Port Saint [NAME] Police Department. The resident was returned to the facility by the police 12 hours after he exited the facility. Review of the police report revealed the police responded to the facility at 4:37 AM on 06/19/25. They were given a description of Resident #1 and began to search for him. He was found by police on US Highway 1 in Fort [NAME] the morning of 06/19/25 walking on the sidewalk north bound. He was not carrying a phone, wallet, or any form of identification. He was identified by verbally telling the police his name. He was then transported back to the facility at 8:41AM on 06/19/25. An interview was conducted with Resident #1 on 06/23/25 at 10:35 AM regarding the elopement on 06/18/25. He stated he left around 8:00 PM and started walking. He ended up in a church parking lot for a while. It was getting dark when he left. He was wearing shorts and sneakers. He pushed the door open. He followed someone out, he didn't know the name of the person. He stated he walked on the sidewalk the entire time. He was found by a public safety officer on US 1 in the morning. The surveyor travelled the route by car from [NAME] Hall to the Fort [NAME] police station. Review of the route the resident stated he walked revealed an 11 mile walk to the Fort [NAME] Police station. The resident would likely have crossed the street at Hillmoor Drive and [NAME] Ave, which is a busy crosswalk with a traffic light in front of a hospital. Travelling northbound on US 1 revealed there is a sidewalk all the way up to the police station. US 1 goes from 3 lanes each direction, to 2 lanes in Fort Pierce. On each side of the highway, there are commercial properties like stores, churches, gas stations. The speed limit was 45 miles per hour (MPH) in Port St [NAME], then 40 MPH near the railroad crossing by [NAME] Road and US 1. At the Fort [NAME] police station, the speed limit was 35 MPH. There are 20 traffic lights from where the resident would have started walking on US 1 to where the Fort [NAME] police station was located. Each traffic light had a side street so the resident would have had to cross the side street. There was one railroad crossing. There were 2 traffic lights with side streets that do not have a crosswalk. Review of the Medication Administration Record (MAR) for June 2025 revealed that on 06/19/25 Resident #1 missed the morning dose of Depakote Sprinkles 125mg, 6 capsules po [orally] which were due upon rising (hours of 6:00 AM-10:00 AM); Abilify 15 mg tab was also due upon rising; and the Lidocaine external patch 4% was due to be applied at 6:00 AM. Depakote Sprinkles are used for Epilepsy and Bipolar Disorder. Abilify is used to treat Schizophrenia, Bipolar Disorder and Depression. A Lidocaine patch is used as a local anesthetic that can help relieve minor pain. The facility submitted an acceptable Immediate Jeopardy Removal Plan on 06/26/25 that included: a. On 06/19/2025, educated the pharmacy vendor they cannot pull the door for 15 seconds to enter the building as it disabled the alerting bracelet system. Thus, allowing the residents to exit the building without the safety measure of the door locks engaging. The 15 second egress is a mandatory fire life safety regulation. Completed 06/19/25. b. Door checks are audited weekly upon completion of every shift audit. The doors that are being checked to ensure the alarm system is functioning in the lobby, northeast corridor door, northwest corridor door, southwest corridor, southeast corridor door, dining room door, employee entrance door, and back entrance service store. Initiated 06/19/25 and will be maintained ongoing. Audits were reviewed for the door checks. c. On 06/19/25 the alarm volume increased to maximum sound to allow the staff to hear the alarm better. Completed 06/19/2025. The surveyor verified the sound on 06/23/25. The maintenance director turned the sound level back to the prior level, then back to the level it was raised to, and the sound was louder. d. On 06/19/2025 the center added an additional receptionist for after hours to ensure 24 hour coverage of the front door. Completed 06/19/2025. The surveyor reviewed the scheduled coverage and observed coverage until the surveyor left at 5:30 PM on 06/23/25-06/26/25. e. By 06/20/25 all staff (RN, LPN, CNA, Therapist, Administrative, Dietary Housekeeping, Activities and Social Service were reeducated on the elopement process. When you hear any alarm you respond immediately, if it is the alerting bracelet alarm you begin searching the center and outside grounds for a resident count to match the census. The NHA/ Risk manager (Nursing Home Administrator, Risk Manager) is notified immediately if a resident is missing and notification to law enforcement and other agencies is completed. (Completed 6/20/25, 35 out of 35 nurses, 50 out of 50 CNA's, 63 out of 63 ancillary staff with a total of 148 out of 148 staff). f. By 6/20/25, all staff, (RN,LPN, CNA, Therapist, Administrative, Dietary, Housekeeping, Activities, and Social Service were reeducated on Abuse, Neglect and Exploitation with emphasis on elopement, responding to door alarms, there is 24 hours front door monitoring but they must still respond timely to the alarm, monitoring of resident who are ambulatory around the center ensuring there is a timely search of the center and notification to the NHA/Risk Manager. Completed 06/20/25. 35/ 35 nurses, 50/ 50 CNA's, 63/ 63 ancillary staff with a total of 148/ 148 staff). g. By 06/20/25, all clinical staff (RN, LPN, CNA, 35/ 35 nurses, 50/ 50 CNA's for a total of 85/ 85 were reeducated on ensuring that walking rounds during shift and that shift change are conducted to ensure all residents are in the facility. h. On 06/19/25 daily checks of the alerting bracelet on each at risk elopement resident is completed every shift for placement and every day for functioning. This process has been in place for 36/ 36 residents at risk for elopement. The surveyor reviewed the Treatment Administration Records of the residents at risk for elopement. i. On 06/19/25 signs added to all egress doors that state Notice to visitors and vendors. This is a secure door equipped with a safety egress system. Do not pull or push on the door continuously. Doing so for 15 seconds will disengage the magnetic lock to disable the resident alert system, creating a potential safety risk. Please press the doorbell and allow staff time to respond. Your patience ensures the safety of all residents. Thank you for your cooperation. [NAME] Hall Nursing and Rehab Center. As well as Attention all family members and vendors please do not assist residents in leaving the facility. The surveyor observed the signs on the front receptionist desk, the inside, and outside of the egress front door. The surveyor pressed the egress front door and additional doors. Alarms sounded. j. On 06/19/25, the center has identified 36 residents who are at risk for elopement. All 36 residents have a new elopement risk assessment and Brief Interview for Mental Status (BIMS). All 36 residents have alerting bracelets in place with monitoring every shift for placement and every day for functioning. k. The other egress doors have an additional alarming device exit door alarm that when the door is accessed will signal very loud sound when the door has been accessed. The employee entrance is key coded. Observations of every door were made, and a loud sound was made when the doors were pushed open. l. On 06/19/25 the receptionists were reeducated on never leaving the front door unattended. When leaving for break they must call the supervisors to send a staff member to cover the break. The surveyor interviewed the receptionist on 8:00 AM to 4:00 PM and the 4:00 PM to 8:00 PM receptionist who verified the education that was given. m. On 6/19/25 the staff member that did not respond to alarm was re educated on the importance of responding to any alarm and initiate the elopement process immediately upon determining a missing resident. In addition, received education on When you hear any alarm you respond immediately, if it is the alerting bracelet system alarm you being searching the center and outside grounds for resident count to match the census. The NHA/Risk Manager is notified immediately if a resident is missing, and notification to law enforcement and other agencies is completed. n. On 06/19/25, the maintenance director was reeducated on the importance of not resetting any alarm without initiating the elopement process and completing an outside search. In addition, he received education on when you hear any alarm you respond immediately if it is the alerting bracelet system alarm you begin searching the center and outside grounds for a resident count to match the census, the NHA/Risk Manager is notified immediately if a resident is missing ,and notification to law enforcement and other agencies is completed. The surveyor interviewed the maintenance director on 06/23/25 at 3:10 PM who verified he was educated on this. o. The QAA/QAPI (Quality Assessment and Assurance) (Quality Assurance and Performance Improvement) committee reviewed the initial QAPI on 06/19/25,06/20/25 and 06/24/25 the removal plan was reviewed on 06/26/25. The surveyor verified the implementation of the following immediate actions in the Immediate Jeopardy Removal Plan prior to the Exit on 06/26/25: a. The surveyor reviewed the pharmacy letter that was sent on 6/19/25.b. The surveyor reviewed the door checks are audited-weekly audits are due to start tomorrow.c. Alarm volume was heard at the low sound and increased sound by the surveyor on 06/23/25.d. Receptionist schedule revealed 24 hour coverage starting 6/19/25 and education. The receptionists who worked the day and evening shifts were interviewed on 06/25/25 at 4:00 PM and they verified their education.e. The surveyor reviewed staff education and compliant with education and # of staff educated.f. The surveyor reviewed staff education and compliant with education and # of staff educated.g. Education for walking rounds was reviewed for LPN and RN assigned to Resident #1 on 06/18/25.h. The elopement risks are completed and on the Treatment Administration Records for the residents at risk.i. Signs were as written in the removal plan. Signs were observed by the surveyor.j. All 36 residents identified as elopement risk, were in all 3 elopement books.k. Observed the doors and heard the loud sound the doors make when opened.l. The surveyor reviewed their education.m. Reviewed the 1:1 education for the nurse.n. Reviewed the 1:1 education for the Maintenance Director.o. Reviewed QAPI for 06/19/25, 06/20/25, 06/24/25, 06/25/25, 06/26/25. The following staff were interviewed for verification of staff education: Staff A, RN, interviewed on a telephone interview on 06/23/25 at 12:30 PM stated after the incident they had elopement drills. Code silver means we go to every exit and closet check and the residents are accounted for and do a head check. We report the room number and the patient who is missing then the administration is notified. Staff F, CNA, interviewed on a telephone interview on 06/23/25 at 1:25 PM. He stated he started working in May and he had an elopement drill on Friday. On 06/23/25 at 1:36 PM an interview was conducted via telephone to Staff C, CNA. They have had Elopement drills since 2018. They have had more elopement drills in the past days. When you notice the patient is missing, you look for the patient, and report to the nurse if you don't see the patient. On 06/23/25 at 1:40 PM an interview was conducted via telephone with Staff D, RN. He worked in the facility since March 2025. Elopement drills have been given close to the hire date and since then. They have had drills throughout the week after the elopement. On 06/23/25 at 2:00 PM a telephone interview was conducted with Staff G, LPN. She stated they have done many elopement drills. They called Code Silver and everybody was looking. On 06/25/25 at 3:48 PM, Staff H, CNA was interviewed. She stated when the door alarms you go out try to see cause, see if resident there, check rooms, let nurse know, check all locations, announce code silver. I received education a couple evenings ago. I received a test with scenarios, on neglect and elopement topics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record and policy review, the facility failed to provide appropriate supervision to prevent an elopement which resulted in the resident exiting the facility undetected and whereabouts unknown for 12 hours as he walked along a highway that put him at risk of being hit by an automobile for 1 of 3 sampled residents (Resident #1). The deficient practice allowed Resident #1 to exit the facility undetected on 06/18/25 at 8:26 PM. There were 111 residents in the facility at the time of the survey. The facility's Administrator was notified of Immediate Jeopardy on 06/25/25 at 4:09 PM. The Immediate Jeopardy was removed by the time of the facility exit on 06/26/25. Cross reference to F600. The findings included: Review of the facility's policy titled Resident Elopement revised 8/2023, documented when a resident is unable to be located on the premises, staff will: Determine if the resident is out on an authorized leave or pass. If not: Notify the Administrator and the Director of Nursing Services. Conduct a thorough search of the center and premises. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Speech and Language Deficits Following Other Nontraumatic Intracranial Hemorrhage, Schizophrenia, and Traumatic Subarachnoid Hemorrhage. Resident #1 was readmitted to the facility on [DATE] post hospitalization for a fall with tibial fracture. He ambulated without assistance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 that indicated the resident was cognitively intact. On 06/19/25, the resident's BIMS score was 15 that indicated the resident was cognitively intact. Review of a psychiatry note dated 06/19/25 revealed the resident had a speech impairment that can make communication challenging, but he is alert to person, place and time. Resident #1 had an elopement risk screen completed on 12/06/24 with an elopement risk screen score of 2, which indicated the resident was at elopement risk. An alert bracelet was applied to the resident's left ankle and a care plan was developed. The goal of the care plan was to maintain safety. At the time of elopement, the alert bracelet was worn on his left ankle. The alert bracelet alarms when the resident is near a door that has a sensor on it. The door automatically locks. A staff member can use a secure code to bypass the system. The video of the elopement event was viewed by the surveyor. The video had no sound. The video noted that on 06/18/25 at 8:09 PM, the pharmacy courier entered the exterior door of the facility which was unlocked. Once inside, the courier rang the doorbell of the inside interior door and waited until 8:11 PM for someone to open the door. When no one came to answer the doorbell, he pushed the inside interior door open at 8:11 PM. This is a fire door and when pushed for 15 seconds, the door will unlock, the alarm will sound, and it will disarm the bracelet alert system. He entered the facility at 8:11:41 PM. At that time, Resident #1 was in the courtyard walking around. At 8:26:12 PM, the courier left the building through the front door. At 8:26:17 PM, Resident #1 walked out the front door. No staff were observed by the door until the Maintenance Director reset the alarm at 8:36 PM. At the time of the elopement, there were 5 nurses and 11 certified nursing assistants working in the facility. When the front door alarmed, no staff initially responded to the alarm. It was alarmed for 25 minutes and was turned off by the Maintenance Director. The surveyor heard the alarm volume at the current sound level on 06/23/25 at 10:30 AM, then asked for the sound to be heard at the level it was at the time of the elopement, and it was at softer level at that time. The facility is shaped as a square. An observation was conducted on 06/19/25 at 10:00 AM of Resident #1's room. Resident #1's room was located on the west, front side of the facility. There is a west front unit, a nurse's station, and a west back unit. A hallway joins the west back to the east back unit. There is an east back unit, a nurse's station, and then an east front unit. A hallway joins the east front to the west front and the front door is in the middle of the joined hallway. The courtyard is opposite of the front door. In an interview with the Maintenance Director at 3:10 PM on 06/23/25, he stated he was working in the back section of the facility, and when he walked through the facility before he left for the evening, he noticed the annunciator and buzzer sounding and a light which told what door it was (this was located at the nurse's station). The front door was unlocked, and the alarm was beeping. He punched in the pass code which is on the side of the door, to reset it. He stated that the alarm stays beeping until it is reset. Staff A, Registered Nurse (RN), who worked the 3-11 shift, stated in a phone interview on 06/23/25 at 12:30 PM that she was aware of the alarm at the time the Maintenance Director turned it off. She worked the 3PM-11PM shift that day (06/18/25) in the 200 unit (east side). She heard the alarm on 06/18/25 around 8:00 PM. When she stepped out of one of the residents' rooms on the east side, the Maintenance Director was approaching the same direction to the door. Because he was going to the door, she did not. He disarmed it. Prior to the alarm going off, she saw the pharmacy courier and she got the medications from him. She does not know how he got into the building. He gave the medications to the east wing first, then the west wing. She did not see him after that. She did not say anything to anyone about hearing the alarm. A review was conducted of a witness statement from Staff E, Certified Nursing Assistant (CNA), who was assigned to Resident #1 on the 3PM-11PM shift on 06/18/25. The statement revealed she saw him in bed at approximately 7:45-8 PM. Around 9:30 PM, she rounded again, and the resident was not in the room. It was not strange since he is always walking. She did not hear any alarm. She continued to do the care to residents until it was time to leave (11PM). A telephone interview was conducted with Staff F, CNA on 06/23/25 at 1:25 PM. He was revealed he worked the 3PM-11PM shift. He was helping another CNA change the roommate of Resident #1 around 9:00 PM on 06/18/25. At 8:00 PM, he saw Resident #1 on the courtyard bench. The resident always goes into the courtyard. Staff F stated he left the facility around 11:15 PM and did not know Resident #1 was missing. A telephone interview was conducted on 06/23/25 at 1:36 PM, with Staff C, CNA on 11PM-7AM shift. She was working with Resident #1's roommate when she first came into the facility at 10:32 PM. She is not sure if Resident #1 was in bed at the time. During the second round, she reported to Staff B, the resident's assigned nurse, that Resident #1 was not in bed (she rounds every 2 hours, but she did not know the exact time). They looked in all the rooms for him and outside the building. A telephone interview was conducted with Staff B, Licensed Practical Nurse (LPN), on 06/23/25 at 12:15 PM. She stated she was the night nurse taking care of Resident #1 on 06/18/25 on the 11:00 PM-7:00 AM shift. She stated at 11:00 PM, she thought she saw the resident in bed but later found out he was not. She did not make any other observations at that time. At about 12:15 AM, she went back to the unit. When she went into Resident #1's room to check on him, she noticed he was not in bed. It did not alarm her because he is easy to redirect and comes to the nursing station during the night. She stated that she was going to check on where he was, but another room put the call-light on and needed assistance. Then, she forgot to look for Resident #1. About 30 minutes later, Staff C, CNA, came to her and asked if Resident #1 was watching television. Staff B then realized she didn't see him in his bed. Everyone started looking for him. She and Staff D, RN, who was working the 11PM-7AM shift on the east back area of the facility, went outside to search the perimeter but did not find him. She stated that around 1:45 AM, Code Silver was called. Per the facility's guideline titled Emergency Color-Code Guide, Code Silver is designated for elopements in the facility. Code Silver + room number denotes that a resident cannot be located. This code immediately initiates a center-wide search.Review of the facility's policy titled Resident Elopement revised 8/2023, documented when a resident is unable to be located on the premises, staff will: Determine if the resident is out on an authorized leave or pass. If not: Notify the Administrator and the Director of Nursing Services. Conduct a thorough search of the center and premises.The facility staff did not inform the Administrator of the missing resident for over 2 hours after staff realized the resident was missing. A telephone interview was conducted on 06/23/25 at 1:40 PM, with Staff D, RN, who worked the 11PM-7AM on the east back hall. He stated around 3:00 AM, he was charting and was notified that Resident #1 was missing. He started searching all the bathrooms but did not find him. Then he started looking outside. Another nurse called the Administrator and Director of Nurses (DON) and he continued searching. He and Staff B went by car to see if they could locate him. In an interview with the Administrator, who is also the Risk Manager, on 06/23/25 at 10:00 AM, she stated she was notified of the elopement on 06/19/25 at approximately 3:30 AM. She immediately made her way to the facility and called the Port Saint [NAME] police and DCF (Department of Children and Families) to notify them of the elopement. Resident #1 was returned to the facility on [DATE] at approximately 8:30 AM by the Port Saint [NAME] Police Department. The resident was returned to the facility by the police 12 hours after he exited the facility. Review of the police report revealed the police responded to the facility at 4:37 AM on 06/19/25. They were given a description of Resident #1 and began to search for him. He was found by police on US Highway 1 in Fort [NAME] the morning of 06/19/25 walking on the sidewalk north bound. He was not carrying a phone, wallet, or any form of identification. He was identified by verbally telling the police his name. He was then transported back to the facility at 8:41AM on 06/19/25. An interview was conducted with Resident #1 on 06/23/25 at 10:35 AM regarding the elopement on 06/18/25. He stated he left around 8:00 PM and started walking. He ended up in a church parking lot for a while. It was getting dark when he left. He was wearing shorts and sneakers. He pushed the door open. He followed someone out, he didn't know the name of the person. He stated he walked on the sidewalk the entire time. He was found by a public safety officer on US 1 in the morning. The surveyor travelled the route by car from [NAME] Hall to the Fort [NAME] police station. Review of the route the resident stated he walked revealed an 11 mile walk to the Fort [NAME] Police station. The resident would likely have crossed the street at Hillmoor Drive and [NAME] Ave, which is a busy crosswalk with a traffic light in front of a hospital. Travelling northbound on US 1 revealed there is a sidewalk all the way up to the police station. US 1 goes from 3 lanes each direction, to 2 lanes in Fort Pierce. On each side of the highway, there are commercial properties like stores, churches, gas stations. The speed limit was 45 miles per hour (MPH) in Port St [NAME], then 40 MPH near the railroad crossing by [NAME] Road and US 1. At the Fort [NAME] police station, the speed limit was 35 MPH. There are 20 traffic lights from where the resident would have started walking on US 1 to where the Fort [NAME] police station was located. Each traffic light had a side street so the resident would have had to cross the side street. There was one railroad crossing. There were 2 traffic lights with side streets that do not have a crosswalk. Review of the Medication Administration Record (MAR) for June 2025 revealed that on 06/19/25 Resident #1 missed the morning dose of Depakote Sprinkles 125mg, 6 capsules po [orally] which were due upon rising (hours of 6:00 AM-10:00 AM); Abilify 15 mg tab was also due upon rising; and the Lidocaine external patch 4% was due to be applied at 6:00 AM. Depakote Sprinkles are used for Epilepsy and Bipolar Disorder. Abilify is used to treat Schizophrenia, Bipolar Disorder and Depression. A Lidocaine patch is used as a local anesthetic that can help relieve minor pain. The facility submitted an acceptable Immediate Jeopardy Removal Plan on 06/26/25 that included: a. On 06/19/2025, educated the pharmacy vendor they cannot pull the door for 15 seconds to enter the building as it disabled the alerting bracelet system. Thus, allowing the residents to exit the building without the safety measure of the door locks engaging. The 15 second egress is a mandatory fire life safety regulation. Completed 06/19/25. b. Door checks are audited weekly upon completion of every shift audit. The doors that are being checked to ensure the alarm system is functioning in the lobby, northeast corridor door, northwest corridor door, southwest corridor, southeast corridor door, dining room door, employee entrance door, and back entrance service store. Initiated 06/19/25 and will be maintained ongoing. Audits were reviewed for the door checks. c. On 06/19/25 the alarm volume increased to maximum sound to allow the staff to hear the alarm better. Completed 06/19/2025. The surveyor verified the sound on 06/23/25. The maintenance director turned the sound level back to the prior level, then back to the level it was raised to, and the sound was louder. d. On 06/19/2025 the center added an additional receptionist for after hours to ensure 24 hour coverage of the front door. Completed 06/19/2025. The surveyor reviewed the scheduled coverage and observed coverage until the surveyor left at 5:30 PM on 06/23/25-06/26/25. e. By 06/20/25 all staff (RN, LPN, CNA, Therapist, Administrative, Dietary Housekeeping, Activities and Social Service were reeducated on the elopement process. When you hear any alarm you respond immediately, if it is the alerting bracelet alarm you begin searching the center and outside grounds for a resident count to match the census. The NHA/ Risk manager (Nursing Home Administrator, Risk Manager) is notified immediately if a resident is missing and notification to law enforcement and other agencies is completed. (Completed 6/20/25, 35 out of 35 nurses, 50 out of 50 CNA's, 63 out of 63 ancillary staff with a total of 148 out of 148 staff). f. By 6/20/25, all staff, (RN,LPN, CNA, Therapist, Administrative, Dietary, Housekeeping, Activities, and Social Service were reeducated on Abuse, Neglect and Exploitation with emphasis on elopement, responding to door alarms, there is 24 hours front door monitoring but they must still respond timely to the alarm, monitoring of resident who are ambulatory around the center ensuring there is a timely search of the center and notification to the NHA/Risk Manager. Completed 06/20/25. 35/ 35 nurses, 50/ 50 CNA's, 63/ 63 ancillary staff with a total of 148/ 148 staff). g. By 06/20/25, all clinical staff (RN, LPN, CNA, 35/ 35 nurses, 50/ 50 CNA's for a total of 85/ 85 were reeducated on ensuring that walking rounds during shift and that shift change are conducted to ensure all residents are in the facility. h. On 06/19/25 daily checks of the alerting bracelet on each at risk elopement resident is completed every shift for placement and every day for functioning. This process has been in place for 36/ 36 residents at risk for elopement. The surveyor reviewed the Treatment Administration Records of the residents at risk for elopement. i. On 06/19/25 signs added to all egress doors that state Notice to visitors and vendors. This is a secure door equipped with a safety egress system. Do not pull or push on the door continuously. Doing so for 15 seconds will disengage the magnetic lock to disable the resident alert system, creating a potential safety risk. Please press the doorbell and allow staff time to respond. Your patience ensures the safety of all residents. Thank you for your cooperation. [NAME] Hall Nursing and Rehab Center. As well as Attention all family members and vendors please do not assist residents in leaving the facility. The surveyor observed the signs on the front receptionist desk, the inside, and outside of the egress front door. The surveyor pressed the egress front door and additional doors. Alarms sounded. j. On 06/19/25, the center has identified 36 residents who are at risk for elopement. All 36 residents have a new elopement risk assessment and Brief Interview for Mental Status (BIMS). All 36 residents have alerting bracelets in place with monitoring every shift for placement and every day for functioning. k. The other egress doors have an additional alarming device exit door alarm that when the door is accessed will signal very loud sound when the door has been accessed. The employee entrance is key coded. Observations of every door were made, and a loud sound was made when the doors were pushed open. l. On 06/19/25 the receptionists were reeducated on never leaving the front door unattended. When leaving for break they must call the supervisors to send a staff member to cover the break. The surveyor interviewed the receptionist on 8:00 AM to 4:00 PM and the 4:00 PM to 8:00 PM receptionist who verified the education that was given. m. On 6/19/25 the staff member that did not respond to alarm was re educated on the importance of responding to any alarm and initiate the elopement process immediately upon determining a missing resident. In addition, received education on When you hear any alarm you respond immediately, if it is the alerting bracelet system alarm you being searching the center and outside grounds for resident count to match the census. The NHA/Risk Manager is notified immediately if a resident is missing, and notification to law enforcement and other agencies is completed. n. On 06/19/25, the maintenance director was reeducated on the importance of not resetting any alarm without initiating the elopement process and completing an outside search. In addition, he received education on when you hear any alarm you respond immediately if it is the alerting bracelet system alarm you begin searching the center and outside grounds for a resident count to match the census, the NHA/Risk Manager is notified immediately if a resident is missing ,and notification to law enforcement and other agencies is completed. The surveyor interviewed the maintenance director on 06/23/25 at 3:10 PM who verified he was educated on this. o. The QAA/QAPI (Quality Assessment and Assurance) (Quality Assurance and Performance Improvement) committee reviewed the initial QAPI on 06/19/25,06/20/25 and 06/24/25 the removal plan was reviewed on 06/26/25. The surveyor verified the implementation of the following immediate actions in the Immediate Jeopardy Removal Plan prior to the Exit on 06/26/25: a. The surveyor reviewed the pharmacy letter that was sent on 6/19/25.b. The surveyor reviewed the door checks are audited-weekly audits are due to start tomorrow.c. Alarm volume was heard at the low sound and increased sound by the surveyor on 06/23/25.d. Receptionist schedule revealed 24 hour coverage starting 6/19/25 and education. The receptionists who worked the day and evening shifts were interviewed on 06/25/25 at 4:00 PM and they verified their education.e. The surveyor reviewed staff education and compliant with education and # of staff educated.f. The surveyor reviewed staff education and compliant with education and # of staff educated.g. Education for walking rounds was reviewed for LPN and RN assigned to Resident #1 on 06/18/25.h. The elopement risks are completed and on the Treatment Administration Records for the residents at risk.i. Signs were as written in the removal plan. Signs were observed by the surveyor.j. All 36 residents identified as elopement risk, were in all 3 elopement books.k. Observed the doors and heard the loud sound the doors make when opened.l. The surveyor reviewed their education.m. Reviewed the 1:1 education for the nurse.n. Reviewed the 1:1 education for the Maintenance Director.o. Reviewed QAPI for 06/19/25, 06/20/25, 06/24/25, 06/25/25, 06/26/25. The following staff were interviewed for verification of staff education: Staff A, RN, interviewed on a telephone interview on 06/23/25 at 12:30 PM stated after the incident they had elopement drills. Code silver means we go to every exit and closet check and the residents are accounted for and do a head check. We report the room number and the patient who is missing then the administration is notified. Staff F, CNA, interviewed on a telephone interview on 06/23/25 at 1:25 PM. He stated he started working in May and he had an elopement drill on Friday. On 06/23/25 at 1:36 PM an interview was conducted via telephone to Staff C, CNA. They have had Elopement drills since 2018. They have had more elopement drills in the past days. When you notice the patient is missing, you look for the patient, and report to the nurse if you don't see the patient. On 06/23/25 at 1:40 PM an interview was conducted via telephone with Staff D, RN. He worked in the facility since March 2025. Elopement drills have been given close to the hire date and since then. They have had drills throughout the week after the elopement. On 06/23/25 at 2:00 PM a telephone interview was conducted with Staff G, LPN. She stated they have done many elopement drills. They called Code Silver and everybody was looking. On 06/25/25 at 3:48 PM, Staff H, CNA was interviewed. She stated when the door alarms you go out try to see cause, see if resident there, check rooms, let nurse know, check all locations, announce code silver. I received education a couple evenings ago. I received a test with scenarios, on neglect and elopement topics.