**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to protect the residents' right to be free from neglect. The facility failed to revise the care plan and closely supervise 2 (Resident #1, and #2) of 6 sampled cognitively impaired residents with known exit seeking behavior and/or identified to be at risk for unsafe wandering and elopement. On 1/23/23 at approximately 6:25 p.m., Resident #1 who was cognitively impaired with previous elopement attempt walked out of the facility without staff knowledge. A visitor alerted the staff Resident #1 was walking away in the parking lot. On 2/8/23 at approximately 3:00 a.m., Resident #2 who was cognitively impaired with wandering behavior walked out of the facility without staff knowledge. Resident #2 was found 0.3 mile from the facility at an intersection of a busy four lane major road. Residents #1, and #2 had a likelihood for serious harm, injury, or death due to the risk for serious injury from a fall, getting lost or being hit by a car. The facility's failure to provide the necessary care and services to prevent neglect resulted in the determination of Immediate Jeopardy level as a scope and severity of isolated (J) starting on 1/23/23. On 2/17/23 at 12:47 p.m., the Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The facility census was 58. The findings included: Cross reference to F689, F835 and F867 The facility's policy and procedure titled, Abuse, Neglect, Mistreatment and Exploitation Policy with a date revised of 10/2022 noted the facility is, committed to maintaining a safe environment for residents . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Prevention . Identification, correction and intervention in situations in which . neglect is more likely to occur (this should include analysis of the physical environment that might make . neglect more likely to occur . deployment of associates on each shift to meet the needs of the residents . assessment, care planning and monitoring of residents with needs and behaviors which might lead to . neglect). Protection of Resident . Upon learning of alleged . neglect, the Administrator or supervisor on duty should attempt to take necessary steps to verify residents are protected from subsequent episodes of . neglect. Review of the clinical record revealed Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including altered mental status, and dementia. On 1/16/23, the facility completed an elopement evaluation which noted the resident had a medical diagnosis of dementia, no history of exit seeking, wandering away or getting lost, and no history of unmet needs, alcohol, or drug use. The Registered Nurse completing the elopement evaluation determined Resident #1 was not at risk for elopement. Review of the case management note dated 1/17/23 showed Resident #1 had recently moved into the memory care unit (specialized unit providing safe, structured environment for people with Alzheimer's or dementia) of an Assisted Living Facility where he required 24 hours caregivers due to behaviors. On 1/19/23 at 3:38 p.m., the dietitian documented Resident #1 was now on one-to-one supervision due to elopement risk per social service. On 1/21/23 the nurse documented in a progress note at 6:28 p.m., the resident was oriented to self. Resident was found wandering outside of the skilled nursing facility door. The nurse brought the resident back. The Director of Nursing (DON) was notified about the placement of a wander alert bracelet (alerts staff of resident unsafe wandering). The resident was placed on hourly monitoring until wander alert placement. The clinical record lacked documentation of hourly monitoring for Resident #1. On 1/22/23 at 3:36 p.m., a nurse's notes written by Licensed Practical Nurse (LPN) Staff N, stated sits in wheelchair throughout the day but often gets up out of it and walks around. The 5-day Minimum Data Set (MDS) Version 1.17.1 assessment with a reference date of 1/22/23 noted Resident #1 required the supervision (oversight, encouragement, and cueing) to ambulate on the unit. The admission MDS noted the resident's cognition was severely impaired. The assessment noted Resident #1 was wandering, and the behavior of this type occurred one to three days. The care plan was not updated on 1/21/23 to address the resident's wandering behavior and attempt at elopement. The care plan did not document interventions, such as increased supervision to prevent unsafe wandering and elopement. Further review of the progress notes revealed on 1/23/23 at 7:33 p.m., the Registered Nurse documented in a change of condition note Resident #1 had increased confusion, personality change. Resident #1 was nowhere to be found. Staff on site started looking for him. A family member told staff Resident #1 was walking toward the parking lot. Two nurses went to get the resident and assisted him back to the facility. Resident #1 was placed on every 15 minutes monitoring. The facility submitted a Federal Day 1 and Five Day report to the Florida Agency for Healthcare Administration for an allegation of injury of unknown source after Resident #1 walked out of the facility without staff knowledge. The facility failed to identify neglect related to the lack of supervision of Resident #1 resulting in unsafe wandering and elopement. The corrective actions listed included: Resident #1 was placed on one-on-one supervision until discharge. An elopement drill was conducted. All residents were evaluated for elopement risk, and none were found to be at risk. On 2/13/23 at 3:40 p.m., Registered Nurse (RN) Staff G said she completed the paperwork when Resident #1 arrived at the facility on 1/16/23. He was very weak; therefore, she did not think he was an elopement risk. She said Resident #1 did not show signs of exit seeking. On 1/23/23 Resident #1 was sitting in the lobby near the front entrance of the facility. They keep an eye on every resident when they are sitting in the lobby. A resident's daughter who was coming in said to the staff, I don't think [Resident #1] is supposed to be out by the parking lot. That's when they ran out to look for him. He was found standing next to a car, around the building, in the shared parking lot of the Assisted Living Facility and the skilled nursing facility. She said she didn't know which door the resident eloped from, but he was closer to the front door of the skilled nursing facility. On 2/14/23 at 6:03 p.m., RN Staff L said Resident #1 usually sat by the nurse's station. On 1/23/23 at approximately 6:20 p.m., she did not see him sitting at the nurse's station next to the lobby and started looking for him. She said, A family member told us he was in the parking lot. We found him around the building in the parking lot. He was walking like he was going to leave. He was okay when we brought him back. We placed him on one-to-one supervision. The sunset time on 1/23/23 was 6:04 p.m., the weather was clear, and the high and low temperature between 6:00 p.m., and 12:00 a.m., was 57/54 degrees Fahrenheit (www.TimeandDate.com). On 2/14/23 at 2:13 p.m., in a telephone interview the Administrator said she was not aware Resident #1 had a prior attempt to leave the facility or exhibited exit seeking behavior. She said the interdisciplinary team discussed Resident #1's elopement, including how he and why he got out. She said her understanding was a reassessment for elopement risk was done for all the residents in the building, and in-services conducted on elopement prevention to make sure they are keeping an eye on the residents. The Administrator said she did not have documentation of systemic or process changes to monitor other residents with needs and behaviors which may lead to neglect, including adequate supervision to prevent subsequent episodes of unsafe wandering and elopement. 2. Review of the facility's incidents list revealed on 2/10/23 at 1:05 p.m., the facility submitted and substantiated neglect in a Federal Five Day report to the Agency For Health Care Administration. Review of the investigation revealed on 2/8/23 at approximately 3:20 a.m., staff noticed Resident #2 was not in her room and started to look for her. Resident #2 left the facility without staff knowledge and was found on 2/8/23 at approximately 3:30 a.m., at the corner of a busy four lanes road. The investigation noted Resident #2 was confused and stated she woke up and did not know where she was or what she was doing. The facility's investigation noted Resident #2, exited the community through ALF (Assisted Living Facility) front door. Review of the clinical record for Resident #2 revealed an admission date of 12/21/22 with diagnoses including encephalopathy (a broad term for any brain disease that alters brain function or structure). The elopement risk evaluation dated 12/21/22 noted Resident #2 did not have a diagnosis of Dementia, Alzheimer's disease, Anxiety disorder or Delusions and the resident was not currently capable of independent mobility. Staff completing the evaluation entered No to the question, Does the resident have a history of exit seeking, wandering away or getting lost? and Does the resident have a history of unmet needs, alcohol or drug abuse? The facility determined Resident #2 was not at risk for elopement. The clinical record lacked documentation Resident #2 was reassessed for risk for elopement after Resident #1's elopement on 1/23/23. The admission Minimum Data Set (MDS) assessment Version 1.17.1 with an assessment reference date of 12/27/22 noted Resident #2 required extensive physical assistance of one person for walking in room and off the unit. The resident was not steady for walking, and only able to stabilize with human assistance. Resident #2 used a walker for ambulation. The admission noted the resident's cognition was severely impaired. The care plan initiated on 1/3/23 noted Resident #2 had impaired cognitive function/Dementia or impaired thought processes. Review of the progress notes from 12/21/22 through 2/8/23 revealed several entries noting Resident #2 was confused. On 1/27/23 at 1:35 a.m., the nurse documented, tonight she is up out of bed walking r/t (related to) having problems sleeping. This has been for a couple of nights. On 1/28/23 at 10:30 p.m., the nurse documented the resident had been having difficulty sleeping at night. She would get up and walk around the facility with her walker, sit in the lobby and then go back to bed. On 2/13/23 at 3:20 p.m., CNA (Certified Nursing Assistant) Staff F said sometimes Resident #2 would get up at night, walk around and talk to the staff. On 2/13/23 at 3:40 p.m., RN Staff G said Resident #2 was pleasantly confused, and would walk around the facility. On 2/13/23 at 4:10 p.m., CNA Staff J said Resident #2 was pleasantly confused, and wandered around the halls. On 2/13/23 4:30 p.m., CNA Staff E said Resident #2 was confused, and walked around the hall with her walker. On 2/8/23 at 3:00 p.m., the Scheduler said everyone knew Resident #2 was confused and walked around. The care plan was not updated to increase supervision when Resident #2 was up at night walking around the unit. On 2/15/22 at 4:50 p.m., the Administrator said Resident #2 left through the double doors of the skilled nursing unit that leads into the Assisted Living Facility (ALF). She said the ALF door alarmed when the resident left but the ALF staff did not respond to the alarm. They only responded after the Skilled Unit Staff called and told them they were looking for Resident #2. She said she realizes now that although the resident did not have dementia or Alzheimer's, she was definitely at risk for elopement. She was ambulatory, cognitively impaired and a wanderer. She verified Resident #2 should have been identified to be at risk for elopement, although she did not show signs of exit seeking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to implement processes to ensure adequate supervision of 2 (Resident #1 and #2) of 6 sampled cognitively impaired resident at risk for elopement to prevent unsafe wandering and elopement. On 1/23/23 at approximately 6:25 p.m., Resident #1 who was a vulnerable cognitively impaired with previous elopement attempt walked out of the facility without staff knowledge. A visitor alerted the staff Resident #1 was walking away in the parking lot. On 2/8/23 at approximately 3:00 a.m., Resident #2 who was cognitively impaired with wandering behavior walked out of the facility without staff knowledge. Resident #2 was found approximately 0.3 mile from the facility at an intersection of a busy four lane major road. The failure to ensure adequate supervision to protect vulnerable residents from unsafe wandering and elopement resulted in a determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 1/23/23 when Resident #1 walked out of the facility without staff knowledge. The Administrator was notified of the Immediate Jeopardy on 2/17/23 at 12:47 p.m. and provided the IJ templates. The Immediate Jeopardy was ongoing. The facility census was 58 with four residents at risk for elopement. The findings included: Cross reference to F600, F835 and F867. The Facility's Elopement Risk policy last revised on 10/2022 noted, Skilled Nursing Elopement: A situation in which a resident leaves the premises or a safe area without the community's knowledge and supervision which may represent a risk to the resident's health and safety . Residents accepted for admission should be assessed upon admission into the Community and appropriate interventions should be established to respond to the resident's potential exit/elopement seeking behavior . Residents should be assessed on admission and a minimum of quarterly or as condition change warrants . Note: Emergency fire exit doors should always be alarmed in the instant auditory alarm mode. Upon exit door alarm activation . The designated associates and available associates should immediately go to the site of the activation . 1. Review of the clinical record revealed Resident #1 was a vulnerable [AGE] year-old male admitted to the facility for short term rehabilitation on 1/16/23. Diagnoses included altered mental status, dementia, cognitive communication deficit. Review of the case management note dated 1/17/23 showed Resident #1 had recently moved into the memory care unit (specialized unit providing safe, structured environment for people with Alzheimer's or dementia) of an Assisted Living Facility where he required 24 hours caregivers due to behaviors. On 1/16/23, the facility completed an elopement evaluation which noted the resident had a medical diagnosis of dementia, no history of exit seeking, wandering away or getting lost, and no history of unmet needs, alcohol, or drug use. The Registered Nurse completing the elopement evaluation determined Resident #1 was not at risk for elopement. On 1/17/23 the nurse documented in a progress note at 3:49 a.m., the resident is alert to himself, with significant confusion. Resident was placed on one-to-one (supervision) due to wandering out of his room and out of his wheelchair without a walker or assistance. On 1/19/23 at 3:38 p.m., the Registered Dietitian documented Resident #1 was now on one-to-one supervision due to elopement risk per social service. The clinical record lacked documentation Resident #1 received one-to-one supervision. On 1/21/23 the nurse documented in a progress note at 6:28 p.m., the resident was oriented to self. Resident was found wandering outside of the skilled nursing facility door. The nurse brought the resident back. The Director of Nursing (DON) was notified about the placement of a wander alert bracelet (alerts staff of resident unsafe wandering). The resident was placed on hourly monitoring until wander alert placement. The clinical record lacked documentation of hourly monitoring for Resident #1. On 1/22/23 at 3:36 p.m., a nursing progress note documented Resident #1 was alert and oriented with confusion and ambulated independently. The 5-day Minimum Data Set (MDS) Version 1.17.1 assessment with a reference date of 1/22/23 noted Resident #1 required the supervision (oversight, encouragement, and cueing) to ambulate on the unit. The admission MDS noted the resident's cognition was severely impaired. The assessment noted Resident #1 was wandering, and the behavior of this type occurred one to three days. The care plan was not updated to address the resident's wandering behavior and attempt at elopement. The care plan did not document interventions to prevent unsafe wandering and elopement. Further review of the progress notes revealed on 1/23/23 at 7:33 p.m., the Registered Nurse documented in a change of condition note Resident #1 had increased confusion, and personality change. Resident #1 was nowhere to be found. Staff on site started looking for him. A family member told staff Resident #1 was walking toward the parking lot. Two nurses went to get the resident and assisted him back to the facility. Resident #1 was placed on every 15 minutes monitoring. The facility's investigation dated 1/23/23 noted Resident #1 was sitting in common area at the nursing station on 1/23/23 at around 6:20 p.m. At 6:25 p.m., the resident was not in the common area and the nurses started looking for the resident. A family member came in through the front door and stated there was a resident in the parking lot. The investigation findings noted Resident #1 walked out the door of the skilled nursing facility unsupervised. Resident was placed on one on one immediately and discharged the next day to a secured facility. The facility submitted a Day 1 and Five Day report to the Florida Agency for Healthcare Administration and substantiated an allegation of injury of unknown source for Resident #1. The facility failed to identify the lack of supervision despite known exit seeking behavior and attempt at elopement resulted in Resident #1's unsafe wandering and elopement. The corrective actions listed included: Resident #1 was placed on one-on-one supervision until discharge. An elopement drill was conducted. All residents were evaluated for elopement risk, and none were found to be at risk. On 2/14/23 at 2:13 p.m., in a telephone interview the Administrator said she was not aware Resident #1 had a prior attempt to leave the facility or exhibited exit seeking behavior. She said the interdisciplinary team discussed the elopement, including how and why he got out. She said her understanding was a reassessment for elopement risk was done for all the residents in the building, and in-services conducted on elopement prevention to make sure they are keeping an eye on the residents. The Administrator said she did not have documentation of the residents' reassessments or staff in-services conducted. On 2/13/23 at 3:40 p.m., Registered Nurse (RN) Staff G said she completed the paperwork when Resident #1 arrived at the facility on 1/16/23. He was very weak; therefore she did not think he was an elopement risk. She said Resident #1 did not show signs of exit seeking. They keep an eye on every resident when they are sitting in the lobby. On 1/23/23 Resident #1 was sitting in the lobby near the front entrance of the facility. A resident's daughter who was coming in said to staff, I don't think [Resident #1] is supposed to be out by the parking lot. That's when they ran out to look for him. He was found standing next to a car, around the building, in the shared parking lot of the Assisted Living Facility and the skilled nursing facility. She said she didn't know which door the resident eloped from, but he was closer to the front door of the skilled nursing facility. On 2/14/23 at 6:03 p.m., RN Staff L said Resident #1 usually sat by the nurse's station. On 1/23/23 at approximately 6:20 p.m., she did not see him sitting at the nurse's station next to the lobby and started looking for him. She said, A family member told us he was in the parking lot. We found him around the building in the parking lot. He was walking like he was going to leave. He was okay when we brought him back. We placed him on one-to-one supervision. The sunset time on 1/23/23 was 6:04 p.m., the weather was clear, and the high and low temperature between 6:00 p.m., and 12:00 a.m., was 57/54 degrees Fahrenheit (www.TimeandDate.com). On 2/15/23 at 4:50 p.m., the Administrator reviewed the elopement investigation for Resident #1 and verified the resident walked out the front door of the facility without staff knowledge. She verified since the elopement the facility had not implemented a process to prevent cognitively impaired residents at risk for elopement from leaving the facility without staff knowledge through the front door. She said the front door is equipped with a wander alert system that goes off if a resident with a wander alert bracelet approaches the door. She said residents who do not have a wander alert bracelet would be able to leave the facility unattended without any intervention from the receptionist. The facility provided a list of four cognitively impaired current residents identified to be at risk for elopement who did not have a wander alert bracelet. She said starting today (2/15/23) all four residents would be fitted with a wander alarm to prevent them from leaving the facility without staff knowledge. 2. Review of the clinical record revealed Resident #2 was a vulnerable [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included encephalopathy (a broad term for any brain disease that alters brain function or structure). On 12/21/22, the facility completed an elopement evaluation which noted resident was not at risk for elopement. The clinical record lacked documentation Resident #2 was reassessed for risk for elopement after Resident #1's elopement on 1/23/23. The admission Minimum Data Set (MDS) Version 1.17.1 assessment with an assessment reference date of 12/27/22 noted Resident #2 required extensive physical assistance of one person for walking in room and off the unit. The resident was not steady for moving from seated to standing positions, walking, and only able to stabilize with human assistance. Resident #2 used a walker for ambulation. The admission noted the resident's cognition was severely impaired. Resident #2 did not display any behaviors. The care plan initiated on 1/3/23 noted Resident #2 had impaired cognitive function/Dementia or impaired thought processes. Review of the progress notes from 12/21/22 through 2/8/23 revealed several entries noting Resident #2 was confused. On 1/27/23 at 1:35 a.m., the nurse documented, tonight she is up out of bed walking r/t (related to) having problems sleeping. This has been for a couple of nights. On 1/28/23 at 10:30 p.m., the nurse documented the resident had been having difficulty sleeping at night. She would get up and walk around the facility with her walker, sit in the lobby and then go back to bed. The care plan was not updated to increase supervision when Resident #2 was up at night walking around the unit to prevent unsafe wandering and elopement. On 2/8/23 at 3:50 a.m., the Licensed Practical Nurse documented in a progress note Resident #2 went to the front door of the Assisted Living Facility and was found by the light at the corner of [NAME] Ranch Parkway and [NAME] Avenue (busy four lane road). Review of the facility's investigation revealed on 2/8/23 at around 3:20 a.m., Resident #2 could not be located. The nurses and Certified Nursing Assistants looked for the resident within the skilled nursing facility (SNF), the Assisted Living Facility connected to the SNF, and the outside perimeter of the community. Certified Nursing Assistant (CNA) Staff O said the laboratory guy told her he saw Resident #2 at the light. Registered Nurse Staff I got in her car to look for the resident. She located Resident #2 approximately 0.3 mile in the street between [NAME] Ranch Parkway and [NAME] Avenue. The weather on 1/23/23 was clear, and the high and low temperature between 12:00 a.m., and 6:00 a.m., were 64/59 degrees Fahrenheit (www.TimeandDate.com). The facility's investigation noted, Resident exited the community through the ALF (Assisted Living Facility) front door. The facility's investigation did not address the lack of adequate supervision to prevent the unsafe wandering and elopement. On 2/13/23 at 11:20 a.m., the Maintenance Director said the double door leading to the ALF was not functioning properly, and did not lock. The door alarm would only go off if a resident with a wander alarm approached the door, but it would not lock, and anyone could walk through the door and get to the ALF. On 2/13/23 at 3:40 p.m., RN Staff G said Resident #2 was pleasantly confused, and would walk around the facility. On 2/13/23 at 4:10 p.m., CNA Staff J said Resident #2 was pleasantly confused, and wandered around the halls. On 2/13/23 4:30 p.m., CNA Staff E said Resident #2 was confused, and walked around the hall with her walker. On 2/14/23 at 4:40 p.m., the Maintenance Director said after Resident #2 eloped on 2/8/23, he checked the door and realized the door was not functioning properly, and he ordered the part to fix the door. He said they were still waiting for the part they ordered from a contractor. He said he used to check the doors every Friday but now checks them twice a week. On 2/14/23 at 7:15 p.m., observation of route walked by Resident #2 from the facility to [NAME] Ranch Park way to [NAME] Avenue showed uneven and surfaces on the sidewalk walking towards [NAME] Avenue, no streets lights due to construction making for poor night visibility. The speed limit on [NAME] Avenue was 45 miles per hour. *Photographic Evidence Obtained* On 2/15/22 at 4:50 p.m., the Administrator verified Resident #2 eloped through the double doors connecting the skilled nursing facility to the Assisted Living Facility. She verified the double door was defective, did not lock and did not alarm when someone without a wander alert went through. She verified since Resident #2's elopement, the facility had not implemented increase supervision of cognitively impaired residents at risk for elopement to prevent unsafe wandering through the ALF, and out of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility's Administration failed to utilize its resources effectively to prevent neglect and ensure cognitively impaired residents at risk for elopement were free from unsafe wandering and elopement. On 1/23/23 at approximately 6:25 p.m., Resident #1 who was cognitively impaired with previous elopement attempt walked out of the facility without staff knowledge. A visitor alerted the staff Resident #1 was walking away in the parking lot. On 2/8/23 at approximately 3:00 a.m., Resident #2 who was cognitively impaired with wandering behavior walked out of the facility without staff knowledge. Resident #2 was found 0.3 mile from the facility at an intersection of a busy four lane major road. Residents #1, and #2 had a likelihood for serious harm, injury, or death due to the risk for serious injury from a fall, getting lost or being hit by a car. The failure of the facility's Administration to provide the necessary care and services to prevent neglect, unsafe wandering and elopement of cognitively impaired residents at risk for elopement resulted in the determination of Immediate Jeopardy level as a scope and severity of isolated (J) starting on 1/23/23. On 2/17/23 at 12:47 p.m., the Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The facility census was 58. The findings included: Cross reference to F600, F689 and F867 The Administrator's job description signed on 10/4/22 stated, Under minimal supervision, directs the day-to-day health care functions of the community in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to ensure the highest degree of quality care is provided to our residents at all times . The Director of Nursing's job description signed on 2/6/23 noted, Responsible and accountable for maintaining the highest degree of quality care at all times . Oversee the coordination of care plans for each resident; 3) works with other team members to monitor date to day care levels of residents for quality assurance . 1. Review of the facility's incident investigations and reports revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to altered mental status, Dementia, and cognitive communication deficit. Review of the case management note dated 1/17/23 showed Resident #1 previously resided in a memory care unit (specialized unit providing safe, structured environment for people with Alzheimer's or dementia) of an Assisted Living Facility (ALF) where he required 24 hours caregivers due to behaviors. On 1/6/23 the facility completed an elopement evaluation and determined Resident #1 was not at risk for elopement despite diagnoses of Dementia, and previously residing in a memory care unit at an ALF where he required 24 hours supervision. The progress note dated 1/21/23 at 6:28 p.m. documented Resident #1 was oriented to self. He was found wandering outside of the skilled nursing facility door. The nurse brought him back. The Director of Nursing was notified about the placement of a wander alert bracelet (alerts staff of resident unsafe wandering). The resident was placed on hourly monitoring until wander alert placement. There was no documentation Resident #1 was placed on hourly monitoring or fitted with a wander alert bracelet. On 1/23/23 at 7:33 p.m., in a progress note, the Registered Nurse documented Resident #1 had increased confusion, and personality change. Resident #1 was nowhere to be found. Staff on site started looking for him. A family member told staff Resident #1 was walking toward the parking lot. Two nurses went to get the resident and assisted him back to the facility. Resident #1 was discharged on 1/24/23 to the secured unit of the ALF where he previously resided. On 2/14/23 at 2:13 p.m., in a telephone interview the Administrator said she was not aware Resident #1 had a prior attempt to leave the facility or exhibited exit seeking behavior. She said the interdisciplinary team discussed the elopement, including how and why he got out. She said her understanding was a reassessment for elopement risk was done for all the residents in the building, and in-services conducted on elopement prevention to make sure they are keeping an eye on the residents. The Administrator did not have documentation of the residents' reassessments or staff in-service conducted. 2. Further review of the facility's incident investigations and reports revealed Resident #2 was a vulnerable cognitively impaired [AGE] year-old female admitted to the facility on [DATE] with diagnoses including encephalopathy (a broad term for any brain disease that alters brain function or structure). The elopement evaluation completed on 12/21/22 noted Resident #2 was not at risk for elopement even though she was confused, ambulatory and wandered on the unit. On 1/27/23 at 1:35 a.m., Resident #2 started wandering at night. The nurse documented, tonight she is up out of bed walking r/t (related to) having problems sleeping. This has been for a couple of nights. On 1/28/23 at 10:30 p.m., the nurse documented Resident #2 had been having difficulty sleeping at night. She would get up and walk around the facility with her walker, sit in the lobby and then go back to bed. The clinical record lacked documentation of increased supervision of the cognitively impaired resident with behavior of wandering at night to prevent unsafe wandering and elopement. On 2/8/23 at 3:50 a.m., the Licensed Practical Nurse documented in a progress note Resident #2 went to the front door of the Assisted Living Facility and was found at the corner of [NAME] Ranch Parkway and [NAME] Avenue (busy four lane road). On 2/15/23 at 10:30 a.m., the Director of Nursing said she had been employed at the facility since 2/6/23. She said for the three days she had been employed at the facility she had seen Resident #2 in the lobby area, she liked to be around people. On 2/15/23 at 4:50 p.m., the Administrator said she currently was the Risk Manager for the facility, and was not aware Resident #1 attempted to leave the facility without staff knowledge on 1/21/23. She said the process is to look at incidents as a team and investigate. She did not know why Resident #1's attempt at elopement was not reported to her. She said she could not speak to a process to ensure cognitively impaired residents at risk for elopement did not walk through the front door of the facility unsupervised from 8:00 a.m., to 6:00 p.m. when the receptionist leaves. She said two weeks ago, the receptionist started a new schedule and leaves at 4:30 p.m. The Administrator said the community includes and Assisted Living Facility which is connected to the skilled nursing facility by a set of double doors which are equipped with a wander alert system. She verified the door has not been functioning properly and did not lock. She said Resident #2 was able to walk through the doors unsupervised, and exited the building through the front door of the Assisted Living Facility. She said the facility did not increase supervision of cognitively impaired residents to prevent further incidents of unsafe wandering and elopement. On 2/13/23 the facility identified four residents who were at risk for elopement and did not have a wander alert bracelet and said they could have walked out of the facility without staff knowledge through the front door of the skilled nursing facility or through the Assisted Living Facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policies and procedures, resident, and staff interviews the facility failed to develop and implement appropriate corrective actions related to adequate supervision of cognitively impaired residents at risk for elopement and exit seeking behaviors. Resident #1 was a vulnerable [AGE] year-old male who was in the facility for short term rehabilitation needing increase supervision. On 1/23/23 at approximately 6:25 p.m., Resident #1 who was cognitively impaired with previous elopement attempt walked out of the facility without staff knowledge. A visitor alerted the staff Resident #1 was walking away in the parking lot. Resident #2 was vulnerable [AGE] year-old female who resides in the facility with wandering behaviors. On 2/8/23 at approximately 3:00 a.m., Resident #2 who was cognitively impaired with wandering behavior walked out of the facility without staff knowledge. Resident #2 was found 0.3 mile from the facility at an intersection of a busy four lane major road. The facility failure to develop and implement appropriate corrective actions related to adequate supervision of cognitively impaired residents at risk for elopement and exit seeking behaviors resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) beginning on 1/23/23. The Administrator was notified of the Immediate Jeopardy on 2/17/23 at 12:47 p.m. and provided the IJ templates. The Immediate Jeopardy was ongoing. The facility census was 58 with 4 other residents the facility identified at risk for elopement. The findings included: Cross reference to F600, F689 and F835. The facility's Quality Assurance & Performance Improvement (QAPI) Program Overview revised 1/23 stated: The QAPI plan provides guidance for the overall quality improvement program to enrich the lives of those we serve with compassion, respect, excellence and integrity . seeks to identify trends, patterns and opportunities to improve our excellence in quality of care, quality of life, resident choice, person-direct care, and resident transitions within the organization . identify trends . based on system analysis established thresholds and outcomes . Governance and Leadership Accountability and Responsibility: The Health Care Administrator (HCA) is responsible and accountable for verifying QAPI is implemented within community . Success Plan: Opportunities shall be identified, and a Success Plan developed to take a systematic approach to revise and improve care or services in areas identified .The completed Success Plan forms are to be utilized by the Community Team to present the success plan, progress, and resolution attained for unresolved opportunities during the monthly Quality Assurance Performance Improvement Meeting. The facility's Administrator job description signed on 10/4/22 stated Assumes the administrative authority, responsibility, and accountability of these . Serves on various committees of the facility (i.e., Infection Control, Quality Assurance & Assessment, etc.) . Assists in developing and implementing appropriate plans of action to correct identified quality deficiencies; Consults with department directors concerning operations to assist in eliminating/correcting problem areas, and/or improvement of services. 1. Review of the facility's incident investigations and reports revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to altered mental status, Dementia, and cognitive communication deficit. Review of the case management note dated 1/17/23 showed Resident #1 previously resided in a memory care unit (specialized unit providing safe, structured environment for people with Alzheimer's or dementia) of an Assisted Living Facility (ALF) where he required 24 hours caregivers due to behaviors. On 1/6/23 the facility completed an elopement evaluation and determined Resident #1 was not at risk for elopement despite diagnoses of Dementia, and previously residing in a memory care unit at an ALF where he required 24 hours supervision. The progress note dated 1/21/23 at 6:28 p.m. documented Resident #1 was oriented to self. He was found wandering outside of the skilled nursing facility door. The nurse brought him back. The Director of Nursing was notified about the placement of a wander alert bracelet (alerts staff of resident unsafe wandering). The resident was placed on hourly monitoring until wander alert placement. There was no documentation Resident #1 was placed on hourly monitoring or fitted with a wander alert bracelet. On 1/23/23 at 7:33 p.m., in a progress note, the Registered Nurse documented Resident #1 had increased confusion, and personality change. Resident #1 was nowhere to be found. Staff on site started looking for him. A family member told staff Resident #1 was walking toward the parking lot. Two nurses went to get the resident and assisted him back to the facility. Resident #1 was discharged on 1/24/23 to the secured unit of the ALF where he previously resided. On 2/14/23 at 2:13 p.m., in a telephone interview the Administrator said she was not aware Resident #1 had a prior attempt to leave the facility or exhibited exit seeking behavior. She said the interdisciplinary team discussed the elopement, including how and why he got out. She said her understanding was a reassessment for elopement risk was done for all the residents in the building, and in-services conducted on elopement prevention to make sure they are keeping an eye on the residents. The Administrator did not have documentation of the residents' reassessments or staff in-service conducted. 2. Resident #2 was a vulnerable cognitively impaired [AGE] year-old female admitted to the facility on [DATE] with diagnoses including encephalopathy (a broad term for any brain disease that alters brain function or structure). The elopement evaluation completed on 12/21/22 noted Resident #2 was not at risk for elopement even though she was confused, ambulatory and wandered on the unit. Review of the progress notes showed on 1/27/23 at 1:35 a.m., the nurse documented, tonight she [Resident #2] is up out of bed walking r/t (related to) having problems sleeping. This has been for a couple of nights. On 1/28/23 at 10:30 p.m., the nurse documented Resident #2 had been having difficulty sleeping at night. She would get up and walk around the facility with her walker, sit in the lobby and then go back to bed. The clinical record lacked documentation of increased supervision of the cognitively impaired resident with behavior of wandering at night to prevent unsafe wandering and elopement. On 2/8/23 at 3:50 a.m., the Licensed Practical Nurse documented in a progress note Resident #2 went to the front door of the Assisted Living Facility and was found at the corner of [NAME] Ranch Parkway and [NAME] Avenue (busy four lane road). On 2/15/23 at 10:30 a.m., the Administrator said she did not have documentation of a Quality Assurance and Performance Improvement meeting to discuss the recent elopements at the facility. She said the interdisciplinary team discussed the incidents in a clinical meeting the following day. They looked at other residents to see if anyone else was at risk for elopement. She said the previous Director of Nursing was responsible for the education and the audits. She said she recognized elopement was a major concern. The Administrator said, I don't think I would say there was not a problem. I think we recognized that there is an issue. The Administrator did not have documentation of systems altered to prevent further incidents of unsafe wandering and elopements of cognitively impaired residents identified to be at risk for elopement.