**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of facility's policies and procedures, and staff interview the facility failed to protect residents' rights to be free from neglect. The facility neglected to develop a care plan and ensure adequate supervision to prevent unsafe wandering and elopement for 1 (Resident #386) of 5 sampled cognitively impaired residents with active exit seeking behaviors. On 4/1/23 at approximately 4:30 p.m., Resident #386 who was cognitively impaired, and wheelchair bound was not adequately supervised. The resident wheeled herself through an unsecured door of the skilled nursing facility into a hallway leading to the adjoining Assisted Living Facility. Resident #386 left through the front door of the Assisted Living Facility, and traveled unsupervised in her wheelchair, approximately three tenths of a mile, and crossed two streets. On 4/1/23 at 5:45 p.m., a staff member from a neighboring skilled nursing facility found Resident #386 wandering the streets. Resident #386 had a likelihood for serious harm, injury, or death due to the risk for serious injury from a fall, getting lost or getting 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 at a scope and severity of isolated (J) starting on 4/1/23. On 7/14/23 at 4:00 p.m., the facility's Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The facility census was 37 with five residents at risk for unsafe wandering and elopement. The findings included: Cross reference to F689, F835 and F867. The facility's policy and procedure for abuse with a revised date of 10/23/22 noted, Neglect. Failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness . Prevention. Identify, correct, and intervene in situations where . neglect, and/or mistreatment are more likely to occur. This includes, but is not limited to, identification/analysis of: a. Secluded areas of the facility. b. Sufficient staffing on each shift to meet the needs of the residents/patients. c. Assigned staff demonstrating knowledge of individual resident/patient needs. d. Sufficient and appropriate supervisory staff to identify inappropriate behaviors. e. Residents/patients with needs and behaviors which might lead to . neglect. .The facility will take all necessary corrective actions depending on the results of the investigation . Occurrences will be analyzed to determine if any changes in policy and procedures should be implemented to prevent future occurrences . Review of the clinical record revealed Resident #386 was an [AGE] year-old female admitted to the facility from an acute care hospital on 1/17/23 with diagnoses including Alzheimer's disease, history of intracranial hemorrhage (bleeding), visual loss in both eyes, traumatic brain injury, and seizures. Review of the progress notes showed on 1/21/23 Resident #386 was up wandering in the hallway, attempting to go out exit door. The resident stated she was looking for the kitchen. The resident was reoriented and assisted back to her room and to bed. The admission Minimum Data Set (MDS) Assessment with a target date of 1/23/23 noted the resident's cognition was severely impaired with a Brief Interview for Mental Status of 05. The MDS did not document Resident #386's wandering behaviors. On 2/7/23 the physician ordered to apply a wanderguard (Brand name wander alert to notify staff when the resident leaves a safe area), and check the placement of the wanderguard every shift. Resident #386 was discharged to an acute care hospital on 3/9/23 and returned to the facility on 3/20/23. The elopement evaluation completed on 3/20/23 upon return to the facility noted Resident #386 was exhibiting exit-seeking searching behaviors such as standing by the exit door, looking for someone, asking to go home et cetera. Review of the Medication Administration Record for 3/2023, and 4/2023 noted a physician's order dated 3/21/23 for a wanderguard. The 5-Day Minimum Data Set (MDS) Assessment with a target date of 3/26/23 noted the resident's cognition was severely impaired with a Brief Interview for Mental Status of 01. The MDS noted Resident #386 exhibited wandering behaviors, one to three days. The MDS was inaccurate and did not reflect the use of the wander/elopement alarm. Resident #386 used a wheelchair and required extensive physical assistance of one person for locomotion off unit (How resident moves to and returns from off-unit locations), if in wheelchair, self-sufficiency once in a chair. The care plan was not revised to reflect the risk for elopement and interventions to prevent unsafe wandering and elopement. On 4/1/2023 at 6:56 p.m., a nursing progress note read, Resident was last seen during med pass by nurse in W/C (wheelchair) at nurses station at 1630 (4:30 p.m.). CNA (Certified Nursing Assistant) notified nurse as 1755 (5:55 p.m.) that resident was no longer in nurses station area nor in dining area. Head count completed and noticed that the resident was no longer on grounds. Absence of alarms did not notify facility that resident had exited the building. Found at near [sic] by facility . Family, MD, and DON (Director of Nursing) notified of elopement. Review of the facility's investigation, and analysis of the incident revealed on 4/1/23 at 4:30 p.m., Resident #386 was seen at the nurses station. Upon investigation it was apparent she then traveled in her wheelchair down the back hallway where the wander guard was alarming outside room [ROOM NUMBER] outside door. There was no documentation staff increased supervision when Resident #386 attempted to leave the facility and triggered the wander alarm. The investigation noted after triggering the wander alarm to the outside door close to room [ROOM NUMBER], Resident #386 when through the double doors into the Assisted Living Facility (ALF), traveled that hallway until she made a right heading to the main entrance of the facility where the wander guard in that hallway was also triggered. She then exited the building through the main entrance and to the road where she turned left and proceeded down Pinebrook Avenue in her wheelchair. The elopement occurred during mealtime for both sides of the house and staff were either serving in their perspective dining rooms or on break in the ALF. Resident #386's family typically visit her daily between 4:00 p.m., and 5:00 p.m., and take her outside to visit and enjoy fresh air. On 4/1/23, Resident #386's family did not come. Upon interviewing staff who were on shift, they did not think her absence was unusual during this time because she is routinely outside at this time to visit with family. The facility's immediate corrective action was to place the resident on one to one supervision to prevent further incidents of unsafe wandering and elopement. On 4/4/23 Resident #386 was discharged to a secured memory care unit. On 4/1/23 Registered Nurse Staff Y documented in a witness statement, On 4/1/23 I did not see (Resident #386) in the dining room or in the facility from the time I came on to the floor at 3:00 pm today. (Facility name) called Advinia Care at 6 pm asking if we were missing a resident. (Resident #386) was found at (facility name) and her nurse brought resident back. She was in her wheelchair. The facility provided documentation on 4/3/23 (two days after the elopement) they educated staff for 10 minutes on responding to the wander alarm, including not turn off the alarm until all residents are accounted for. There was no documentation five staff members on duty when Resident #386 eloped were educated. There was no documentation the facility-initiated elopement drills on all shifts, including weekends to verify staff understood the education and responded appropriately to the wander alarm when activated. On 7/11/23 the facility provided a list of current residents identified to be at risk for unsafe wandering and elopement, including Residents #8, #26, #11, #287, and #288. On 7/11/23 at approximately 5:50 p.m., the door connecting the skilled nursing facility to the ALF remained unsecured. It was not equipped with an alarm to alert staff to unsafe wandering. On 7/11/23 at 5:54 p.m., the surveyor used the fob provided by the facility to trigger the alarm of a door equipped with a wander alarm system at the skilled nursing facility to observe the staff response to the alarm. On 7/11/23 at 5:57 p.m., CNA Staff AA started closing all residents' bedroom doors in response to the alarm. She said, I thought it was a fire alarm. Staff AA did not investigate or look around to see if Residents #8, #26, #11, #287, and #288 identified to be at risk for elopement and wore a wander alarm had left the facility. Review of the Agency For Health Care Administration Background Screening Clearing house revealed Staff AA permanent hire date was 1/12/23. Review of the in-service related to wanderguards dated 4/3/23 lacked documentation CNA AA attended the in-service which specified, If anyone hears this alarm they are to investigate it immediately. Look around do you see a resident with a white bracelet and alarm? Look outside, if there a resident outside who has on a white bracelet and alarm. On 7/11/23 at 6:00 p.m., Licensed Practical Nurse (LPN) Staff P turned off the alarm, and said, The alarm means it is an elopement risk. She looked out the door and said she did not see anyone. She did not initiate a count of the residents to ensure all cognitively impaired residents at risk for elopement, including Residents #8, #26, #11, #287, and #288 were accounted for. LPN Staff P attended the 10 minutes in-service on 4/3/23 and did not follow the procedure which specified, You can not [sic] turn off the alarm until you know that all residents are accounted for. The facility's policy on Elopement Prevention effective 2/10/21 and revised on 6/22/23 noted when a resident is deemed to be an elopement risk, photos of the resident should be taken and placed in the elopement risk book. Documentation of the elopement risk should be made on the Facility elopement Book, placed at nursing station and front entry. On 7/11/23 at approximately 3:00 p.m., the elopement book at the receptionist desk at the entrance of the skilled nursing facility, and the entrance of the adjoining Assisted Living Facility were reviewed. The elopement books did not include Resident #26, #288, and #287. On 7/12/23 at 9:00 a.m., the Director of Nursing stated not all current employees had completed the Inservice. She verified the skilled nursing unit was not a secured unit. She stated the elopement book was updated with each resident added. The DON said she did not know what was going to be done about the unsecured door between the assisted living facility and the skilled unit. On 7/14/23 at 10:30 a.m., the Administrator said he did not have any additional information related implementation of processes to ensure a safe environment, including adequate supervision of cognitively impaired residents with known exit seeking behaviors to prevent unsafe wandering and elopement.

**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 1 (Resident #386) of 5 cognitively impaired residents at risk for elopement to prevent unsafe wandering and elopement. On 4/1/23 at approximately 4:30 p.m., Resident #386 who was a vulnerable cognitively impaired, wheelchair bound resident with known wandering behavior was not adequately supervised. The resident wheeled herself through an unsecured door of the skilled nursing facility into a hallway leading to the adjoining Assisted Living Facility. Resident #386 wore a wander alarm and triggered the alarm of two doors without staff response. Resident #386 left through the front door of the Assisted Living Facility, and traveled in her wheelchair, approximately three tenths of a mile, and crossed two streets. Resident #386 was missing for approximately one hour and 30 minutes without staff knowledge. On 4/1/23 at 5:45 p.m., a staff member from a neighboring skilled nursing facility found Resident #386 wandering the streets. Resident #386 had a likelihood for serious harm, injury, or death due to the risk for serious injury from a fall, getting lost or getting hit by a car. 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 4/1/23 when Resident #386 left the building without staff knowledge. On 7/14/23 at 4:00 p.m., the facility Administrator was notified of the Immediate Jeopardy and provided the IJ templates. The immediate Jeopardy was ongoing. The facility census was 37 with five residents at risk for elopement. The findings included: Cross reference to F600, F835 and F867 The facility's policy for Elopement Prevention with a revised date of 6/22/2021 noted, When a resident is deemed to be an elopement risk the following measures should be put in place: Residents should be placed in a secured unit. A wander guard bracelet should be placed on the resident. A Physicians order should be written to check placement of the wander guard every shift and function of bracelet daily. Photos should be taken of the resident to be placed in the Elopement Risk book. Communication to all staff on duty should be completed and carried on from shift to shift. Documentation of the Elopement Risk should be made . facility Elopement Book, placed at nursing station and front entry . Elopement concerns and resident at risk should be reviewed monthly and discussed at the facility QAPI (Quality Assurance and Performance Improvement) meeting to discuss trends and concerns. Elopement Risk Book should be reviewed daily and discussed at change of shift. Photos should be current with description of resident along with any other pertinent information that may help with locating the resident in an elopement situation. The Elopement-Missing Resident Policy CE-2, Revised 10/2022 noted the facility administration should complete a thorough investigation including the wanderguard (wander alarm to alert staff when a resident leaves a safe area) system and evaluating any preventative measure that may have been in place. Resident #386 was an [AGE] year-old female admitted to the facility from an acute care hospital on 1/17/23 with diagnoses including Alzheimer's disease, history of intracranial hemorrhage (bleeding), visual loss in both eyes, traumatic brain injury, and seizures. The elopement evaluation completed on 3/20/23 noted Resident #386 was exhibiting exit-seeking searching behaviors such as standing by the exit door, looking for someone, asking to go home et cetera. The physicians orders dated 3/21/23 included the use of a wander guard for Resident #386. The care plan was not revised to reflect the risk for elopement and interventions to prevent unsafe wandering and elopement. The 5-Day Minimum Data Set (MDS) Assessment with a target date of 3/26/23 noted the resident's cognition was severely impaired with a Brief Interview for Mental Status of 01. The MDS noted Resident #386 exhibited wandering behaviors, one to three days. The MDS was inaccurate and did not reflect the use of the wander/elopement alarm that was used during the assessment observation period. A nursing progress note dated 4/1/23 (Saturday) read, Resident (Resident #383) was last seen during med pass by nurse in W/C (wheelchair) at nurses station at 1630 (4:30 p.m.). CNA (Certified Nursing Assistant) notified nurse as 1755 (5:55 p.m.) that resident was no longer in nurses station area nor in dining area. Head count completed and noticed that the resident was no longer on grounds. Absence of alarms did not notify facility that resident had exited the building. Found at near [sic] by facility . Family, MD, and DON (Director of Nursing) notified of elopement. Review of the facility's investigation, and analysis of the incident revealed on 4/1/23 at 4:30 p.m., Resident #386 was seen at the nurses station. Upon investigation it was apparent she then traveled in her wheelchair down the back hallway where the wander guard was alarming outside room [ROOM NUMBER] outside door. The investigation noted after triggering the wander alarm to the outside door, close to room [ROOM NUMBER], Resident #386 went through the double door into the Assisted Living Facility (ALF), traveled that hallway until she made a right heading to the main entrance of the facility where the wander guard in that hallway was also triggered. She then left the facility through the main entrance where that alarm was also triggered. She then exited the building through the main entrance and to the road where she turned left and proceeded down Pinebrook Avenue in her wheelchair. All wander guard checks have shown no fault in the system alerting when triggered. The elopement occurred during mealtime for both sides of the house and staff were either serving in their perspective dining rooms or on break in the ALF. Resident #386's family typically visited her daily between 4:00 p.m., and 5:00 p.m. and took her outside to visit and enjoy fresh air. On 4/1/23 the family did not come. Upon staff interview, staff who were on shift and knew Resident #386 said they did not think the resident's absence was unusual during this time since she was routinely outside at that time of the day to visit with family. Resident #386 was discovered down Pinebrook Avenue on 4/1/23 at approximately 6:00 p.m., by a member of a nearby skilled nursing facility who contacted the facility and asked if they were missing a resident. There was no documentation staff increased supervision after Resident #386's first attempt to leave the facility when she triggered the wander alarm of the door leading to the outside near room [ROOM NUMBER]. The facility's immediate corrective action was to place Resident #386 on one-to-one supervision to prevent further incidents of unsafe wandering and elopement. On 4/4/23 Resident #386 was discharged to a secured memory care unit. Resident #386's care plan was not updated with interventions to prevent further incidents of unsafe wandering and elopement until 4/6/23, two days after discharge. On 4/1/23 Registered Nurse Staff Y documented in a witness statement, On 4/1/23 I did not see (Resident #386) in the dining room or in the facility from the time I came on to the floor at 3:00 pm today. [Facility name] called Advinia Care at 6 pm asking if we were missing a resident. (Resident #386) was found at Orchid Cove and she was brought back to the facility. The facility provided documentation on 4/3/23 (two days after the elopement) they educated staff for 10 minutes. The topic of the education was Wanderguards, and included responding to the wander alarm, including not turning off the alarm until all residents are accounted for. There was no documentation Licensed Practical Nurse Staff X, Certified Nursing Assistants (CNAs) Staff CC, DD, EE, and FF who were on duty when Resident #386 eloped were educated. There was no documentation the facility-initiated elopement drills on all shifts, including weekends to verify staff understood the education and responded appropriately to the wander alarm when activated. On 7/11/23 the facility provided a list of current residents identified to be at risk for unsafe wandering and elopement, including Residents #8, #26, #11, #287, and #288. Residents #11, #287, and #288 wore a wander alert bracelet. On 7/11/23 at 5:00 p.m., the Administrator in training provided the surveyor a fob to trigger the wander alarm from front entrance door of the Assisted Living Facility to observe staff response. The Administrator in training was present when the alarm was triggered. The ALF receptionist and business office manager said they were new employees and had completed their orientation. Both staff members said they did not receive education about the wander alarm system. A staff member from the skilled nursing facility started educating the receptionist and the business office manager on response when the wander alarm is triggered. On 7/11/23 at approximately 5:50 p.m., the door connecting the skilled nursing facility to the ALF remained unsecured. It was not equipped with an alarm to alert staff to unsafe wandering. On 7/11/23 at 5:54 p.m., the surveyor used the fob to trigger the alarm of a door equipped with a wander alarm system at the skilled nursing facility to observe the staff response to the alarm. On 7/11/23 at 5:57 p.m., CNA Staff AA started closing all residents' bedroom doors in response to the alarm. She said, I thought it was a fire alarm. Staff AA did not investigate or look around to see if Residents #11, #287, and #288 identified to be at risk for elopement and wore a wander alarm had left the facility. Review of the Agency For Health Care Administration Background Screening Clearing House website revealed Staff AA's permanent hire date was 1/12/23. Review of the in-service related to Wanderguards dated 4/3/23 lacked documentation CNA AA attended the in-service which specified, If anyone hears this alarm they are to investigate it immediately. On 7/11/23 at 6:00 p.m., Licensed Practical Nurse (LPN) Staff P turned off the alarm, and said, The alarm means it is an elopement risk. She looked out the door and said she did not see anyone. She did not initiate a count of the residents to ensure all cognitively impaired residents including Residents #8, #26, #11, #287, and #288 were accounted for. On 7/12/23 at approximately 4:00 p.m., Resident #288 was observed on the unit. He did not have a wander alert bracelet. LPN Staff P verified Resident #288 was not wearing a wander alert bracelet as ordered. She said the resident had removed the wander alert bracelet. Review of the clinical record for Resident #288 revealed a physician's order dated 7/11/23. Resident #288's diagnoses included Alzheimer's, and Dementia. Resident #288 did not have a care plan alerting the staff of the risk for elopement. Review of the clinical record for Resident #26 revealed an admission date of 6/15/23 with diagnoses including Dementia. There was no care plan alerting the staff of the risk for elopement. On 7/11/23 at approximately 4:30 p.m., Resident #26 was observed in a wheelchair wandering in the hallways. On 7/11/23 at approximately 3:00 p.m., the elopement book at the receptionist desk at the entrance of the skilled nursing facility, and the entrance of the adjoining Assisted Living Facility were reviewed. The elopement books did not include Resident #26, #288, and #287. On 7/12/23 at 9:00 a.m., the Director of Nursing said she recommended installing a wander alert system which would automatically lock the doors when a resident with a wander alert bracelet came near an exit door. She said she did not know what the plan was for the unsecured door between the skilled nursing facility and the ALF. On 7/12/23 at 10:30 a.m., the Director of Nursing verified the elopement books were not updated. She said Resident #26 was at risk for unsafe wandering and elopement and should have been in the book. She said the Activities Staff was responsible to update the elopement book and ensuring all residents identified to be at risk for elopement were in the books. On 7/12/23 at 10:50 a.m., the Activities Director said she did not know her responsibilities included updating the elopement books. On 7/14/23 at 10:30 a.m., the Administrator said he did not have any additional information related implementation of processes to ensure a safe environment, including adequate supervision of cognitively impaired residents with known exit seeking behaviors to prevent unsafe wandering and elopement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility's administration failed to utilize its resources effectively to ensure a safe environment, including adequate supervision of cognitively impaired residents with known exit seeking behaviors to prevent unsafe wandering and elopement. On 4/1/23 at approximately 4:30 p.m., Resident #386 who was cognitively impaired, and wheelchair bound was not adequately supervised. The resident wheeled herself through an unsecured door of the skilled nursing facility into a hallway leading to the adjoining Assisted Living Facility. Resident #386 left through the front door of the Assisted Living Facility, and traveled unsupervised in her wheelchair, approximately three tenths of a mile, and crossed two streets. On 4/1/23 at 5:45 p.m., a staff member from a neighboring skilled nursing facility found Resident #386 wandering the streets. Resident #386 had a likelihood for serious harm, injury, or death due to the risk for serious injury from a fall, getting lost or getting 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 at a scope and severity of isolated (J) starting on 4/1/23. On 7/14/23 at 4:00 p.m., the facility's Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The facility census was 37 with five residents at risk for unsafe wandering and elopement. The findings included: Cross reference to F600, F689, and F867. The Executive Director's job description signed on 3/31/23 specified the Executive Director is totally responsible for the management of the skilled nursing facility, ensures high quality resident care services. The job description read, . Monitor resident care on a daily basis; conduct daily rounds . Directs community safety and loss prevention program; monitors adherence to safety rules and regulations and takes remedial action when necessary . Review of signed, not dated Director of Nursing responsibilities revealed the Director of Nursing is responsible for managing the care of residents from admission through discharge and for maintaining the delivery of quality care. Direct nursing department in the delivery of the individual patient's plan of care as well as identifying interdisciplinary needs and coordination of health care clinicians. The Director of Nursing, Understands and implements rules and regulations under Medicare . understands and implements adequate clinical patient assessments identifying specific needs of residents in the facility . Demonstrates sound, logical and timely decision making skills . Oversees incidents/accident of patients. Provides in-services as needed in areas of expertise . Scheduling ongoing training of employees . The facility's policy for Elopement Prevention with a revised date of 6/22/2021 noted, When a resident is deemed to be an elopement risk the following measures should be put in place: Resident should be placed in a secured unit. A wander guard bracelet should be placed on the resident. A Physicians order should be written to check placement of the wander guard every shift and function of bracelet daily. Photos should be taken of the resident to be placed in the Elopement Risk book. Communication to all staff on duty should be completed and carried on from shift to shift. Documentation of the Elopement Risk should be made . facility Elopement Book, placed at nursing station and front entry . Elopement concerns and resident at risk should be reviewed monthly and discussed at the facility QAPI (Quality Assurance and Performance Improvement) meeting to discuss trends and concerns. Elopement Risk Book should be reviewed daily and discusses at change of shift. Photos should be current with description of resident along with any other pertinent information that may help with locating the resident in an elopement situation. Review of the facility's incident investigations revealed on 4/1/23 Resident #386 who was cognitively impaired, and wheelchair bound, wheeled herself through an unsecured door into a hallway leading to the adjoining Assisted Living Facility (ALF). Resident #386 left through the front door of the ALF. The resident was last seen at the nurse's station of the skilled nursing facility at approximately 4:30 p.m. Resident #386 traveled alone, and unsupervised in a wheelchair three tenths of a mile and crossed two streets. On 4/1/23 at 6:00 p.m., a staff member from a neighboring facility found the resident wandering the streets. Resident #1 was returned unharmed to the skilled nursing facility. Review of the facility's investigation, and analysis of the incident revealed documentation, Upon investigation it was apparent that she (Resident #386) traveled in her wheelchair down the back hallway where the wander guard was alarming outside room [ROOM NUMBER] outside door, she then went through the double doors into the ALF. She then exited the building through the main entrance and to the road where she turned left and proceeded down Pinebrook Ave (Avenue) in her wheelchair . Resident #386 was placed on one to one supervision and discharged to a secured unit ALF on 4/4/23. Review of the corrective actions implemented by the facility revealed on 4/3/23 (two days after the elopement) the Regional Director of Clinical Operations educated staff for 10 minutes on responding to the wander alarm, including not turn off the alarm until all residents are accounted for. There was no documentation Licensed Practical Nurse Staff X, Certified Nursing Assistants (CNAs) Staff CC, DD, EE, and FF who were on duty when Resident #386 eloped were educated. On 7/11/23 the Director of Nursing provided a handwritten list of current residents identified to be at risk for unsafe wandering and elopement and wore wander guards including Residents #8, #26, #11, #287, and #288. On 7/11/23 at approximately 3:00 p.m., the elopement book at the receptionist desk at the entrance of the skilled nursing facility, and the entrance of the adjoining Assisted Living Facility were reviewed. The elopement books did not include Resident #26, #288, and #287. On 7/12/23 at 11:11 a.m., CNA Staff K said she would refer to the elopement risk book at the nurse's station to identify residents at risk for unsafe wandering and elopement. She said Residents #26, #11, and #287 had wandering behaviors. On 7/12/23 at 11:21 a.m., CNA Staff L said Residents #26, #11, and #287 had wandering behaviors. She the nurses would tell them if someone has a potential for elopement and they would have a wander guard on. On 7/12/23 at approximately 4:00 p.m., Resident #288 was observed on the unit. He did not have a wander alert bracelet. LPN Staff P verified Resident #288 was not wearing a wander alert bracelet as ordered. She said the resident had removed the wander alert bracelet. Review of the clinical record for Resident #288 revealed a physician's order dated 7/11/23. Resident #288's diagnoses included Alzheimer's, and Dementia. Resident #288 did not have a care plan alerting the staff of the risk for elopement. Review of the clinical record for Resident #26 revealed an admission date of 6/15/23 with diagnoses including Dementia. There was no care plan alerting the staff of the risk for elopement. On 7/11/23 at approximately 4:30 p.m., the resident was observed in a wheelchair wandering in the hallways. On 7/12/23 at 9:00 a.m., the Director of Nursing (DON) said she recommended installing a wander alert system which would automatically lock the doors when a resident with a wander alert bracelet came near an exit door. She said she did not know what the plan was for the unsecured door between the skilled nursing facility and the ALF. The DON said although she has been employed at the facility for over a year, she was not the DON at the time of the incident. She said on 5/1/23 she became the DON at the facility. On 7/12/23 at 10:30 a.m., the Director of Nursing verified Resident #26 was at risk for unsafe wandering and elopement. She said the Activities Staff was responsible to update the elopement book and ensure all residents identified to be at risk for elopement were in the books. Review of the Agency For Health Care Administration Background Screening Clearing House revealed the Activities Director had a date of hire of 5/8/23. On 7/12/23 at 10:50 a.m., the Activities Director said she did not know her responsibilities included updating the elopement books. On 7/14/23 at 10:30 a.m., the Director of Nursing verified no one ensured the elopement book risk was updated. Review of the facility's policy and procedure for Elopement-Missing Resident revised on 10/22 noted if an employee discovers that a resident is missing from the facility, he/she should announce on the overhead paging system, Code Orange three times, the unit/area involved or the room number of the missing resident, the time the resident was determined missing. On 7/14/23 at 10:57 a.m. Staff Q, Transporter said he did not know the overhead code for elopement. On 7/14/23 at 11:00 a.m. Staff R, Activities Assistant said Code Orange was an emergency, You make sure everyone is in their rooms and shut the doors. On 7/14/23 at 10:30 a.m., during a review of the facility's Quality Assurance and Performance Improvement process review, the Administrator said he did not have any additional information related implementation of processes to ensure a safe environment, including adequate supervision of cognitively impaired residents with known exit seeking behaviors to prevent unsafe wandering and elopement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policies and procedures, and staff interviews the facility failed to develop and implement appropriate corrective actions related to adequate supervision of cognitively impaired residents at risk for unsafe wandering, elopement and exit seeking behaviors. On 4/1/23 at approximately 4:30 p.m., Resident #386 who was vulnerable, cognitively impaired, and wheelchair bound was not adequately supervised. The resident wheeled herself through an unsecured door of the skilled nursing facility into a hallway leading to the adjoining Assisted Living Facility. Resident #386 left through the front door of the Assisted Living Facility, setting off a wander alarm, and traveled unsupervised in her wheelchair, approximately three tenths of a mile, and crossed two streets. On 4/1/23 at 6:00 p.m., a staff member from a neighboring skilled nursing facility found Resident #386 wandering the streets. Resident #386 had a likelihood for serious harm, injury, or death due to the risk for serious injury from a fall, getting lost or getting hit by a car. The facility failure to implement appropriate corrective actions to prevent further incidents of unsafe wandering and elopement of cognitively impaired residents identified at risk for elopement and unsafe wandering resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) beginning on 4/1/23. The Immediate Jeopardy was ongoing. On 7/14/23 at 4:00 p.m., the facility's Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The facility census was 37 with five residents at risk for unsafe wandering and elopement. The findings included: Cross reference to F600, F689, and F835 The facility's Quality Assurance and Performance Improvement (QAPI) plan reviewed 2/7/2021 noted, The organizational program, established by the Medical Director and Director of Nursing and interdisciplinary Performance Improvement Committee, with support and approval from the Governing Body, shall have the responsibility for monitoring every aspect of resident care and service (including contracted services) from the time the resident enters the facility through diagnosis, treatment, recovery and discharge in order to identify and resolve any breakdowns that may result in suboptimal resident care and safety, while striving to continuously improve and facilitate positive resident outcomes . The committee shall identify quality deficiencies and develop and implement plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans . The Executive Director's job description signed by the Administrator on 3/31/23 noted the Executive Director (Administrator) oversees and monitors nursing services to ensure high quality nursing delivery systems. The Director of Nursing Job Performance, signed (undated) noted the Director of Nursing participates in quality assurance performance improvement set and meet department goals to meet expectations of quality. Maintains knowledge and skills required to perform job. Review of the facility's incident investigations revealed on 4/1/23 Resident #386 who was cognitively impaired, and wheelchair bound, wheeled herself through an unsecured door into a hallway leading to the adjoining Assisted Living Facility (ALF). Resident #386 left through the front door of the ALF. The resident was last seen at the nurse's station of the skilled nursing facility at approximately 4:30 p.m. Resident #386 traveled alone, and unsupervised in a wheelchair three tenths of a mile and crossed two streets. On 4/1/23 at 6:00 p.m., a staff member from a neighboring facility found the resident wandering the streets. Resident #1 was returned unharmed to the skilled nursing facility. Review of the analysis of the incident revealed documentation, Upon investigation it was apparent that she (Resident #386) traveled in her wheelchair down the back hallway where the wander guard was alarming outside room [ROOM NUMBER] outside door, she then went through the double doors into the ALF. She then exited the building through the main entrance and to the road where she turned left and proceeded down Pinebrook Ave (Avenue) in her wheelchair. Review of the corrective actions implemented by the facility to prevent recurrence of unsafe wandering and elopement revealed: Resident #386 was placed on one to one supervision and discharged to a secured unit ALF on 4/4/23. On 4/3/23 (two days after the elopement) the Regional Director of Clinical Operations educated staff for 10 minutes on responding to the wander alarm, including not turn off the alarm until all residents are accounted for. There was no documentation Licensed Practical Nurse Staff X, Certified Nursing Assistants (CNAs) Staff CC, DD, EE, and FF who were on duty when Resident #386 eloped were educated. There was no documentation the facility-initiated elopement drills on all shifts, including weekends to verify staff understood the education and responded appropriately to the wander alarm when activated. On 7/11/23 at approximately 5:50 p.m., the door connecting the skilled nursing facility to the ALF remained unsecured. It was not equipped with an alarm to alert staff to unsafe wandering. On 7/11/23 at approximately 10:35 a.m., the Director of Nursing provided a handwritten list of current residents identified to be at risk for unsafe wandering and elopement, including Residents #8, #26, #11, #287, and #288. She said residents #8, #26, #11, #287, and #288 wore a wander alert bracelet to alert staff of unsafe wandering and attempt at elopement. Review of the clinical record for Resident #26 revealed an admission date of 6/15/23 with diagnoses including Dementia. There was no care plan alerting the staff of the risk for elopement. On 7/11/23 at approximately 4:30 p.m., the resident was observed in a wheelchair wandering in the hallways. On 7/11/23 at 5:54 p.m., the alarm of a door equipped with a wander alarm system was triggered to observe the staff response to the alarm. On 7/11/23 at 5:57 p.m., CNA Staff AA started closing all residents' bedroom doors in response to the alarm. She said, I thought it was a fire alarm. Staff AA did not investigate or look around to see if Residents #11, #287, and #288 identified to be at risk for elopement and wore a wander alarm had left the facility. Review of the 10 minutes in-service related to wanderguards dated 4/3/23 lacked documentation CNA AA with a date of hire of 1/12/23 attended the in-service which specified, If anyone hears this alarm they are to investigate it immediately. Look around do you see a resident with a white bracelet and alarm? Look outside, if there is a resident outside who has on a white bracelet and alarm. On 7/11/23 at 6:00 p.m., five minutes after the alarm was triggered, Licensed Practical Nurse (LPN) Staff P turned off the alarm, and said, The alarm means it is an elopement risk. She looked out the door and said she did not see anyone. She did not initiate a count of the residents to ensure all cognitively impaired residents including Residents #8, #26, #11, #287, and #288 were accounted for. Staff P said she did not respond to the alarm quickly because she could barely hear anything, especially in the dining room with the clanking of the dishes. LPN Staff P attended the in-service on 4/3/23 and did not follow the procedure outlined in the in-service which specified, You can not turn [sic] off the alarm until you know that all residents are accounted for. No staff present on the unit looked at the unsecured double door leading to the ALF where Resident #386 eloped from. Review of the facility's policy for Elopement Prevention with a revised date of 6/22/2021 noted photos of residents at risk for elopement should be taken and placed in the Elopement Risk book. On 7/11/23 at approximately 3:00 p.m., the elopement book at the receptionist desk at the entrance of the skilled nursing facility, and the entrance of the adjoining Assisted Living Facility were reviewed. The elopement books did not include Resident #26, #288, and #287. On 7/12/23 at 9:00 a.m., the Director of Nursing said she recommended installing a wander alert system which would automatically lock the doors when a resident with a wander alert bracelet came near an exit door. She said she did not know what the plan was for the unsecured door between the skilled nursing facility and the ALF. On 7/12/23 at 9:31 a.m., the DON said she was the designated Risk Manager. She said she was not involved in developing a performance improvement plan for elopement. She said, The Administrator would know that. She said, I told them I thought the doors were the cause of the elopement in the QAPI (Quality Assurance and Performance Improvement) meetings. On 7/12/23 at 10:30 a.m., the Director of Nursing said the Activities Staff was responsible to update the elopement book and ensure all residents identified to be at risk for elopement were in the books. On 7/12/23 at 10:50 a.m., the Activities Director who had a date of hire of 5/8/23 said she did not know her responsibilities included updating the elopement books. On 7/12/23 at approximately 4:00 p.m., Resident #288 who had a physician's order for a wander alert bracelet was observed on the unit. He did not have a wander alert bracelet. On 7/14/23 at 10:30 a.m., during a review of the facility's Quality Assurance and Performance Improvement (QAPI) process review, the Administrator presented an elopement drill QAPI worksheet dated 4/1/23 which noted, Time in: 6:00 p.m. There was no Time out noted on the worksheet. The comment noted Education on door alarms for all SNF (Skilled Nursing Facility), ALF (Assisted Living Facility) and entire building staff and elopement At the time of the survey there were 39 active nursing staff (Licensed Nurses and Certified Nursing Assistants) employed at the facility. There was no documentation 24 of the 39 had received elopement prevention training since the elopement incident of 4/1/23. An elopement Drill QAPI worksheet dated 5/23/23 at 11:20 a.m. to 11:32 a.m. consisted of a check mark placed next to each item on the list. The form noted after the drill is completed, review drill with staff, provide feedback and answer questions, staff to sign in-service sheet. There was no documentation the drill was reviewed, who participated and feedback. Review of the QAPI minutes for the May 2023 meeting noted an elopement drill was held on 5/23/23 on the day shift with 100% accuracy in action and response time. There was no discussion of the unsecured SNF door to prevent further incidents of unsafe wandering into the ALF and elopement. The Administrator presented an undated document titled, Performance Improvement Plan-Life Safety and Clinical Operations The document listed the following Issues: Elopement Drills and Process. Solution: Life Safety Director and Clinical Director will work together in submitting Elopement audits to QAPI Committee monthly. The project was ongoing and X entered on the Completed column. Monitoring. Monthly education will be provided to staff on the elopement procedures with an X entered in the column, indicating the monthly education was completed. QAPI. Audit results will be brought to QAPI had an X entered indicating the audit results were brought to QAPI. The Administrator only had documentation of the check off Elopement drill QAPI worksheet completed on 5/23/23. There was no sign in sheet making it impossible to determine who participated in the drill. On 7/14/23 at 10:30 a.m., the Administrator said he did not have any additional information related implementation of processes to ensure a safe environment, including adequate supervision of cognitively impaired residents with known exit seeking behaviors to prevent unsafe wandering and elopement.