**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, record and policy review, the facility failed to protect the resident's right to be free from neglect by failing to provide necessary supervision to prevent the likelihood of serious injury, harm, impairment, or death by allowing an elopement for 1 of 3 sampled residents (Resident #1) reviewed for an elopement. The facility failed to ensure effective measures were in place to prevent the elopement in both the secured unit and the exit from the building.The deficient practice allowed Resident #1 to exit the facility undetected on 08/30/25 at 4:23 PM. There were 182 residents in the facility at the time of the survey. The facility's Administrator was notified of Immediate Jeopardy and given the IJ Template on 09/04/25 at 3:05 PM. The immediate jeopardy was removed on 09/04/25 at 4:45 PM, and the deficiency was lowered to a scope and severity of D, isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Cross reference to F689.The findings included: A review of the facility's policy titled Abuse and Neglect, reviewed 11/19/24, documented: To minimize the threat of abuse and or neglect, nursing homes must incorporate clear cut policies and practices that demonstrate a hard line, 0 tolerance approach to resident abuse. Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. How: The facility has procedures in place to provide protection for the health, welfare and rights of each resident residing in the facility. In order to provide these protections, the facility has implemented procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. These procedures include but are not limited to the following.2). Training, 3). Prevention, 4). Identification.6). Protection.Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, General Muscle Weakness, Dysphagia, Cognitive Communication Deficit, Major Depressive Disorders, Altered Mental Status, Epilepsy, Alcohol Abuse, and Blindness of the Right Eye.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. This same MDS indicated that Resident #1 was able to ambulate without any assistive devices with supervision and touching assistance. A BIMS score conducted on 09/01/2025 revealed a score of 5 indicating the resident had severe cognitive impairment. An Elopement risk evaluation conducted on 08/06/2025 indicated the resident was at risk for Elopement. Review of the clinical census revealed Resident #1 had been in the facility's secured unit (west wing) since her admission date. (A secured unit is a designated area within a facility that offers enhanced security and supervision for residents who may be prone to wandering or require specialized care. These units are specifically designed to meet the unique needs of individuals with memory-related disorders, ensuring their safety and well-being.)Review of Resident #1's care plan initiated on 08/03/25 documented, At risk for elopement . Goal: The resident will not leave facility unattended through the review date with an intervention that documented, Provide for safe wandering - resident is an elopement risk.Review of the active orders dated 08/09/25 documented, Exit seeking. Provide safe wandering, resident is at risk for elopement. every shift.The video of the elopement incident, involving Resident #1 was viewed by the surveyor on 09/03/25 at 1:36 PM. The following was noted: On 08/30/25 at 4:23 PM the receptionist was attending to two visitors in the main lobby by the entrance of the facility. These two visitors blocked the view of the receptionist who was sitting down at that moment and Resident #1 walked behind the two visitors and walked out towards the door. During this same time at 4:23 PM, another visitor is buzzed in by the receptionist Resident #1 walked out quickly as the visitor walked in. (This door remains locked and must manually be unlocked by an individual after engaging a buzzer to enter the facility). The receptionist did not notice Resident #1 had exited the facility unaccompanied, via the main entrance camera in front of her, which she was responsible for monitoring. The resident was observed to be wearing a red T-shirt, red leggings with a pattern and black tennis shoes. She was seen walking in a fast and steady manner with no assistive devices at the time of exit. In the surveillance footage, there were no additional staff present at the main entrance at time of the resident's exit.Resident #1's room was located on the west side of the facility in a locked unit. Two hallways lead to the west unit (C and D unit) both unsecured. A middle hallway ( center core) joins the C and D unit on the west side; this same hallway's east side leads to two additional units (A and B units) which lead to the East Unit on the opposite side of the building. The middle hallway leads to the main lobby and facility's main entrance.An interview with the administration team was conducted on 09/03/25 at 10:35 AM. The Executive Director (Administrator), Director of Nursing (DON), Regional Director of Clinical Services, Regional [NAME] President, and Divisional Director of Clinical Services were present. When asked what happened regarding the incident that occurred on 08/30/25, involving Resident #1, the Administrator stated, I was contacted on 08/30/25 at approximately 5:19 PM by the facility that there was a missing resident. The Administrator voiced at that time there was a birthday party for another resident, who was turning 100, going on in back of the main dining room. This dining room was not located in the locked unit. They stated their investigation led them to believe that a visitor from the birthday party let Resident #1 out of the locked unit. They assumed Resident #1 could have passed as a visitor and was let off the unit by visitors. When asked what was done when they found out Resident #1 was missing, the Regional Director of Clinical Services and the Administrator stated they did an immediate in-house and facility wide search. When they confirmed she was not in the building, they called law enforcement. They stated the nurses and team which involved all department heads of the facility split into a grid and individual staff were assigned to a search zone. They added that this occurred over the weekend, but regional and divisional staff were still involved. When asked where Resident #1 was found, they stated law enforcement found her approximately 2 miles from the facility on [NAME] Street. Law enforcement contacted the facility, and the administration team brought her back to the facility. When asked how Resident #1's condition was when found, the Regional Director of Clinical Services stated she had dirt on her feet and sides of her pants and a skin tear but, denied falling. When asked what interventions were in place prior to Resident #1's elopement, they stated she had a care place in place, assessments, placed in a locked unit, and that staff watched for behaviors. They added the day of the incident, she did not display any behaviors indicating a risk for elopement. When asked if Resident #1 had family, they stated she was estranged from her family and does not get any visitors; they have found a couple numbers in the chart but have not been able to contact anyone. Resident #1 occasionally spoke of a sister, brother, and a friend but they have been unsuccessful in determining who. The Regional Director of Clinical Services added Resident #1 had not been deemed incapacitated. When asked if there were cameras in the area she eloped from, they stated they were unable to determine which exit (C or D unit exit) she eloped from; neither unit had cameras.During an interview on 09/03/25 at 11:17 AM, Resident #1 was observed with a one-to-one sitter, Staff A, Certified Nursing Assistant (CNA). The resident was observed sitting in bed fiddling with her personal belongings and attempting to get out of bed unassisted; a wheelchair was seen by her bedside. Resident #1 did not have the appearance to pass as a visitor. When the surveyor asked what her name was and the date and her location, she responded, My name is [Resident #1], I am located in a facility somewhere and the date is late May 2025. When asked, Did you leave the facility on Saturday 08/30/25?, she stated that was what she was being told but stated she didn't remember what happened. When asked where she was trying to go and who let her out, Resident #1 stated, no particular place, Saturday is my favorite day of the week and I decided to go out; I don't remember who let me out, I just walked out; I was bored so I left. When asked if she left because she felt unsafe at the facility, Resident #1 stated she felt safe, but she just wanted to leave.During an interview on 09/03/25 at 11:30 AM, when asked if she knew what happened on Saturday 08/30/25 with Resident #1, Staff A stated she heard what happened, but she was not working that day. She stated that Resident #1 went missing and didn't know how she was able to leave the facility. When asked if Resident #1 ever tried to elope or wander, Staff A stated, No, she can walk but her balance is not that good, so she uses a wheelchair instead.An observation and interview was conducted on 09/03/25 at 11:51 AM, when asked where the back of the main dining room was located, the DON offered to show the surveyor a tour to see the location. It was observed that the dining room was not located in the secured unit and upon entrance to the main dining room this same room led to the back dining room (another smaller dining room where the Birthday Party was held on Saturday for another Resident)When asked where the birthday party member resided, the DON stated she also resided in the locked unit (west wing). The DON voiced that the visitors were coming in and out (of the locked unit) that day. When asked if there were other visitors that day also visiting the unit, she stated not to her knowledge and that there was a kiosk in the front they used for check in; she would have to check there. When asked if the family members were called to confirm if they let a resident out by mistake, the DON stated not that she was aware of. When asked how did family get access to the locked unit, the DON stated prior to the incident, you could push the door to get into the unit without a passcode, but needed a code to leave; now you need a code to enter and exit the facility, due to the incident. When asked where Resident #1 was admitted from, she stated from a hospital from another county. When asked how long the resident was missing, on the day of the incident, she stated from 08/30/25 at 4:23 PM, law enforcement found her on 08/31/25 at 12:10 AM and then called the facility; she was brought back to facility around 1:00 AM on 08/31/25. When asked if she went to the hospital, the DON stated that the doctor saw her the following day and ordered an X-ray and labs but did not order her to go to the hospital. When asked what psych evaluated upon Resident #1's arrival and if they made any changes to her treatment, the DON stated they changed her Trazadone (medication) dose to help her sleep, did an assessment and a BIMS re-evaluation upon her arrival on 08/31/25.An interview was conducted on 09/03/25 at 11:57 AM, when asked what was evaluated for Resident #1 after the incident from 08/30/25, the Advanced Registered Nurse Practitioner (ARNP) for Psychiatry stated she saw Resident #1 via Telehealth on 08/31/2025. She stated I got a report that the resident was not sleeping all night and eloped. When I saw the resident, she was calm with on and off confusion; there were no more signs. She stated she changed her Trazadone dose to help her sleep and when asked if her BIMS evaluation changed, she stated her BIMS was 11 prior to the incident and had a BIMS of 10 on 08/31/2025 after the incident. She stated she checked it yesterday on 09/2/25 and her BIMS score was a 10 in the morning and her BIMS was 12 at about 2:30 PM that same day. She stated there are no other treatment changes and the plan was to reassess the resident every day since she has an ongoing one-to-one sitter.During an interview on 09/03/25 at 12:25 PM, when asked if she knew anything regarding the incident from 08/30/25 related to Resident #1, the Assistant Director of Nursing (ADON) stated she was not working the day of the incident but had seen the resident the following day. The ADON voiced that the resident had stated I was riding my bike looking for my kitty. The ADON stated she completed a head-to-toe assessment and spoke to her doctor who came to see the resident and also performed an assessment on her. When asked which residents are considered elopement risks, the ADON stated everyone in the secured unit (west wing) was identified as an elopement risk. When asked if there were residents in unsecured units with elopement risks, she replied no and stated they arrange beds in the locked unit as necessary. The ADON provided a census of residents with risk of elopement, who reside on the secured unit, at the time of the survey which was a total of 52. The secured unit has a capacity of 56 beds.During an interview on 09/03/25 at 12:39 PM, when asked about Resident #1's incident, the Social Services Director stated she was not at the facility on the day of the incident but recalled a resident in the locked unit was turning 100 and his family requested to have his birthday party in the back of the main dining room. When asked how the family would have access to the secured unit, the Social Service Director stated before the incident you could push a button and then push the doors to the unit to get in without a code; to exit you would need a code or a staff member to exit. When asked if staff are allowed to give codes to family, the Social Service Director stated typically staff lets them out and they don't give out codes. The Social Service Director stated she believed upon entering the unit, someone could have let her (Resident #1) out.A telephone interview was attempted on 09/03/25 at 12:58 PM with Staff C, a Licensed Practical Nurse (LPN) who was the primary nurse assigned to Resident #1 on the 3-11 shift on 08/30/25. Staff C stated she wasn't feeling well and couldn't talk.Review of a progress note written by Staff C on 08/30/25 at 8:41 PM with an effective time at 4:20 PM documented, Writer noticed resident was not present during meds pass and dinner, writer alerted all staff to search for resident in all the room, and went to central to notified all staff and supervisor made aware, PCP was called no answered and left voice mail, Emergency contact was called the woman in the phone stated she does not know the resident.A telephone interview was attempted on 09/03/25 at 1:12 PM with the local Police Department involved in the elopement incident regarding Resident #1, a voicemail was left, and a call back was not received during the time of the survey.A telephone interview was conducted on 09/03/25 at 1:16 PM with Staff D, a Certified Nursing Assistant (CNA) who was the primary CNA assigned to Resident #1 on the 3-11 shift on 08/30/25. When asked what happened on her shift on 08/30/25, Staff D stated. I was floating that day; I was assigned to west, but to both sides of the hallways. My shift started at 3 PM but at around 2:50 PM, I started doing my rounds. Resident #1 was in the dining room in the unit. Resident #1 usually walks around but doesn't try to leave the floor. At 4:00 PM I saw her by the medication cart. At around 4:10 PM another CNA I was working with saw her food arrive. I told her she was by the dining room, and I told her to check there. She could not find Resident #1 in the dining room, so she checked her room, and she was not there. At about 4:20 PM, we told the primary nurse, and the nurse called the supervisor. When asked if Resident #1 was showing any behaviors of trying to escape the unit that day, Staff D stated, no she has never done this before, this was the first time this happened on my shift. Staff D voiced Resident #1 can walk by herself and move without a wheelchair. When asked if Resident #1 was alert and oriented, she stated she was not too confused, when you ask her to do something she does it. When asked how family members came in on 08/30/25, Staff D stated, I think they had a party that day, but everyday family members come in. When asked, do you give a code to family members, Staff D stated, No we are not supposed to do that. Staff D voiced, Before this happened you didn't need a code to get in, but to get out you did. I think they might have changed it now.On 09/03/25 at 1:36 PM, the surveyor reviewed the surveillance footage of Resident #1's incident side-by-side with the Administrator. The video revealed the following: On 08/31/25 at 12:37 AM upon re-entering the facility, Resident #1 was observed to enter the facility accompanied by the Administrator, Regional Director of Clinical Services, Divisional Director of Clinical Services, Maintenance Director, Social Services Director, Marketer, and the DON. Resident #1 was observed to be wearing the same outfit she left with but was walking in with only socks on and her tennis shoes were missing. When asked what happened to Resident #1's shoes, the Administrator stated, We don't know what happened to her shoes. The resident was observed to walk in with a steady gait.An interview was conducted on 09/03/25 at 2:17 PM with Staff E, Registered Nurse (RN), who worked the 7 AM- 3PM shift on 08/30/25. When asked what happened in Resident #1's incident, Staff E recalled the events, It was a quiet day, I had no issues that day; I gave report to the next nurse, Staff C. I gave report on 08/30/25 at about 3:45 PM; Resident #1 was next to me standing while I was giving report. Staff C doesn't work there often. I don't know if she is per diem or part time and normally works in another unit. Staff C was not really familiar with Resident #1; she was not a regular nurse who worked there. After I gave report, I left a little after 4 PM. I was called around 5:00 pm and they told me the resident was missing. I told them she was standing next to him during report. Staff E voiced Resident #1 was always walking around by the hallway rails but never saw her try to leave; she was not showing any behaviors that day. She never pushed any doors or tried to leave. I never thought in my mind she would exit the facility, she normally doesn't walk fast, she normally walks very slow. Staff E stated he drove around to see if he saw her, he lived close by and knew the neighborhood well but could not locate her. He stated, They called me in the middle of the night to tell me she came back; I was happy she was back, we try to keep everybody safe, unfortunately this happened. When asked how he believed Resident #1 got out, Staff E stated, I remember there was a party for another resident, but I don't really know. When asked if he saw family visitors that day on his shift, Staff E stated, a resident was turning [AGE] years old in the west unit and their family was in their room. When asked if the staff gives codes to family, Staff E stated, No that doesn't happen, if there is a suspicion they might know a code it gets changed right away. When asked how you could get to the locked unit, Staff E stated, Before you push the green knob and could open the door, but to get out you would need a code, now it is changed you need a code in and out.Review of the record revealed a Skin Assessment was conducted on Resident #1 on 08/31/25. The Assessment documented Abrasion: Right posterior forearm- c-shaped abrasion, no active bleeding, no acute signs of infection. left lateral face vertical abrasion- no active bleeding no drainage on signs of infection. Bruising(s): Right upper arm, right lateral thigh with scattered scab. Scars(s) Right elbow, long oval scar Scabs on left knee and chin, left hand. Doctor made aware of skin issues. Resident denies pain at this time. No active bleeding to sites, no acute signs of infection. Treatment to left forearm rendered, resident tolerated well.In a review of the Medication Administration Record (MAR) for August, 2025, it revealed that on 08/30/25 Resident #1 missed the 5 PM of Bethanechol Chloride Oral Tablet 25 MG for urinary retention, the 5 PM dose of Carbidopa-Levodopa Oral Tablet 25-100 MG for Parkinson's, the 5 PM dose of Clonazepam Oral Tablet 0.5 MG for anxiety, the 8 PM dose of Famotidine Oral Tablet 20 MG for acid reflux, the 8 PM dose of Gabapentin Capsule 300 MG for nerve pain, the 8 PM dose of Metoprolol Tartrate Tablet 12.5 MG for hypertension, the 9 PM dose of Rosuvastatin Calcium Oral Tablet 10 MG for high cholesterol, the 9 PM dose of Tamsulosin HCl Oral Capsule 0.4 MG for urinary issues, and the 9 PM dose of Topiramate Oral Tablet 200 MG for seizures.The facility submitted an acceptable Immediate Jeopardy removal plan on 09/04/25, which was verified by observations, interviews and record review, as follows: 1. 08/30/25- 100% headcount of residents was completed to ensure no other residents were missing. All other residents were accounted for. 2. 08/30/25 a whole house search of the facility was completed. 3. 08/30/25 the executive director was notified by the weekend supervisor who in turn notified facility managers to report to work to assist in the search. Regional and divisional staff were also notified and reported to the facility to assist in the search. The medical director and primary physician were notified. 4. 08/30/25 an external search of the community was initiated. 5. 08/30/25 Executive Director notified the local Police Department who assisted in the search. 6. 08/31/25 upon return, the resident was placed on one-to-one supervision on the secured unit. (1:1 monitoring ordered 09/02/25).Observed on lock unit in room with 1:1 sitter on 09/04/25 2:00 PM, ambulating in hallway 09/04/25 at 3:00 PM. Resident cannot recall elopement. 7. 08/30/25 all facility exit door alarms and screamer devices were inspected by the Maintenance Director.Interviewed Maintenance Director with no concerns 09/05/25 at 1:00 PM. 8. 08/30/25 keypad code to secure unit was changed by the Maintenance Director. Interviewed Maintenance Director with no concerns. Push pad changed to keypad 09/02/25. 9. 08/30/25 immediate education on abuse neglect and exploitation and risk of elopement initiated. 08/30/25 3-11 shift sign-in sheet reviewed. 08/31/25 11-7 signage sheet reviewed. No concerns. 10. 08/30/25 - 09/02/25 the elopement risk assessments of all residents were reviewed for accuracy.Verified 3 sampled residents. 11. 08/30/25 an elopement drill was performed for the 11-7 shift.Verified the sign-in sheet.12. 08/31/25 the resident was assessed by the nurse upon return and by the physician on the same day. Skin assessment done 08/31/25. 13. 08/31/25 an elopement drill was performed for the 7-3 shift. Verified by sign-in sheet. 14. 09/02/25 the care plans and kardexes of residents at risk for elopement were reviewed for accuracy.3 sampled residents reviewed. 15. 08/31/25 visitor lanyards were ordered for identification of visitors/vendors to differentiate visitors from residents. The lanyards arrived on 09/02/25 and were put into use immediately.Visitors observed wearing visitor lanyards on 09/04/25 and 09/05/25. 16. 09/01/25 keypad order to replace push button for entry to units. Keypad was installed 09/02/25.Observed on 09/04/25. (photographic evidence obtained). 17. 09/02/25 elopement books were reviewed for accuracy.Observed at nursing stations and receptionist desk on 09/04/25 and 09/25/24. 18. 09/02/25 an ad hoc QAPI was performed by the facility IDT and reviewed by the Medical Director. Sign-in sheet dated 09/02/25 verified. 19. 08/30/25, the Executive Director initiated education related to abuse/neglect reporting. 20. On 08/30/25, the Assistant Executive Director notified the Department of Children and Families of the elopement of Resident #1. 21. A Federal Immediate Report was submitted on 08/30/25. 22. From 08/30/25 until 09/4/25, current facility staff were provided education by the Director of Nursing and Assistant Director of Nursing pertaining to what constitutes resident mistreatment, abuse, neglect, and misappropriation of resident property. 202 out of 285 current facility staff had education completed by 09/04/25. Any employees who have not received the training were notified they must receive the training prior to working their next scheduled shift. New employees hired after 09/04/25 will receive education during the facility orientation process. Education pertaining to abuse/neglect is provided annually and as needed. 23. Facility practices which assist in monitoring/identifying potential abuse and neglect include, but are not limited to: grievance process, complaints resolution process, facility theft and loss reporting, resident council, incident reporting, internal audits of resident trust accounts, daily staffing practices, and regular direct indirect supervision of nursing home employees and resident care by supervisory and administrative staff. 24. Root cause analysis was performed on 09/02/25 by the regional director of clinical services related to the circumstances of the resident elopement which occurred on 08/30/25. Also, on 09/02/25, an IDT review and investigation of the residence episode of elopement was completed through the ad hoc copy process. Included in the investigation was reviewed the residence condition preadmission and post admission, resident evaluations including the accuracy of elopement evaluation resident care plan, staffing, facility environments and equipment.Verified by sign-in sheets. 25. The residency elopement risk evaluation was completed accurately at the time of admission and a care plan for elopement risk was initiated. The resident was correctly placed on the locked [NAME] wing unit at the time of admission. 26. The staffing PPD on 08/30/25 for 1.28 for licensed nurse assist and 2.43 for CNA's. On the [NAME] Wing units on the 3:00 PM to 11:00 PM shift, if there were two nurses and five CNA's for the 52 residents. 2 weeks staffing calculations (State only Requirement) reviewed with no concerns. 27. Staff who predominantly work on the [NAME] Wing were interviewed via a questionnaire and asked if the resident displayed any exit seeking behaviors prior to the incident, verbalizations of wanting to leave, packing belongings, or pushing on exit doors. The staff report no indications of such desire to exit or knowledge of any exit seeking behavior.Interviews reviewed and staff interviewed by surveyor. Resident had no exit seeking behaviors. 28. The investigation and root cause analysis revealed potential root cause scenarios (birthday party and push button entrance).Per ad-hoc on 09/02/25 29. Elopement risk evaluation facility systems processes in place related to patient identification of potential for elopement/ wandering and safety in place and followed.Policy reviewed. 30. The elopement risk evaluation is completed on admission, quarterly, and after a significant change period the evaluation consists of ambulatory mobility status, wandering behaviors, cognitive status, and exit seeking indicators. Policy reviewed. 31. If a patient is identified as a potential risk, based upon the evaluation, a patient identification form, which will include a current photo, a current description, and personalized care plans, and interventions, and redirection strategies. He locks the patient elopement book contains copy of the patient identification form, a colored photo of the patient and a face sheet. The elopement books are maintained at each nursing station and at the entrance to the reception facility area.Elopement books verified at nursing desk and reception desk. 32. Facility door prevention maintenance, monitoring and checked for function weekly conducted as scheduled. No deficits noted.Weekly log reviewed. 33. All exit doors are inspected weekly.Weekly log reviewed. 34. All designated entrance/exit areas have scheduled staff assigned to the receptionist area from 8:00 AM to 8:00 PM seven days a week. 35. Staffing schedules are monitored daily by staffing coordinator and reviewed with executive director of nursing and or nursing supervisor on duty to ensure adequate staffing is maintained. Adequate staffing means all minimum PPD, and ratios are met and in addition, staffing is adjusted based on acuity of patient needs.2 weeks staffing reviewed (State requirements only). No concerns. 36. All staff are screened prior to hire and a job specific orientation is performed. Receptionist not only receive training but have a completed competency on file.Sign-in reviewed for training. 37. On 09/02/25 a review of five receptionist staff employees' file revealed all had completed training and had a competency on file. The receptionist on duty on 08/30/25 at the time of the residence elopement was suspended immediately and has subsequently been terminated.Signage reviewed for training. 38. Immediately on 08/30/25 the maintenance staff performed an inspection of the facility exit doors and screamer devices and all were found to be fully functional.Audit reviewed and interviewed. 39. Weekly door checks by the Maintenance Director will be performed to ensure proper function. On 09/02/25, the push button entry system onto the memory care unit was replaced with the keypad the truth device. Audit reviewed. 40. From 08/31/25 through 09/01/25 facility licensed nurses completed a review of the accuracy of 185 current residents elopement risk evaluations period of the 185 residents, 52 residents resided in the memory care unit and 51 of those who were already assessed to be at risk for elopement. The remaining 1 of 52 residents was originally placed on The [NAME] Wing unit for behavior management but has since become a risk for elopement. The residence assessment was updated to reflect the risk of elopement.Sample of 3 confirmed. 41. On 09 02/25 the care plans and CNA Kardexs' of 52 of 52 residents at risk for elopement were reviewed. All were found to be in compliance with risk for elopement identified.Audit verified. 42. Director of Nursing /designee to complete monitoring of new admission evaluations to ensure risk for a low moment inaccuracy identified and care plan and Kardex are reflective of the risk, where appropriate.3 new admissions, 09/04/25 audited reviewed. 43. The Medical Director was informed of the citations and is in agreement with the removal plan. The following staff were interviewed for verification of staff education: Staff A, CNA was interviewed on 09/03/25 at 11:30 AM. Staff A stated she had recently completed elopement and abuse & neglect education after the incident with Resident #1; knowledge verified.Staff D, CNA was interviewed on 09/03/25 at 1:17 PM, Staff D stated she had recently completed elopement and abuse & neglect education after the incident with Resident #1; knowledge verified.Staff E, RN was interviewed 09/03/25 at 2:17 PM, Staff E stated a code silver which means a missing person in the facility, was called and every department participated in search. The education was provided after the incident occurred.The ADON was interviewed on 09/04/25 at 3:30 PM, the ADON had an elopement drill this morning. A written Elopement quiz was completed and stated some were done over the phone. She stated on the [NAME] unit they changed the entrance touch pad to have a code residents have a wrist band on, and visitors wear red lanyard for identification. An elopement book is on every unit as well as at the receptionist's desk.Staff F, CNA was interviewed on 09/04/25 at 3:45 PM. Staff F gave examples of wandering behavior and elopement such as pushing doors and staying next to the exit. She stated they call a code silver- missing person if they have an elopement and training included what to do if there is a missing resident. Staff F acknowledged the change of the lock system up[TRUN

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, record and policy review, the facility failed to provide necessary supervision to prevent the likelihood of serious injury, harm, impairment, or death by allowing an elopement for 1 of 3 sampled residents (Resident #1) reviewed for an elopement. The facility failed to ensure effective measures were in place to prevent the elopement in both the secured unit and the exit from the building.The deficient practice allowed Resident #1 to exit the facility undetected on 08/30/25 at 4:23 PM. There were 182 residents in the facility at the time of the survey. The facility's Administrator was notified of Immediate Jeopardy and given the IJ Template on 09/04/25 at 3:05 PM. The immediate jeopardy was removed on 09/04/25 at 4:45 PM and the deficiency was lowered to a scope and severity of D, isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Cross reference to F600.The findings included:A review of the facility's policy titled, Missing Residents/Actual Elopement, review date 03/27/25, documented: Definition of elopement, this occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Situation in which a resident with decision, making capacity leaves the facility intentionally but generally not be considered an elopement unless the facility is unaware of the resident's departure and/or whereabouts. The Executive Director or designee will report the event to all appropriate agencies as well as the regional divisional team. The event will be reviewed in an ad-hoc QAPI meeting, to determine how to ensure that a plan and system is in place to mitigate another occurrence.Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, General Muscle Weakness, Dysphagia, Cognitive Communication Deficit, Major Depressive Disorders, Altered Mental Status, Epilepsy, Alcohol Abuse, and Blindness of the Right Eye.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. This same MDS indicated that Resident #1 was able to ambulate without any assistive devices with supervision and touching assistance. A BIMS score conducted on 09/01/2025 revealed a score of 5 indicating the resident had severe cognitive impairment. An Elopement risk evaluation conducted on 08/06/2025 indicated the resident was at risk for Elopement. Review of the clinical census revealed Resident #1 had been in the facility's secured unit (west wing) since her admission date. (A secured unit is a designated area within a facility that offers enhanced security and supervision for residents who may be prone to wandering or require specialized care. These units are specifically designed to meet the unique needs of individuals with memory-related disorders, ensuring their safety and well-being.)Review of Resident #1's care plan initiated on 08/03/25 documented, At risk for elopement . Goal: The resident will not leave facility unattended through the review date with an intervention that documented, Provide for safe wandering - resident is an elopement risk.Review of the active orders dated 08/09/25 documented, Exit seeking. Provide safe wandering, resident is at risk for elopement. every shift.The video of the elopement incident, involving Resident #1 was viewed by the surveyor on 09/03/25 at 1:36 PM. The following was noted: On 08/30/25 at 4:23 PM the receptionist was attending to two visitors in the main lobby by the entrance of the facility. These two visitors blocked the view of the receptionist who was sitting down at that moment and Resident #1 walked behind the two visitors and walked out towards the door. During this same time at 4:23 PM, another visitor is buzzed in by the receptionist Resident #1 walked out quickly as the visitor walked in. (This door remains locked and must manually be unlocked by an individual after engaging a buzzer to enter the facility). The receptionist did not notice Resident #1 had exited the facility unaccompanied, via the main entrance camera in front of her, which she was responsible for monitoring. The resident was observed to be wearing a red T-shirt, red leggings with a pattern and black tennis shoes. She was seen walking in a fast and steady manner with no assistive devices at the time of exit. In the surveillance footage, there were no additional staff present at the main entrance at time of the resident's exit.Resident #1's room was located on the west side of the facility in a locked unit. Two hallways lead to the west unit (C and D unit) both unsecured. A middle hallway ( center core) joins the C and D unit on the west side; this same hallway's east side leads to two additional units (A and B units) which lead to the East Unit on the opposite side of the building. The middle hallway leads to the main lobby and facility's main entrance.An interview with the administration team was conducted on 09/03/25 at 10:35 AM. The Executive Director (Administrator), Director of Nursing (DON), Regional Director of Clinical Services, Regional [NAME] President, and Divisional Director of Clinical Services were present. When asked what happened regarding the incident that occurred on 08/30/25, involving Resident #1, the Administrator stated, I was contacted on 08/30/25 at approximately 5:19 PM by the facility that there was a missing resident. The Administrator voiced at that time there was a birthday party for another resident, who was turning 100, going on in back of the main dining room. This dining room was not located in the locked unit. They stated their investigation led them to believe that a visitor from the birthday party let Resident #1 out of the locked unit. They assumed Resident #1 could have passed as a visitor and was let off the unit by visitors. When asked what was done when they found out Resident #1 was missing, the Regional Director of Clinical Services and the Administrator stated they did an immediate in-house and facility wide search. When they confirmed she was not in the building, they called law enforcement. They stated the nurses and team which involved all department heads of the facility split into a grid and individual staff were assigned to a search zone. They added that this occurred over the weekend, but regional and divisional staff were still involved. When asked where Resident #1 was found, they stated law enforcement found her approximately 2 miles from the facility on [NAME] Street. Law enforcement contacted the facility, and the administration team brought her back to the facility. When asked how Resident #1's condition was when found, the Regional Director of Clinical Services stated she had dirt on her feet and sides of her pants and a skin tear but, denied falling. When asked what interventions were in place prior to Resident #1's elopement, they stated she had a care place in place, assessments, placed in a locked unit, and that staff watched for behaviors. They added the day of the incident, she did not display any behaviors indicating a risk for elopement. When asked if Resident #1 had family, they stated she was estranged from her family and does not get any visitors; they have found a couple numbers in the chart but have not been able to contact anyone. Resident #1 occasionally spoke of a sister, brother, and a friend but they have been unsuccessful in determining who. The Regional Director of Clinical Services added Resident #1 had not been deemed incapacitated. When asked if there were cameras in the area she eloped from, they stated they were unable to determine which exit (C or D unit exit) she eloped from; neither unit had cameras.During an interview on 09/03/25 at 11:17 AM, Resident #1 was observed with a one-to-one sitter, Staff A, Certified Nursing Assistant (CNA). The resident was observed sitting in bed fiddling with her personal belongings and attempting to get out of bed unassisted; a wheelchair was seen by her bedside. Resident #1 did not have the appearance to pass as a visitor. When the surveyor asked what her name was and the date and her location, she responded, My name is [Resident #1], I am located in a facility somewhere and the date is late May 2025. When asked, Did you leave the facility on Saturday 08/30/25?, she stated that was what she was being told but stated she didn't remember what happened. When asked where she was trying to go and who let her out, Resident #1 stated, no particular place, Saturday is my favorite day of the week and I decided to go out; I don't remember who let me out, I just walked out; I was bored so I left. When asked if she left because she felt unsafe at the facility, Resident #1 stated she felt safe, but she just wanted to leave.During an interview on 09/03/25 at 11:30 AM, when asked if she knew what happened on Saturday 08/30/25 with Resident #1, Staff A stated she heard what happened, but she was not working that day. She stated that Resident #1 went missing and didn't know how she was able to leave the facility. When asked if Resident #1 ever tried to elope or wander, Staff A stated, No, she can walk but her balance is not that good, so she uses a wheelchair instead.An observation and interview was conducted on 09/03/25 at 11:51 AM, when asked where the back of the main dining room was located, the DON offered to show the surveyor a tour to see the location. It was observed that the dining room was not located in the secured unit and upon entrance to the main dining room this same room led to the back dining room (another smaller dining room where the Birthday Party was held on Saturday for another Resident)When asked where the birthday party member resided, the DON stated she also resided in the locked unit (west wing). The DON voiced that the visitors were coming in and out (of the locked unit) that day. When asked if there were other visitors that day also visiting the unit, she stated not to her knowledge and that there was a kiosk in the front they used for check in; she would have to check there. When asked if the family members were called to confirm if they let a resident out by mistake, the DON stated not that she was aware of. When asked how did family get access to the locked unit, the DON stated prior to the incident, you could push the door to get into the unit without a passcode, but needed a code to leave; now you need a code to enter and exit the facility, due to the incident. When asked where Resident #1 was admitted from, she stated from a hospital from another county. When asked how long the resident was missing, on the day of the incident, she stated from 08/30/25 at 4:23 PM, law enforcement found her on 08/31/25 at 12:10 AM and then called the facility; she was brought back to facility around 1:00 AM on 08/31/25. When asked if she went to the hospital, the DON stated that the doctor saw her the following day and ordered an X-ray and labs but did not order her to go to the hospital. When asked what psych evaluated upon Resident #1's arrival and if they made any changes to her treatment, the DON stated they changed her Trazadone (medication) dose to help her sleep, did an assessment and a BIMS re-evaluation upon her arrival on 08/31/25.An interview was conducted on 09/03/25 at 11:57 AM, when asked what was evaluated for Resident #1 after the incident from 08/30/25, the Advanced Registered Nurse Practitioner (ARNP) for Psychiatry stated she saw Resident #1 via Telehealth on 08/31/2025. She stated I got a report that the resident was not sleeping all night and eloped. When I saw the resident, she was calm with on and off confusion; there were no more signs. She stated she changed her Trazadone dose to help her sleep and when asked if her BIMS evaluation changed, she stated her BIMS was 11 prior to the incident and had a BIMS of 10 on 08/31/2025 after the incident. She stated she checked it yesterday on 09/2/25 and her BIMS score was a 10 in the morning and her BIMS was 12 at about 2:30 PM that same day. She stated there are no other treatment changes and the plan was to reassess the resident every day since she has an ongoing one-to-one sitter.During an interview on 09/03/25 at 12:25 PM, when asked if she knew anything regarding the incident from 08/30/25 related to Resident #1, the Assistant Director of Nursing (ADON) stated she was not working the day of the incident but had seen the resident the following day. The ADON voiced that the resident had stated I was riding my bike looking for my kitty. The ADON stated she completed a head-to-toe assessment and spoke to her doctor who came to see the resident and also performed an assessment on her. When asked which residents are considered elopement risks, the ADON stated everyone in the secured unit (west wing) was identified as an elopement risk. When asked if there were residents in unsecured units with elopement risks, she replied no and stated they arrange beds in the locked unit as necessary. The ADON provided a census of residents with risk of elopement, who reside on the secured unit, at the time of the survey which was a total of 52. The secured unit has a capacity of 56 beds.During an interview on 09/03/25 at 12:39 PM, when asked about Resident #1's incident, the Social Services Director stated she was not at the facility on the day of the incident but recalled a resident in the locked unit was turning 100 and his family requested to have his birthday party in the back of the main dining room. When asked how the family would have access to the secured unit, the Social Service Director stated before the incident you could push a button and then push the doors to the unit to get in without a code; to exit you would need a code or a staff member to exit. When asked if staff are allowed to give codes to family, the Social Service Director stated typically staff lets them out and they don't give out codes. The Social Service Director stated she believed upon entering the unit, someone could have let her (Resident #1) out.A telephone interview was attempted on 09/03/25 at 12:58 PM with Staff C, a Licensed Practical Nurse (LPN) who was the primary nurse assigned to Resident #1 on the 3-11 shift on 08/30/25. Staff C stated she wasn't feeling well and couldn't talk.Review of a progress note written by Staff C on 08/30/25 at 8:41 PM with an effective time at 4:20 PM documented, Writer noticed resident was not present during meds pass and dinner, writer alerted all staff to search for resident in all the room, and went to central to notified all staff and supervisor made aware, PCP was called no answered and left voice mail, Emergency contact was called the woman in the phone stated she does not know the resident.A telephone interview was attempted on 09/03/25 at 1:12 PM with the local Police Department involved in the elopement incident regarding Resident #1, a voicemail was left, and a call back was not received during the time of the survey.A telephone interview was conducted on 09/03/25 at 1:16 PM with Staff D, a Certified Nursing Assistant (CNA) who was the primary CNA assigned to Resident #1 on the 3-11 shift on 08/30/25. When asked what happened on her shift on 08/30/25, Staff D stated. I was floating that day; I was assigned to west, but to both sides of the hallways. My shift started at 3 PM but at around 2:50 PM, I started doing my rounds. Resident #1 was in the dining room in the unit. Resident #1 usually walks around but doesn't try to leave the floor. At 4:00 PM I saw her by the medication cart. At around 4:10 PM another CNA I was working with saw her food arrive. I told her she was by the dining room, and I told her to check there. She could not find Resident #1 in the dining room, so she checked her room, and she was not there. At about 4:20 PM, we told the primary nurse, and the nurse called the supervisor. When asked if Resident #1 was showing any behaviors of trying to escape the unit that day, Staff D stated, no she has never done this before, this was the first time this happened on my shift. Staff D voiced Resident #1 can walk by herself and move without a wheelchair. When asked if Resident #1 was alert and oriented, she stated she was not too confused, when you ask her to do something she does it. When asked how family members came in on 08/30/25, Staff D stated, I think they had a party that day, but everyday family members come in. When asked, do you give a code to family members, Staff D stated, No we are not supposed to do that. Staff D voiced, Before this happened you didn't need a code to get in, but to get out you did. I think they might have changed it now.On 09/03/25 at 1:36 PM, the surveyor reviewed the surveillance footage of Resident #1's incident side-by-side with the Administrator. The video revealed the following: On 08/31/25 at 12:37 AM upon re-entering the facility, Resident #1 was observed to enter the facility accompanied by the Administrator, Regional Director of Clinical Services, Divisional Director of Clinical Services, Maintenance Director, Social Services Director, Marketer, and the DON. Resident #1 was observed to be wearing the same outfit she left with but was walking in with only socks on and her tennis shoes were missing. When asked what happened to Resident #1's shoes, the Administrator stated, We don't know what happened to her shoes. The resident was observed to walk in with a steady gait.An interview was conducted on 09/03/25 at 2:17 PM with Staff E, Registered Nurse (RN), who worked the 7 AM- 3PM shift on 08/30/25. When asked what happened in Resident #1's incident, Staff E recalled the events, It was a quiet day, I had no issues that day; I gave report to the next nurse, Staff C. I gave report on 08/30/25 at about 3:45 PM; Resident #1 was next to me standing while I was giving report. Staff C doesn't work there often. I don't know if she is per diem or part time and normally works in another unit. Staff C was not really familiar with Resident #1; she was not a regular nurse who worked there. After I gave report, I left a little after 4 PM. I was called around 5:00 pm and they told me the resident was missing. I told them she was standing next to him during report. Staff E voiced Resident #1 was always walking around by the hallway rails but never saw her try to leave; she was not showing any behaviors that day. She never pushed any doors or tried to leave. I never thought in my mind she would exit the facility, she normally doesn't walk fast, she normally walks very slow. Staff E stated he drove around to see if he saw her, he lived close by and knew the neighborhood well but could not locate her. He stated, They called me in the middle of the night to tell me she came back; I was happy she was back, we try to keep everybody safe, unfortunately this happened. When asked how he believed Resident #1 got out, Staff E stated, I remember there was a party for another resident, but I don't really know. When asked if he saw family visitors that day on his shift, Staff E stated, a resident was turning [AGE] years old in the west unit and their family was in their room. When asked if the staff gives codes to family, Staff E stated, No that doesn't happen, if there is a suspicion they might know a code it gets changed right away. When asked how you could get to the locked unit, Staff E stated, Before you push the green knob and could open the door, but to get out you would need a code, now it is changed you need a code in and out.On 09/04/25 at approximately 10:15 AM, the surveyor travelled the route by car from [NAME] Hall of Life Care to [NAME] Drive in [NAME] Palm Beach Florida which led to a residential trailer park. Review of the route revealed the resident walked approximately 2 miles by foot. The resident would have likely passed 2 canals, with uneven sidewalks/pavement, through commercial and residential areas, onto a busy 4 lane and 8 lane roadways with speed limits in between 30 and 45 MPH (miles per hour). The resident was at extreme risk of getting hit by a automobile, tripping and falling, drowning, getting injured or death. The weather in [NAME] Palm Beach, Florida on 08/30/25 at 4PM- 08/31/25 at12AM was approximately in between 94 degrees Fahrenheit during the day and 84 degrees at night and wind speeds were in between 6-8 miles per hour (mph) with no precipitation.Review of the record revealed a Skin Assessment was conducted on Resident #1 on 08/31/25. The Assessment documented Abrasion: Right posterior forearm- c-shaped abrasion, no active bleeding, no acute signs of infection. left lateral face vertical abrasion- no active bleeding no drainage on signs of infection. Bruising(s): Right upper arm, right lateral thigh with scattered scab. Scars(s) Right elbow, long oval scar Scabs on left knee and chin, left hand. Doctor made aware of skin issues. Resident denies pain at this time. No active bleeding to sites, no acute signs of infection. Treatment to left forearm rendered, resident tolerated well.In a review of the Medication Administration Record (MAR) for August, 2025, it revealed that on 08/30/25 Resident #1 missed the 5 PM of Bethanechol Chloride Oral Tablet 25 MG for urinary retention, the 5 PM dose of Carbidopa-Levodopa Oral Tablet 25-100 MG for Parkinson's, the 5 PM dose of Clonazepam Oral Tablet 0.5 MG for anxiety, the 8 PM dose of Famotidine Oral Tablet 20 MG for acid reflux, the 8 PM dose of Gabapentin Capsule 300 MG for nerve pain, the 8 PM dose of Metoprolol Tartrate Tablet 12.5 MG for hypertension, the 9 PM dose of Rosuvastatin Calcium Oral Tablet 10 MG for high cholesterol, the 9 PM dose of Tamsulosin HCl Oral Capsule 0.4 MG for urinary issues, and the 9 PM dose of Topiramate Oral Tablet 200 MG for seizures.The facility submitted an acceptable Immediate Jeopardy removal plan on 09/04/25, which was verified by observations, interviews and record review, as follows: 1. 08/30/25- 100% headcount of residents was completed to ensure no other residents were missing. All other residents were accounted for. 2. 08/30/25 a whole house search of the facility was completed. 3. 08/30/25 the Executive Director was notified by the weekend supervisor who in turn, notified facility managers to report to work to assist in the search. Regional and divisional staff were also notified and reported to the facility to assist in the search. The Medical Director and primary physician were notified. 4. 08/30/25 an external search of the community was initiated. 5. 08/30/25 Executive Director notified the local Police Department who assisted in the search. 6. 08/31/25 upon return, the resident was placed on one-to-one supervision on the secured unit. 1:1 monitoring ordered 09/02/25.Observed on lock unit in room with 1:1 sitter on 09/04/25 2:00 PM, ambulating in hallway 09/04/25 at 3:00 PM. Resident cannot recall elopement. 7. 08/30/25 all facility exit door alarms and screamer devices were inspected by the Maintenance Director. Interviewed Maintenance Director with no concerns 09/05/25 at 1:00 PM. 8. 08/30/25 keypad code to secure unit was changed by the maintenance director. Interviewed maintenance director with no concerns. Push pad changed to key pad 09/02/25. 9. 08/30/25 immediate education on abuse neglect and exploitation and risk of elopement initiated. 8/30/25 13-11 shift sign-in sheet reviewed. 08/31/25 11-7 signage sheet reviewed. 10. 08/30/25 - 09/02/25 the elopement risk assessments of all residents were reviewed for accuracy.Verified 3 sampled residents. 11. 08/30/25 an elopement drill was performed for the 11-7 shift.Verified sign-in sheet.12. 08/31/25 the resident was assessed by the nurse upon return and by the physician on the same day. Skin assessment done 08/31/25. 13. 08/31/25 an elopement drill was performed for the 7-3 shift. Verified by sign-in sheet. 14. 09/02/25 the care plans and kardexes of residents at risk for elopement were reviewed for accuracy.3 sampled residents reviewed. 15. 08/31/25 visitor lanyards were ordered for identification of visitors/vendors to differentiate visitors from residents. The lanyards arrived on 09/02/25 and were put into use immediately.Visitors observed wearing visitor lanyards on 09/04/25 and 09/05/25. 16. 09/01/25 keypad order to replace push button for entry to units. Keypad was installed 09/02/25.Observed on 09/04/25. (photographic evidence obtained). 17. 09/02/25 elopement books were reviewed for accuracy.Observed at nursing stations and receptionist desk on 09/04/25 and 09/25/24. 18. 09/02/25 an ad hoc QAPI was performed by the facility IDT and reviewed by the Medical Director. Sign-in sheet dated 09/02/25 verified.19. On 08/30/25, the Assistant Executive Director notified the Department of Children and Families of the elopement of Resident #1. 20. A Federal Immediate Report was also submitted on 08/30/25. 21. From 08/30/25 until 09/04/25 current facility staff were provided education by the director of nursing and assistant director of nursing pertaining to unsafe wandering and elopement prevention. 202 out of 285 current facility staff education was completed by 09/04/25. New employees hired after 09/04/25 will receive education we're in the facility orientation process. Education pertaining to unsafe wandering and elopement prevention is provided annually and as needed. Sign-in sheets reviewed. 22. Director of Nursing designee to complete daily new admission chart reviews to ensure risks for elopement is identified and care planned times 4 weeks, weekly times 2 months, then quarterly and as needed thereafter to ensure no concerns related to risk for elopement. Audits reviewed. 23. Root cause analysis was performed on 09/02/25 by the Regional Director of Clinical services related to the circumstances of the resident elopement which occurred on 08/30/25. 24. On 09/02/25 an IDT review an investigation of the residents episode of elopement was completed through the ad hoc coffee process. Included in the investigation was a view of the residence condition preadmission and post admission resident evaluations including the accuracy of the allotment evaluation, resident care plan, staffing, facility environment and equipment. 25. The resident elopement risk evaluation was completed accurately at the time of admission and a care plan for elopement risk was initiated. Initial 08/04/25 not at risk. 08/06/25 at risk. 26. The resident was correctly placed on the locked [NAME] unit at the time of admission. The staffing PPD on 08/30/25 for 1.28 for licensed nurse assist and 2.43 for CNA's. On The [NAME] Wing units on the 3:00 PM to 11:00 PM if there were two nurses and five CNA's for the 52 residents. Verified admitted to [NAME] unit (locked unit 08/04/25). 27. Staff who predominantly work on the [NAME] Wing were interviewed via a questionnaire and asked if the resident displayed any exit seeking behaviors prior to the incident, verbalizations of wanting to leave, packing belongings, or pushing on exit doors. The staff report no indications of such desire to exit or knowledge of any exit seeking behavior. Reviewed statements. Staff on west unit interviewed by surveyor with no concerns. 28. The investigation and root cause analysis revealed potential root cause scenarios (birthday party and push button entrance).Via ad-hoc 09/02/25. 29. Elopement risk evaluation facility systems processes in place related to patient identification of potential for elopement/slash wandering and safety in place and followed.Policy reviewed. 30. The elopement risk evaluation is completed on admission, quarterly, and after a significant change period the evaluation consists of ambulatory mobility status, wandering behaviors, cognitive status, and exit seeking indicators.Policy reviewed. New admission audits reviewed. 31. If a patient is identified as a potential risk, based upon the evaluation, a patient identification form, which will include a current photo, a current description, and personalized care plans, and interventions, and redirection strategies. He locks the patient elopement book contains copy of the patient identification form, a colored photo of the patient and a face sheet. The elopement books are maintained at each nursing station and at the entrance to the reception facility area.Verified at nursing stations and reception desk. 32. Elopement drills are completed quarterly, including nights and weekends. These drills are monitored for quality by using the elopement drill performance summary and discuss at QAPI. 33. Facility door prevention maintenance, monitoring and checked for function weekly conducted as scheduled. No deficits noted.Weekly audits reviewed. 34. All exit doors are inspected weekly.Weekly audits reviewed. 35. All designated entrance/exit areas have scheduled staff assigned to the receptionist area from 8:00 AM to 8:00 PM seven days a week. 36. Staffing schedules are monitored daily by staffing coordinator and reviewed with executive director of nursing and/or nursing supervisor on duty to ensure adequate staffing is maintained. Adequate staffing means all minimum PPD, and ratios are met and in addition, staffing is adjusted based on acuity of patient needs. 2 weeks staffing calculations (State only requirement) reviewed with no concerns. 37. All staff are screened prior to hire and a job specific orientation is performed. Receptionist not only receive training but have a completed competency on file.Training/education verified by sign-in sheet for receptionist. 38. On 09/02/25 a review of five of five receptionist staff employees file revealed all had completed training and had a competency on file. The receptionist on duty on 08/30/25 at the time of the residence elopement was suspended immediately and has subsequently been terminated. Training/education verified by sign-in sheet. 39. Immediately on 08/30/25 the maintenance staff performed an inspection of the facility exit doors and screamer devices and all were found to be fully functional.Audit reviewed and interviewed. 40. Weekly door checks by the maintenance director will be performed to ensure proper function. On 09/02/25, the push button entry system onto the memory care unit was replaced with the keypad the truth device.In-voice dated 09/04/25 was reviewed. 41. From 08/31/25 through 09/01/25 facility licensed nurses completed a review of the accuracy of 185 current residents elopement risk evaluations period of the 185 residents, 52 residents resided on the memory care unit and 51 of those who were already assessed to be at risk for elopement. The remaining 1 of 52 residents was originally placed on The [NAME] Wing unit for behavior management but has since become a risk for elopement. The residence assessment was updated to reflect the risk of elopement. Audits reviewed. No concerns. 42. On 09 02/25 the care plans and CNA kardexes of 52 of 52 residents at risk for elopement were reviewed. All were found to be in compliance with risk for elopement identified.Sample of 3 residents reviewed with no concerns. 43. Director of nursing/designee to complete monitoring of new admission evaluations to ensure risk for elopement inaccuracy identified and care plan and kardex are reflective of the risk, where appropriate. 3 admissions on 09/04/25 and audited (for west unit). 44. The Medical Director was informed of the citations and is in agreement with the removal plan. The following staff were interviewed for verification of staff education: Staff A, CNA was interviewed on 09/03/25 at 11:30 AM. Staff A stated she had recently completed elopement and abuse & neglect education after the incident with Resident #1; knowledge verified.Staff D, CNA was interviewed on 09/03/25 at 1:17 PM, Staff D stated she had recently completed elopement and abuse & neglect education after the incident with Resident #1; knowledge verified.Staff E, RN was interviewed 09/03/25 at 2:17 PM, Staff E stated a code silver which means a missing person in the facility was called and every department participated in search. The education was provided after the incident occurred.The ADON was interviewed on 09/04/25 at 3:30 PM, the ADON had an elopement drill this morning. A written Elopement quiz was completed and stated some were do[TRUNCATE