**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the policy titled Care Plans, Comprehensive Person- Centered, the facility failed to develop a person-centered care plan that focused on wandering and exit seeking behaviors for one resident (R) (R#1) with a known history of elopement from a sample of 14 residents. On 7/18/2023, it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Nurse Consultant were informed of the Immediate Jeopardy (IJ) for F656, F689, and F835 on 7/18/2023 at 3:15 p.m. The noncompliance related to the IJ was identified to have existed on 7/7/2023. An Acceptable IJ Removal Plan was received on 7/21/2023 related to 483.21(b)(1), Development/Implement Comprehensive Care Plan (F656), 483.25(d)(2), Accidents and Hazards (F689), and 483.70, Administration (F835). Based on observations, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/12/2023. It was determined that the facility had completed implementation of the Removal Plan prior to the start of survey, and therefore, the IJ was considered past noncompliance. Findings include: Review of the policy titled Care Plans, Comprehensive Person- Centered updated 12/2022, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: number 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Number 8. The comprehensive person-centered care plan: g. incorporates identified problem areas. h. incorporates risks factors associated with identified problems. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses including encephalopathy, traumatic subdural hemorrhage, dementia, hypertension (HTN), chronic kidney disease (CKD), and agitation. He was admitted post hospital stay after being found unresponsive on the side of the road after eloping from his home. The resident had a five-day Prospective Payment System (PPS) Assessment completed on 7/2/2023 indicating a Brief Interview Mental Status (BIMS) score of four, indicating the resident had severely impaired cognition. Section E revealed the resident exhibited wandering behaviors one to three days. Section G revealed resident required supervision with ambulation. Review of R#1's comprehensive care plan initiated 6/26/2023 revealed there was no indication that nursing staff had developed a care plan with specific goals with interventions to address resident's history of wandering and recent elopement from his home prior to admission. Review of the Nurse's Note dated 6/27/2023 at 7:08 a.m. written by Licensed Practical Nurse (LPN) FF, revealed resident up wandering throughout the shift. Review of the electronic medical record (EMR) revealed an Elopement Risk Assessment was completed on 7/8/2023, the day after the resident eloped from the facility. The assessment revealed resident was at high risk for elopement with a score of 23.0. Interview on 7/17/2023 at 10:40 a.m., Administrator stated the door R#1 exited the building from was not secured and was not considered to be an exit door. Interview on 7/18/2023 at 10:00 a.m., Assistant Director of Nursing (ADON) stated she would expect charge nurses who admit residents to complete an elopement assessment as part of the admission paperwork. During further interview, she stated she would expect the care plan to include the resident was an elopement risk or a wanderer with interventions put in place. Interview on 7/18/2023 at 10:50 a.m., Minimum Data Set (MDS) Coordinator stated she is responsible for collecting MDS data for the development of care plans. She stated when the charge nurses admit new residents, they should complete an Elopement Assessment at that time and make sure it is care planned. Telephone interview on 7/19/2023 at 10:40 a.m., LPN EE stated information for the MDS is obtained from resident's previous history, hospital records, and observations of the resident. She stated the night of R#1's elopement, Certified Nursing Assistant (CNA) GG informed her around 11:15 p.m. that R#1 was missing. LPN EE stated she instructed staff members to search for R#1 inside and outside of the building. During further interview, she stated that CNA GG got in his car and drove around and located the resident on the highway and had been hit by a car. LPN EE confirmed that nurses are supposed to complete an Elopement Assessment when a new resident is admitted to the facility. If the resident is at risk for elopement the care plan should include elopement interventions. Telephone interview on 7/19/2023 at 11:42 a.m. CNA GG stated he works at the facility through a staffing agency. He stated on the night of 7/7/2023 around 11:00 p.m., he realized that he had not seen R#1 for a few hours, so he started looking for him. He stated when he couldn't find R#1, he told one of the charge nurses, who instructed the other staff to start a search for the resident inside and outside of the building. During further interview, he stated he got in his car and started looking for the resident. He stated about three miles from the facility, he came upon a motor vehicle accident where the resident had been hit by a car. He stated the people who had hit the resident were at the scene and had already called 911. Cross Refer F689 The following IJ Removal Plan was provided by the facility and accepted on 7/21/2023. 1. R#1 no longer resides at the facility. 2. On July 10, 2023, the Regional Director of Operations, Regional Director of Clinical Services and Medical Director reviewed the center policy Care Plan. No policy changes or recommendations were made as a result of this review. 3. On July 8, 2023, Center Director of Nursing identified 11 residents at risk for elopement out of the 54 residents on the center resident roster. Resident plans of care were reviewed and updated as needed, and physician and responsible parties were notified. 4. Licensed nurses to include MDS and nurse managers (Center RNs 3 of 3 -100%; Center LPNs 7 of7 -100% and Agency LPNs 8) were educated by Director of Nursing on the importance of completing care plans with interventions on residents identified through their assessments as being at risk for elopement on July 8, 2023. Employees on leave of absence FMLA- vacation or agency staff will be re-educated prior to returning to duty and will not be given an assignment until they are given additional on-site education. 5. The Director of Reimbursement provided additional education to center Nurse Managers and MDS team on Person-Centered Care Plan to include development, implementation, and revision of care plans on July 10, 2023. 6. The Director of Nursing will review incidents and accident reports from the previous day during daily clinical meeting and will verify care plans are developed and revised as needed, to address interventions to prevent elopement risk. 7. Administrator will review the results of the audits in the weekly Quality Assurance Performance Improvement meeting weekly for four weeks then monthly to ensure compliance is achieved and sustained. Administrator will sign and communicate results of the audit review with the physician and the members of the committee. Subsequent plans of corrections will be implemented as necessary. Date corrective action will be completed is 7/11/2023 and IJ to be removed on 7/12/2023. Onsite Verification of Removal Plan: 1. Review of the document on facility letterhead revealed R#1 no longer resides at the center. Review of the progress note on 7/7/2023 at 11:40 p.m. staff was unable to locate R#1 while doing rounds. A search of the facility was conducted by staff inside and outside the facility with no results. 911 was called, the sheriff reported the resident was located and transported to the hospital. Surveyor verified R#1 was still inpatient at the hospital via phone on 7/18/2023 at 9:50 a.m. Interview with the ADON on 7/21/2023 at 2:25 p.m. verified R#1 is no longer in the center. 2. Review of a document entitled Care Plans, Comprehensive Person-Centered and Care Plans - Baseline with a reviewed date of 7/8/2023 with three unidentifiable initials. Interview with the Administrator on 7/21/2023 at 2:26 p.m. verified the initials of the above-named staff as having reviewed the policies. 3. Review of a checklist utilized for elopement risk re-evaluation completed by ADON identified 11 residents highlighted in yellow with risk scores ranging from 13 - 27. Also verified each of the 11 residents had completed Elopement Risk Assessments and care plans. Review of three residents was selected for review (the surveyor had already verified all 11 residents R#'s 2, 3, 7, 8, 9, 10, 11, 12, 13, and 14) had an Elopement Risk Assessment and care plan completed. In an interview with Regional Director of Clinical Operations on 7/21/2023 at 12:55 p.m. stated the 11th resident was R#1 for a total of 11 residents identified to be at risk for elopement. 4. Review of the document entitled [facility name] IJ Education that 7 out of 7 Dietary staff were educated; 12 of 12 CNA/CMA were educated; 7 of 7 LPN's were educated; 3 of 3 RN's were educated; 1 of 1 NP was educated; 2 contract rehab staff were educated, 8 of 8 Agency LPN's; 24 of 24 Agency CNA's received education. Interview with the ADON on 7/21/2023 at 2:33 p.m., verified that she educated all staff as described above. Also verified via the following staff interviews on 7/20/2023 at 11:34 a.m. with LPN EE, 11:46 a.m. CNA PP, 11:49 a.m. CNA QQ, 11:50 a.m. LPN FF, 11:55 a.m. LPN RR. On 7/21/2023 at 11:57 a.m. CNA SS, 11:59 a.m. CNA TT, 4:23 p.m. Staffing Coordinator/Scheduler VV, 4:25 p.m. CNA MM, 4:37 p.m. CNA NN, and 4:41 p.m. CNA OO, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 5. Review of the facility in-service titled Elopement Care Plans dated 7/10/2023 with the MDS Coordinator, Social Services Director and the ADON in attendance. Overview: The MDS Coordinator was educated on the importance of care planning residents who are an elopement risk determined by review of the Elopement Risk Assessment completed on admission and as needed. An interview on 7/21/2023 at 3:55 p.m. with (LPN MDS) Coordinator UU stated she has been in-serviced on making sure the care plans are updated and ensuring that the nurses know how to go in and look at the care plans and update the care plan if needed, as well as making sure the elopement risk assessments are completed. She stated a score of 24 or higher on the Elopement Assessment indicated resident is at risk for elopement. Record Review of the following sample residents (R#7, R#8, R#9, R#10, R#11, R#12, R#13, and R#14) revealed all residents had an Elopement Assessment completed and were care planned as an elopement risk with appropriate interventions. Review of the nurse's notes May 2023 until present day did not reveal any of the residents listed above had made any attempt to elope. 6. Review of the Incident/Accident List dated June 1 - July 16, 2023, identified 19 falls, 8 skin issues, 2 alleged abuse, 1 elopement (R#1). In an interview with the ADON on 7/21/2023 at 2:33 p.m. confirmed the DON had identified the incidences from June 1 through July 16, 2023. 7. Review of the QAPI Meeting Minutes dated 7/10/2023 with subject matter - QAPI Monthly Meeting. Began at 12:30 p.m. and lasted 10 minutes. In attendance were the Administrator, Maintenance Director, DON, ADON, Social Services Director, MDS Coordinator, Medical Director, and Nurse Practitioner. Discussed the incident and timeline. Planned to meet again in four weeks. In an interview with the Administrator on 7/21/2023 at 2:34 p.m. verified the members of the QAPI meeting on 7/10/2023 and items discussed. An interview on 7/21/2023 at 3:35 p.m. Social Services Director stated she was involved in the QAPI meeting. The team discussed what happened, how it happened, and what could be implemented to prevent any other residents from eloping. Also, the QAPI team discussed the residents in the facility that were assessed as high risk for elopement. The SSD was able to name R#9 and R#13 as residents that are high risk for elopement. She stated R#9 must be redirected often from the door. Administrative oversight of the above measures was reviewed and verified. All corrective action was completed on 7/11/2023. The IJ was removed on 7/12/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, document review, and review of the facility policy titled Elopement and Wandering Residents, the facility failed to provide adequate supervision and monitoring for one of 14 sampled residents (R) (R#1) and failed to ensure magnetic locking exit doors were functioning properly to prevent the elopement of R#1. Specifically, R#1 exited the facility on 7/7/2023, undetected through an unlocked door, walked approximately 3.5 miles away from the facility, was struck by a motor vehicle. Resident #1 sustained a fractured right hip, fractured right humerus, and fractured right scapula. On 7/18/2023, it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Nurse Consultant were informed of the Immediate Jeopardy (IJ) for F656, F689, and F835 on 7/18/2023 at 3:15 p.m. The noncompliance related to the IJ was identified to have existed on 7/7/2023. An Acceptable IJ Removal Plan was received on 7/21/2023 related to 483.21(b)(1), Development/Implement Comprehensive Care Plan (F656), 483.25(d)(2), Accidents and Hazards (F689), and 483.70, Administration (F835). Based on observations, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/12/2023. It was determined that the facility had completed implementation of the Removal Plan prior to the start of survey, and therefore, the IJ was considered past noncompliance. Findings include: Review of the policy titled Elopement and Wandering Residents revised June 2022, policy statement indicated residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: Number 1. The facility is equipped with door locks/alarms to help avoid elopements. Number 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Number 4. Monitoring and managing residents at risk for elopement or unsafe wandering: a. Residents will be assessed for risk of elopement and unsafe wandering upon admission; d. Adequate supervision will be provided to help prevent accidents or elopements. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses including encephalopathy, traumatic subdural hemorrhage, dementia, hypertension (HTN), chronic kidney disease (CKD), and agitation. He was admitted post hospital stay after being found unresponsive on the side of the road after eloping from his home. The resident had a five-day Prospective Payment System (PPS) Assessment completed on 7/2/2023 indicating a Brief Interview Mental Status (BIMS) score of four, indicating the resident had severely impaired cognition. Section E revealed the resident exhibited wandering behaviors one to three days. Section G revealed resident required supervision with ambulation. Review of the comprehensive care plan initiated 6/26/2023 revealed there was no indication that nursing staff had developed a care plan with specific goals with interventions to address resident's history of wandering and recent elopement from his home prior to admission. Review of the Nurse's Note dated 6/27/2023 at 7:08 a.m. written by Licensed Practical Nurse (LPN) FF, revealed resident up wandering throughout the shift. Review of the electronic medical record (EMR) revealed an Elopement Risk Assessment was completed on 7/8/2023, the day after the resident eloped from the facility. The assessment revealed resident was at high risk for elopement with a score of 23.0. Review of a document provided by facility titled Elopement Timeline indicated: Friday 7/7/2023: 9:30 p.m. - last time R#1 was seen in facility by Licensed Practical Nurse (LPN) FF 11:00 p.m. - Certified Nursing Assistant (CNA) GG started to look for resident 11:15 p.m. - LPN EE was notified by CNA GG that he could not find R#1 11:20 p.m. - LPN FF was notified by LPN EE that R#1 was missing. All staff continue searching 11:40 p.m. - Daughter of R#1 was notified by LPN FF of resident elopement from the facility 11:55 p.m. - LPN FF called 911 and notified Director of Nursing (DON). DON notified Administrator. Staff continue to search Saturday 7/8/2023: 12:10 a.m. - staff notified that R#1 had been involved in accident and transported to hospital for evaluation 12:15 a.m. - DON on sight as well as police 1:15 a.m. - Administrator on sight as well as additional police. Scheduled CNAs to monitor door until repair was complete 10:00 a.m. - Maintenance placed lock on non-egress door Review of the sheriff's report dated 7/8/2023 at 4:37 a.m. revealed on 7/7/2023 the deputy was dispatched to [name of facility] in reference to a missing person. On 7/7/2023 at approximately 11:54 p.m. Central Dispatch received a 911 call stating that a male patient was missing. The deputy was advised by dispatch that according to the caller, the male patient had been missing 20 minutes prior to them calling. Upon arriving at the scene at approximately 12:09 a.m. the deputy was advised by the nursing home staff that they had received a call stating the resident had been hit by a car on the highway. The deputy left the nursing home and began looking for the resident. The Deputy was able to locate the resident just across the county line, laying on the side of the road. The resident advised the deputy that he had been gone from the nursing home for about two hours and was walking to get cigarettes, when he was hit by a car. The deputy documented that according to Google Maps the location of the scene was approximately 3.5 miles and was roughly an hour and 13-minute walk from the facility. The resident was transported to hospital. Review of the Facility Incident Report dated 7/8/2023 at 11:53 p.m. revealed R#1 eloped from the facility and was discovered on the road with apparent injury. Resident was sent to the hospital for evaluation. Review of the five-day follow-up revealed the following steps were taken to prevent further elopement: all exits were examined to determine how R#1 had exited the building, the door was identified and secured temporarily. Staff were assigned to the door to assure that no other residents in the facility could exit through the door. The facility completed an Elopement Risk Assessment on all residents to ensure appropriate interventions were in place for residents identified at risk. All staff were educated on the Elopement Policy and the Elopement Notebooks. A root cause analysis was completed on 7/10/2023 by the Administrator, the Assistant Director of Nursing (ADON), the DON, the Maintenance Director/Safety Coordinator and The Regional Director of Clinical Operations. Interview on 7/17/2023 at 10:40 a.m., Administrator revealed prior to the elopement, the door which R#1 exited was not secured and was not considered to be an exit door. Interview on 7/18/2023 at 10:00 a.m., Assistant Director of Nursing (ADON) stated her expectation is for the charge nurses to complete elopement assessments on admission. She stated there is an elopement book at the nurses' station that should be kept up to date with the resident's information. During further interview, she stated she expects the residents care plan to include if the resident was an elopement risk or a wanderer with interventions listed. Interview on 7/18/2023 at 10:40 a.m., the facility Administrator and the Maintenance Director revealed they had no idea about how long the door had been unlocked that R#1exited from when he eloped from the facility. Interview on 7/18/2023 at 11:00 a.m. with Dietary Aide CC revealed she has not used the back door in the corner of the dining room, nor had she seen anyone else use that door. Telephone interview on 7/19/2023 at 10:40 a.m., with LPN EE, stated the night of R#1's elopement, Certified Nursing Assistant (CNA) GG informed her around 11:15 p.m. that R#1 was missing. LPN EE stated she instructed the staff members to search for R#1 inside and outside of the building. During further interview, she stated that CNA GG got in his car and drove around and located the resident on the highway and informed her he had been hit by a car. LPN EE confirmed that nurses are supposed to complete an Elopement Assessment when a new resident is admitted to the facility. Telephone interview on 7/19/2023 at 11:42 a.m. with CNA GG, stated he works at the facility through a staffing agency. He stated on the night of 7/7/2023 around 11:00 p.m., he realized that he had not seen R#1 for a few hours, so he started looking for him. He stated when he couldn't find R#1, he told one of the charge nurses, who instructed the other staff to start a search for the resident inside and outside of the building. During further interview, he stated he got in his car and started driving around looking for the resident. He stated about three miles from the facility, he came upon an accident where the resident had been hit by a car. He stated the people who had hit the resident were at the scene and had already called 911. The following IJ Removal Plan was provided by the facility and accepted on 7/21/2023. 1. R#1 no longer resides at the center. 2. On July 7, 2023, at approximately 2300, it was noted that R#l was discovered to be missing by his assigned CNA who alerted her charge nurse. Staff were notified to start a search for R#1. The CNA and another charge nurse got in their vehicles and started driving around looking for R#l. At approx. 00:10 on July 8, 2023, the CNA came upon an accident scene approximately 3miles from the facility and discovered R#l was involved in a pedestrian vs. MVA accident and 911 had been called. On July 8, 2023, an initial state reportable was filed with the state at 1:45 a.m. 3. On July 7, 2023, at approx. 2300, staff at the center used a midnight census report to conduct an in-house head count to determine if other residents were missing from the center. All residents were accounted for except R#l. 4. On July 8, 2023, at approx. 00:00. it was determined that R#l exited the facility by means of the door in the dining room in the far-right corner that was not locked. 5. On July 8, 2023, at 00:15 a staff member was assigned by the DON to be stationed at the door where R#1 exited the center until repaired by maintenance personnel. 1:1 attendant stationed at the door until lock installed. 6. On July 8, 2023, the Regional Director of Operations and Regional Director of Clinical Operations reviewed and the center Elopement Policy and Incidents and Accidents Policy to include the frequency of elopement assessments (upon admission, re-admission, quarterly and change in condition). No changes were made. 7. Only July 8, 2023, the Regional Director of Clinical Operations completed education with the Administrator, DON, ADON, Social Services, MDS and Maintenance Director regarding the Elopement Policy and Incidents and Accidents Policy. 8. On July 8, 2023, at approximately 10:00 the door where R#l exited the center was repaired and a temporal padlock was placed by the center Maintenance Director while waiting for a permanent mag-loc to be installed. The Administrator assigned a CNA to be stationed at the door to monitor until placement of permanent mag-loc. 9. On July 8, the center implemented an hourly door check audit to ensure all doors are secure. This tool (the door check audit tool) was utilized for 72 hours until the mag-loc was installed. 10. On July 11, 2023, the permanent mag -loc was placed on the door and secured by the center Maintenance Director. 11. On July 8, 2023, the Assistant Director of Nursing completed new elopement risk assessments on all residents residing at the center to identify any residents at risks for elopement using the daily census roster to document completion. 12. On July 8, 2023, the MDS Coordinator reviewed the 11 identified at risk for elopement residents to validate elopement assessments and ensured identified risks were addressed in the care plans for all residents in the center. Any concerns identified were addressed according by the MDS Coordinator. 13. On July 8, 2023, the Director of Nursing confirmed that the elopement identification books at the nursing station and receptionist were accurate and up to date. 14. On July 8, 2023, and July 9, 2023, the center ADON completed education with all staff in the center regarding the center elopement policy. Center CNAs (l2 of 12- 100%); Center LPNs (7 of 7-100%); Center RNs (3 of 3-100%); Center Dietary staff (7 of 7-100%); Center EVS/Laundry (7 of 7-100%); Center non-clinical staff (5 of 5-100%); Contract NP (1 of 1-100%); Contract Rehab (2); Agency LPNs (8); Agency CNAs (24) were all educated. 15. On July 9, 2023, the center DON completed an audit of all incidents and accidents log for the last 30 days and no other elopements occurred. Findings of this log will be held in the ADHOC QAPI minutes. 16. On July 10, 2023, a root cause analysis was conducted by the Administrator, the Regional Director of Operations, and the Regional Director of Clinical Operations. The RCA indicated the root cause was related to one unsecured door and lack of individualized care plan for elopement risks on R#l. 17. On July 10, 2023, the center completed an ADHOC QAPI Meeting to review the incident that occurred and root cause analysis results. Members of the QAPI meeting were Administrator, Medical Director, Director of Nursing, and ADON. Date corrective action will be completed is 7/11/2023 and IJ to be removed on 7/12/2023. Onsite Verification of Removal Plan: 1. Review of the removal plan document - a letterhead for the facility revealed R#1 no longer resides at the center. Review of the progress note on 7/7/2023 at 11:40 p.m. staff was unable to locate R#1 while doing rounds. A search of the facility was conducted by staff inside and outside the facility with no results. 911 was called, the sheriff reported the resident was located and transported to the hospital. Surveyor verified R#1 was still inpatient at the hospital via phone on 7/18/2023 at 9:50 a.m. prior to receiving the plan. Interview with the ADON on 7/21/2023 at 2:25 p.m. verified R#1 is no longer in the center. 2. Review of the removal plan documents revealed that a reportable was filed on 7/8/2023 at 1:46 a.m. by the Administrator. He identified R#1 in the facility reportable which stated the resident eloped from the facility and was discovered on the road with apparent injury and the door that is assumed to be the exit was secured. Interview with the Administrator on 7/21/2023 at 2:26 p.m. stated he reported the incident to the state on 7/8/2023. 3. Further review of the removal plan documents revealed [facility name] daily census dated 7/7/2023 - handwritten on the census was Midnight Census Head Count revealed checkmarks next to the residents' names with a total of 56 residents accounted for. Two residents were identified as being in the hospital and there was no checkmark beside R#1's name on the census. Interview with the ADON on 7/21/2023 at 2:25 p.m. stated she completed the Elopement Risk on the residents utilizing the census lists. 4. Review of the facility map with a section highlighted in orange and circled which was identified as a fire door. Interview with the Administrator on 7/21/2023 at 2:26 p.m. verified that he had highlighted the door on the facility map to indicate this was the door R#1 exited out of. 5. Review of an unidentified document with a written statement indicating after incident occurred on July 7th, 2023, Charge Nurses EE and FF monitored the dining room door continuously throughout the shift. The document was signed by Licensed Practical Nurse (LPN) FF and an unidentified signature. Interview with the Assistant Director of Nursing (ADON) on 7/21/2023 at 2:25 p.m. verified she obtained written statements from the LPN Charge Nurses. 6. Review of a document titled Elopement and Wandering Residents dated 7/8/2023 with three unidentifiable initials. Interview with the Administrator on 7/21/2023 at 2:26 p.m. verified the initials of the above-named staff as having reviewed the policies. 7. Review of the Employee Education [facility name] dated 7/10/2023 presenter Registered Nurse (RN) WW with subject matter: elopement/incidents and accidents and overview: elopement policy and prevention to include assessments and care plan interventions and the elopement process. In attendance at the meeting were the Administrator, DON, ADON, Maintenance/Environmental Services Director, MDS Coordinator, and Social Services Director. Interview with the ADON and the Administrator on 7/21/2023 at 2:31 p.m. verified they attended the education provided by RN WW on 7/10/2023. 8. Review of the document titled Log for Door Checks initiated on 7/11/2023 with date/time, signature of staff and comments with hourly checks with no issues identified. The facility provided additional information with staff assigned to door checks beginning 7/7/2023 for 12-hour shifts. Interview with the ADON on 7/21/2023 at 2:31 p.m. stated she initiated the door checks and assigned staff to monitor the door. 9. Review of the removal plan revealed no documents to indicate evidence of a door check audit. 10. Review of the removal plan revealed there were no documents to indicate purchase of the mag-loc or a date and time of placement. In an interview with the [NAME] President of Clinical Services on 7/21/2023 at 12:30 p.m. provided an invoice entitled [name of provider] revealed invoice #41856 dated 7/14/2023 with total amount $1,042.47. 11. Review of the removal plan revealed completed Elopement Risk Assessments for the residents with the Census dated 7/8/2023 used to identify the high-risk residents. Interview with the ADON on 7/21/2023 at 2:31 p.m. verified she used the facility census to ensure she had completed Elopement Risk Assessments on all current residents. 12. Review of a checklist utilized for elopement risk re-evaluation completed by ADON identified 11 residents highlighted in yellow with risk scores ranging from 13 - 27. Verified each of the 11 residents had completed Elopement Risk Assessments and care plans. Review of three residents selected for review (the surveyor had already verified all 11 residents had an 'Elopement Risk Assessment and care plan prior to the IJR plan - R#'s 2, 3, 7, 8, 9, 10, 11, 12, 13, and 14). Interview with Regional Director of Clinical Operations on 7/21/2023 at 12:55 p.m. stated the 11th resident was R#1 for a total of 11 residents. 13. Review of the removal plan revealed pictures and physical descriptions, face sheet for each resident at risk for elopement, with allergies, diagnoses, date of birth , sex, weight, height, and urgent medications for all 10 current residents. There were binders located at the nursing station and receptionist desk. These were verified by surveyor. Interview with the Regional Director of Clinical Operations on 7/21/2023 at 12:55 p.m. verified both books were up to date with information on high-risk elopement residents. 14. Review of the document entitled [facility name] IJ Education that 7 out of 7 Dietary staff were educated; 12 of 12 CNA/CMA were educated; 7 of 7 LPN's were educated; 3 of 3 RN's were educated; 1 of 1 NP was educated; 2 contract rehab staff were educated, 8 of 8 Agency LPN's; 24 of 24 Agency CNA's received education. Interview with the ADON on 7/21/2023 at 2:33 pm who verified that she educated all staff as described above. Also verified via the following staff interviews on 7/20/2023 at 11:34 a.m. with LPN EE, 11:46 a.m. CNA PP, 11:49 a.m. CNA QQ, 11:50 a.m. LPN FF, 11:55 a.m. LPN RR. On 7/21/2023 at 11:57 a.m. CNA SS, 11:59 a.m. CNA TT, 4:23 p.m. Staffing Coordinator/Scheduler VV, 4:25 p.m. CNA MM, 4:37 p.m. CNA NN, and 4:41 p.m. CNA OO, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 15. Review of the Incident/Accident List dated June 1 - July 16, 2023, identified 19 falls, 8 skin issues, 2 alleged abuse, 1 elopement (R#1). Interview with the ADON on 7/21/2023 at 2:33 p.m. confirmed the DON had identified the incidences from June 1 through July 16, 2023. 16. Review of the Root Cause Analysis for the Center's concern - the facilitators were the DON and the Administrator with team members the ADON and the Maintenance Director and The Regional Director of Clinical Operations. Concern - to ensure residents receive the necessary required supervision to maintain safety. Listed the 5 why's - the resident exited the facility through an unlocked door without staff's knowledge or supervision sometime around 9:30 p.m. - staff were unaware resident had left. The facility timeline was attached for review. Interview with the ADON and the Administrator on 7/21/2023 at 2:34 p.m. confirmed they participated in the root cause analysis regarding the elopement. 17. Review of the QAPI Meeting Minutes dated 7/10/2023 with subject matter - QAPI Monthly Meeting. Began at 12:30 p.m. and lasted 10 minutes. In attendance was the Administrator, Maintenance Director, DON, ADON, Social Services Director, MDS Coordinator, Medical Director, and Nurse Practitioner. Discussed the incident and timeline. Planned to meet again in four weeks. Interview with the Administrator on 7/21/2023 at 2:34 p.m. confirmed the members of the QAPI meeting on 7/10/2023 and items discussed. Administrative oversight of the above measures was reviewed and verified. All corrective action was completed on 7/11/2023. The IJ was removed on 7/12/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the Administrator Job Description, Administration failed to provide protective oversight of the facility environment to prevent the elopement for one of eleven residents (R) (R#1) reviewed for elopement. Specifically, facility failed to ensure that exit doors were equipped with functioning locking systems, failed to complete elopement assessment for R#1 with a documented history of elopement, and failed to develop a person-centered care plan with interventions for elopement for R#1. R#1 eloped from the facility on 7/7/2023 and was found 3.5 miles away from the facility, had been hit by a car and sustained a fractured right hip, right arm, and right shoulder. On 7/18/2023, it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Nurse Consultant were informed of the Immediate Jeopardy (IJ) for F656, F689, and F835 on 7/18/2023 at 3:15 p.m. The noncompliance related to the IJ was identified to have existed on 7/7/2023. An Acceptable IJ Removal Plan was received on 7/21/2023 related to 483.21(b)(1), Development/Implement Comprehensive Care Plan (F656), 483.25(d)(2), Accidents and Hazards (F689), and 483.70, Administration (F835). Based on observations, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/12/2023. It was determined that the facility had completed implementation of the Removal Plan prior to the start of survey, and therefore, the IJ was considered past noncompliance. Findings include: Review of the undated document titled Administrator-Job Description revealed position purpose is leads, guides, and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. The Administrator performs rounds to observe residents and ensure overall needs are being met, knows residents by name and sight, practices management by walking around, and makes himself/herself available to employees. Additional tasks include follow appropriate safety measures at all times to protect residents and themselves. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses including encephalopathy, traumatic subdural hemorrhage, dementia, hypertension (HTN), chronic kidney disease (CKD), and agitation. He was admitted post hospital stay after being found unresponsive on the side of the road after eloping from his home. The resident had a five-day Prospective Payment System (PPS) Assessment completed on 7/2/2023 indicating a Brief Interview Mental Status (BIMS) score of four, indicating the resident had severely impaired cognition. Section E revealed the resident exhibited wandering behaviors one to three days. Section G revealed resident required supervision with ambulation. Review of the Facility Incident Report dated 7/8/2023 at 11:53 p.m. revealed R#1 eloped from the facility and was discovered on the road with apparent injury. Resident was sent to the hospital for evaluation. Review of the electronic medical record (EMR) revealed that an Elopement Risk Assessment wasn't completed until 7/8/2023, the day after R#1 eloped from the facility. The assessment revealed a score of 23.0, which indicated high risk for elopement. Review of the Police Report dated 7/8/2023 at 4:37 a.m. revealed during the investigation into R#1 elopement, deputies discovered a door that led to the outside of the facility unlocked. Deputies believe this is the door that R#1 used to leave the facility. According to staff this door stays unlocked, but while examining the door, deputies found the doors locking system to be broken and unrepaired. Deputies also discovered a shelf in front of the door that looked as if it was placed there to block the door. Deputy spoke with staff member about the shelf and staff stated the shelf had been moved, but admitted to moving it back after they noticed resident was missing. Review of the communications invoice #41856 revealed a service dated 7/11/2023 for a door off the dining room area not working. Lock is missing pieces, and the keypad is not working. Replaced a maglock and keypad. Reset all keypads to default and then reprogrammed the codes and tested the door release and function. Interview on 7/18/2023 at 10:40 a.m., the Administrator revealed he was not sure how long the door R#1 exited from had been unlocked. Interview on 7/20/2023 at 10:12 a.m., the Administrator revealed R#1 was admitted to the facility because he climbed out of a window at home and was not found until the next day. He revealed that on 7/7/2023 R#1 left the facility through a door in the dining room that was not locked. The Administrator stated although the door was not used as an exit it leads to the outside of the facility and the door should have had a working lock. During further interview, the Administrator stated the nursing staff failed to complete an admission elopement risk assessment for R#1 and failed to develop a care plan with interventions for elopement for R#1 with a known history of elopement. Cross Refer to F689 and F656 The facility implemented the following actions to remove the IJ: 1. An AD-HOC meeting was held on July 10, 2023- with the Administrator, Director of Nursing, Regional Director of Clinical Operations, and Medical Director to address the concerns identified related to the incident of July 7, 2023, with Resident #1. 2. Resident #1 was discharged from the facility on July 7, 2023. 3. On July 10, 2023, the Center Regional Director of Clinical Operations, Regional Director of Operations, Medical Director, and Administrator reviewed the policies on Care Plans and Incident and Accidents. No changes or recommendations were made or given. 4. On July 10, 2023, the Regional Director of Clinical Operations re-educated the center's administration to include Administrator, Director of Nursing, MDS, ADON, Social Worker, and Maintenance on the importance of implementing effective interventions for Care Plans and properly assessing potential access areas/exits throughout the center. 5. On July 10, 2023, a root cause analysis was conducted by the Administrator, the Regional Director of Operations, and the Regional Director of Clinical Operations. The RCA indicated the root cause was related to one unsecured door and lack of individualized care plan for elopement risks on R#l. 6. On July 10, 2023, the Regional Director of Operations reviewed the job descriptions for the Administrator and Director of Nursing to ensure they understand their duties and responsibilities. No changes were made to the job descriptions and both acknowledged understanding of their responsibilities. Review shows that the Administrator and the DON can carry out their job duties. 7. The Regional Director of Operations reviewed the RCA results and Center's audits and shared the findings with the AD HOC Assurance Performance Improvement Committee on July 10, 2023. Onsite Verification of Removal Plan: 1. Review of the Immediate Jeopardy Removal Plan (IJRP) revealed the document titled QAPI Meeting Minutes. The document revealed ADHOC meeting was conducted on 7/10/2023. The subject matter Quality Assurance Performance Improvement Monthly Meeting, the duration of the meeting was ten minutes. The document attendance at meeting included: Administrator, Maintenance/Environmental Service/Safety, Director of Nursing (DON), Nurse Practitioner (NP), Medical Director (MD), Social Service Director (SSD), Minimum Data Set (MDS), and Assistant Director of Nursing (ADON). The facility discussed how R#1 eloped from the facility, a timeline of the elopement, and the plan of correction. The facility conducted an elopement assessment on the residents in the facility. Interview on 7/20/2023 at 10:12 a.m. with Administrator stated he became aware of R#1 elopement on 7/7/2023 at 11:55 p.m. when he received a phone call from the Maintenance Director (MD). The MD informed him that the resident (R#1) eloped from the facility. He stated the door was secured and the DON conducted a head count to ensure that the other residents were in the facility. 2. Review of the Immediate Jeopardy Removal Plan under F689 two physician progress notes dated 7/8/2023 revealed: A. on 7/7/2023 at 11:40 p.m., staff unable to locate resident during rounds. A search of facility was conducted by staff inside and outside with no results. 911 called. DON and Administrator notified. Responsible Party notified. B. on 7/8/2023 at 00:15 a.m., Sheriff here at facility to investigate and conduct interview about missing resident. Sheriff, DON, Administrator in the building. Sheriff reported resident located and sent to hospital. 3. Review of the document titled Care Plans, Comprehensive Person-Centered and Accidents and Supervision. Both documents in handwriting reviewed to unidentifiable letters /DON. Interview with the Administrator on 7/21/2023 at 2:26 p.m. verified the initials of the above-named staff as having reviewed the policies. 4. Review of the document titled Employe Education/In-Service [facility name]. Subject Matter: Elopement Incidents/Accident. The presenter Regional Nurse Consultant. Overview: Elopement policy and prevention to include assessments and care plan interventions and elopement process. The document attendance at meeting included: the Administrator, DON, ADON, Maintenance/Environmental Service/Safety, MDS-Coordinator and SSD. Interview on 7/20/2023 at 11:55 a.m. with Licensed Practical Nurse (LPN) RR stated the ADON went over the elopement policy and procedures. She stated residents that are high risk for elopement information is in a book located behind the nurse's desk and receptionist desk. The ADON talked about what to do in the case of the eloping happening. The staff should notify the supervisor, look for the resident, call the police, Chief Executive Officer (CEO), Administrator, and responsible party. In the event the resident is not located, staff would provide the elopement book to the police upon arrival. The LPN was able to name R#7 and R#8 as residents that are high risk for elopement. Interview on 7/20/2023 at 11:49 a.m. Certified Nursing Assistant (CNA) QQ stated it was brought to her attention that one of the residents was able to have access outside of the facility and was injured. Moving forward we must have an elopement risk assessment for all residents and follow the protocol for elopement. In the event the resident is not able to be found we notify the supervisor/charge nurse, and we gather around and make sure we know who is responsible for what part of the protocol. The staff should look for the residents, contact the police, and the Administrator. When the police arrive provide them the elopement book. The CNA was able to name R#7, R#8, and R#11 as residents that are high risk for elopement. Interview on 7/21/2023 at 11:57 a.m. with CNA SS stated the Assistant Director of Nursing (ADON) in-serviced the staff to notify the supervisor immediately when a resident cannot be located. Search inside and outside of the facility. The elopement books are at the nursing station and receptionist area that should be provided to the police. 5. Review of the document titled Root Causes and Contributing Factors revealed the cause, corrective actions, the responsible individual, and correction date. Signed by the Administrator and DON. 6. Review of the removal plan revealed the Administrator and DON job descriptions attached. A post survey interview on 7/22/2023 at 9:50 a.m. with Regional Director of Clinical Operations stated the facility will review the baseline care plan document and make some changes that will include a section to include interventions. 7. Review of the document titled QAPI Meeting Minutes revealed a handwritten on the document was reviewed by the Regional Director of Operations (RDO) on 7/10/2023. Attached to the removal plan was a document titled Logbook Documentation [facility name] Emergency Preparedness Drills and Exercises: Conduct elopement drill marked done on-time by Maintenance Director (MD) on July 18, 2023. This drill was conducted on 7/17/2023 with 13 staff and 54 residents. Remarks of the person holding the drill revealed: Very good drill staff patient was hidden in the laundry area with staff supervision. Charge nurse was asked to go get patient and immediately realized patient was missing. Charge Nurse began to verbally communicate the notification. Staff began internal and external search of premises located patient within 4 minutes of notification. 911 notified at beginning and end of drill. The Surveyor also reviewed three residents that were not listed as risk for wander or elopement risk assessment: a. R#15 elopement risk assessment completed on 7/8/2023 score 0. b. R#16 elopement risk assessment completed on 7/8/2023 score 0. c. R#17 elopement risk assessment completed on 7/8/2023 score 0. Administrative oversight of the above measures was reviewed and verified. All corrective action was completed on 7/11/2023. The IJ was removed on 7/12/2023.