**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify a change in a resident condition, failed to provide frequent monitoring, failed to provide accurate information to the physician, and failed to transfer R2 to the hospital in a timely manner. This failure resulted in R2 experiencing a slow deterioration from the morning of [DATE], until she was transferred to the hospital at 12:30 PM on [DATE], in critical condition. R2 died at the hospital on [DATE] from septic shock. This applies to 1 of 3 residents (R2) reviewed for quality of care in the sample of 11. The Immediate Jeopardy began on [DATE] at 1:18 AM when V28 (LPN - Licensed Practical Nurse) failed to identify R2's change in condition, complete an assessment, obtain vital signs, and notify R2's physician. This failure continued when V19 (LPN) failed to provide frequent monitoring, provide accurate information to the physician, and transfer R2 to the hospital in a timely manner. V3 (DON - Director of Nursing) was notified of Immediate Jeopardy on [DATE] at 9:00 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: On [DATE] at 9:19 AM, V16 and V17 (R2's family members) said they had attempted to call R2 the evening of [DATE] and the morning of [DATE]. They said it was a routine for them to speak to R2 twice a day and it wasn't normal that she wasn't answering her phone. They said they contacted V19 (LPN) and asked her to check on R2. They said on [DATE] at 10:30 AM, V19 reported, that something was off and [R2] would probably be sent to the hospital. They said V19 reported that R2 screamed whenever she tried to touch her. V16 said she asked V19 if she was calling 911 and V19 replied, No I don't think so. V16 said she didn't understand why R2 was not picked up by the ambulance until 12:30 PM. V16 said she arrived at the emergency room to find R2 with an IV, indwelling catheter, and oxygen already on. V16 said R2 looked grey and was screaming in pain. V16 said R2 was admitted to the ICU (Intensive Care Unit) and was receiving IV blood pressure medications but was not doing well. V16 said R2 expired at the hospital on [DATE] due to septic shock. On [DATE] at 1:40 PM, V19 (LPN) said R2's wing was her regular assignment. V19 said she was familiar with R2 and was the nurse that sent her out on [DATE]. V19 said R2 was alert and preferred to use the bedpan and perform her own peri-care. V19 said R2 would usually turn on her call light when she needed us to grab her something or empty the bedpan, but otherwise she didn't want us bothering her. V29 said the night shift nurse did not report any issues with R2. V29 said on [DATE] R2 was a little confused, was having diarrhea, looked tired, and couldn't clean herself up, like she usually did. V19 said she had to send the CNA in to help R2 at least 2 times on [DATE]. V19 said that R2 wasn't acting like herself and was very weak. V19 said she called her family, the physician, and sent her to the hospital via non-emergent ambulance. R2's Face sheet printed [DATE] showed R2 had diagnoses to include, but not limited to: COPD (chronic obstructive pulmonary disease), heart failure, peripheral vascular disease, insomnia, atrial fibrillations, major depressive disorder, anemia, non-pressure chronic ulcer to left foot, dementia, and osteoarthritis. R2's facility assessment dated [DATE] showed R2 had moderate cognitive impairment; required partial to moderate assistance for personal hygiene and rolling in bed; required substantial to maximal assistance for toilet hygiene; and was always continent of stool. R2's Vital Signs showed on [DATE] at 9:35 AM her blood pressure (BP) was 121/64, heart rate (HR) was 62, respirations were 18, and her oxygen saturation (Sp02) was 95% on room air. There were no vital signs charted after [DATE] at 9:35 AM. R2's [DATE] MAR showed R2 received Tylenol at 1:18 AM on [DATE] and R2's 11-7 vital signs were not taken on [DATE]. R2 did not have progress notes from [DATE] until [DATE] at 11:58 AM. (R2's progress notes did not contain an assessment or entry on [DATE] by V28 (LPN) regarding R2's increased weakness, change in behavior, and complaints of vaginal pain. There were no vital signs taken on 11-7 shift and the physician was not notified of R2's change in condition.) R2's Progress Note dated [DATE] at 11:58 AM, by V19 (LPN) showed, Noticed resident weak and not doing her own peri-care as usual, said that she is weak and cannot do it and kept on removing her diaper. Also, c/o (complained of) vaginal pain. Called [V34 - R2's Physician], order given and carried out to - send resident to ER (emergency room to (local hospital) for eval and treat via regular ambulance. Called (non-emergent ambulance service), said ETA (estimated time of arrival) 30 minutes . Vital signs stable. Resident left with 2 Paramedics around 12:35 PM. Resident was alert, verbally responsive at the time of leaving. (This note does not contain any detail on the times the family or physician were notified, nor does it contain ongoing assessments and vital signs of R2 between 9:35 AM (identification of R2's change in condition) and 11:47 AM when the ambulance was notified.) R2's Physician Order Sheet printed [DATE] showed an order on [DATE] to send R2 to the emergency room via regular ambulance and an order to obtain vital signs every shift. R2's SNF/NF to Hospital Transfer Form dated [DATE] showed vital signs obtained at 9:35 AM. This form showed the date of transfer was [DATE] at 12:35 PM. R2's Ambulance Patient Care Report dated [DATE] showed the time of injury was 9:30 AM, dispatch was notified at 11:47 AM, and the ambulanced arrive to the patient at 12:23 PM. This report showed, Upon arrival patient was alert and oriented x 1, on room air, laying in bed in a lethargic sate. Patient is currently complaining of vaginal region pain and generalized weakness. (Nurse) on scene states they noticed patient lethargic this morning at 9:30 AM. (Nurse) on scene states patient's normal mental status is alert and oriented x 2-3. (Nurse) states (R2's) last known normal is [DATE] . Patient pale, cold, and dry . This report showed initially R2's oxygen saturation was 86% on room air and she required hot packs on her hands and 100% oxygen, via a non-rebreather mask, to bring her oxygen level up. This report showed that R2's first BP was 56/35 (critically low). R2 had low blood pressure readings, unsuccessful IV attempts and the crew decided to divert to the closest hospital for critical care. R2's Death Certificate dated [DATE] showed the cause of death was Septic Shock due to a UTI (Urinary Tract Infection). On [DATE] at 1:48 PM, V35 (Restorative Aide) said they worked R2's wing the weekend of Memorial Day. V35 said on Saturday R2 complained of constipation and the nurse gave her a laxative. (R2's May MAR showed MiraLAX was administered on [DATE] at 8:34 AM). V35 said R2 was going poop all day on Sunday, she just kept going. V35 said R2 normally would clean herself up and rarely asked for help. V35 said on Sunday ([DATE]) R2 had poop everywhere and was actually letting me help her. V35 said that wasn't like R2, she was normally very independent with peri-care. On [DATE] at 12:47 PM, V30 (CNA - Certified Nursing Assistant) said she was working the overnight shift on [DATE]. V30 said R2 wasn't on her assignment, but she heard her screaming and went into her room. V30 said V29 (CNA) was R2's assigned CNA, but she was busy on another hall. V30 said R2 was screaming, so she went in to check on her. V30 said there was poop everywhere. V30 said R2 had spilled the bedpan on the floor and poop was smeared on the mattress, linens, and R2. V30 said R2 was grabbing at her vaginal area and yelling, It hurts! It burns! It itches! V30 said before she completed a full bed bath, she notified V28 that R2 wasn't acting right and was complaining of vaginal pain. V30 said V28 went in the room and gave R2 a Tylenol (R2's [DATE] MAR showed Tylenol was administered at 1:18 AM on [DATE]). V30 said V28 (LPN) never directed her to take R2's vital signs. V30 said she reported to V29 (R2's assigned CNA) that R2 wasn't acting like herself, and she would need to round on her. V30 said R2 can normally change and toilet herself, but not that night. On [DATE] at 3:06 PM, V29 (CNA) said normally R2 didn't want to be bothered at night. V29 said R2 wanted to do everything herself and usually used the bedpan and cleaned herself up. V29 said she didn't recall providing any care to R2 on the 11-7 shift on [DATE]. On [DATE] at 2:45 PM, V28 (LPN) said she worked 3-11 and 11-7 on [DATE]. V28 said she was familiar with R2. V28 said R2 was alert and oriented and able to make her needs known. V28 said R2 was very private related to peri-care and was normally independent with use of the bedpan and cleaning herself up. V28 said she didn't know anything about R2 having diarrhea, requiring assistance with cleaning up, and complaining of vaginal pain that night. The surveyor asked V28 why she gave Tylenol at 1:18 AM. V28 replied, Just to help her sleep or something. V28 said if R2 had weakness, required assistance with bedpan/peri-care, and was complaining of vaginal pain, then that would be a change in condition for her. V28 said with a change in condition she would complete an assessment, obtain vital signs, notify the physician, and complete any orders given. V28 said she did not do any of that for R2 because she wasn't aware there was an issue. V28 said frequent diarrhea causes dehydration and loss of electrolytes. On [DATE] at 10:58 AM, V19 said she found R2 like that in the morning, after breakfast. V19 said it was during morning medication pass when she did the assessment and took the vital signs. (Vital signs charted at 9:35 AM, morning medications due at 9:00 AM). V19 said during that time R2 was talking to her, but continued to have diarrhea, was complaining of vaginal pain, and kept removing her incontinence brief. The surveyor asked V19 what time she called the family, physician, and ambulance. V19 said she couldn't recall the exact times. The surveyor asked V19 if she took another set of vital signs before she called the physician. V19 stated, I don't remember if I took another BP after 9:35 AM. She was weak when I did her BP. The surveyor asked V19 to check her documentation in EMR and V19 replied, I don't see any more vital signs charted. The surveyor asked V19 if there was any documentation to show continued assessments between 9:35 AM (when she noted R2's condition change) and 11:47 AM (when the ambulance was notified, per Ambulance Patient Care Report). V19 said she didn't see anything specific in R2's progress notes. V19 said they don't complete a SBAR form when notifying the physician. V19 said the only form completed when she transfers a resident to the hospital is the Transfer Form. V19 was unable to explain why she used the 9:35 AM vital signs for the Transfer form completed dated [DATE] at 12:35 PM. On [DATE] at 12:01 PM, V25 (Agency CNA) said she was working 7-3 shift on [DATE]. V25 said she didn't recall the exact time, but she remembered R2 having diarrhea and not being able to clean herself up. V25 said she and the nurse thought something was up, and that she wasn't acting herself. V25 said R2 couldn't use the bedpan and clean herself up like normal. V25 said R2 declined quick and had to be sent to the hospital. On [DATE] at 2:06 PM, V34 (R2's physician) said she didn't recall what time the facility called her about R2 on [DATE]. V34 stated, Most of the residents at the facility are old and frail, so I usually just send them out 911. I remember they called and said she (R2) was a little confused. I usually ask for vital signs and what is going on. If the vital signs were stable, then I would follow the resident's wishes for transport. [R2's family member] preferred to send her to a specific hospital. V34 said she would expect the nurses to provide all pertinent information, regarding a resident's change in condition and a recent set of vital signs. V34 said this information is pertinent in determining the appropriate mode of transportation (911 vs. non-emergent transport). V34 said the vital signs were not stable, then she would have sent R2 out 911. On [DATE] at 2:04 PM, V3 (DON) said if a resident had frequent diarrhea, change in normal behavior/mentation, and complaints of vaginal pain that would be considered a change in condition. V3 said when the nurse identifies a change in condition then they should do an assessment, check vital signs, and discuss any concerns with the physician. The surveyor explained that R2 had frequent diarrhea, change in behavior, increased weakness, and complaints of vaginal pain on 11-7 shift on [DATE]. V3 said she would expect the nurse to notify the physician and document R2's vital signs, complaints, and pertinent assessments. V3 said when the nurse calls the physician, she should provide recent vital signs and accurate assessment information. V3 said it's important to provide the physician with an accurate picture of the resident's condition, so they can determine proper mode of transportation. The facility's Guidelines for Notifying Physicians of Clinical Problems (revised 4/07) showed, These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medial record . When contacting the practitioner, especially at night and on weekends (when physician's not familiar with the residents may be on call), the nurse should have the following information available: 1. Detailed description of current issue or problem, including vital signs, symptoms, and results of physical assessment . The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. The corrective action(s) taken for the resident(s) found to have been affected by the deficient practice: -V19 and V28 were in-serviced and educated on identification of a change in condition and continued monitoring. In-service/Education included: to ensure that assessments, monitoring and documentation is completed on residents with a change in condition, providing MD with accurate information regarding change of condition and transferring to emergency department in a timely manner. -Initiated in-service and education to nurses including agency nurses on identification of a change in condition and continued monitoring, documentation of assessments, and monitoring is completed on residents with a change in condition, providing MD with accurate information regarding change of condition and transferring to emergency department in a timely manner. In-service will be completed by [DATE]. 2. The corrective action(s) for other resident(s) having the potential to be affected by the same deficient practice: -All residents have the potential to be affected. None were identified. 3. The measures put into place and a systemic change made to ensure the deficient practice does not reoccur: -The Director of Nursing and MDS Coordinator in-serviced nurses on Identifying a Change of Condition in a Resident - in particular, to ensure that assessments, monitoring and documentation is completed on residents with a change of condition. In-servicing was [DATE]. V19 and V28 were already in-serviced and educated. Anyone who had not been in-serviced will be in-serviced in person or over the phone prior to their next shift by DON or designee prior to their next shift in this facility. This in-servicing includes nurses on FMLA & PRN and agency nurses. All new hires will be in-serviced during their orientation on the Identifying a Change of Condition in a Resident - in particular, to ensure that assessments, monitoring and documentation is completed on residents with a change of condition. 4. To ensure the deficient practice does not reoccur, the corrective actions(s) will be monitored by: -DON or designee will audit all residents with a change of condition daily x 6 weeks to ensure that all residents with a change of condition were properly assessed, monitored, and documented on, MD was notified with accurate information and transferred in a timely manner. -QAPI Committee have met and discussed the measures that were put in place to ensure that deficient practice does not occur. Medical Director is in agreement of the measures that were put in place and has approved it. 5. Completion date systemic changes will be completed: [DATE]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide supervision for a resident with wandering behaviors and Dementia. As a result, R1 left the secured unit and eloped from the facility without facility knowledge. R1 was found by a bystander on the grounds of neighboring independent living complex near a high traffic area and the bystander notified emergency services. As a result, R1 was transported to the local hospital and was noted with a head injury and nasal fracture and required emergency medical treatment. This failure resulted in Immediate Jeopardy. This applies to 6 of 6 residents (R1 through R6) who were reviewed for supervision and safety from a total sample of 10. The Immediate Jeopardy began on November 7, 2022, when R1 left the secured unit without facility staff being aware and then wandered out of the facility without being witnessed by facility staff. R1 got out from the East exit door of the facility and walked through the backyard, crossed a driveway and a parking lot which was located between the facility and the independent living complex before he reached the grounds of the independent living complex that is near a high traffic street. R1 was found on the grounds of the neighboring independent living facility about 199 yards from the nursing facility around 6:20 PM by a bystander. The bystander found R1 lying on the ground with a head injury and called 911 emergency services. The paramedics arrived, and R1 was taken to the nearest hospital. V1 (Assistant Administrator), V2 Director of Nursing/DON), and V3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on November 10, 2022, at 10:03AM. It was confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on November 14, 2022, at 9:03PM. The non-compliance remains at Level 2 because the additional time is needed to evaluate the implementation and effectiveness of the removal plan. The findings include: 1. Face sheet shows that R1 is 69 years-old who was admitted to the facility on [DATE]. R1 has multiple diagnoses which include maxillary fracture, left side, subsequent encounter for fracture with routine healing, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, generalized muscle weakness, other abnormalities of gait and mobility. Minimum Data Set (MDS) dated [DATE] indicates that R1 is cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 2. The same MDS indicates that R1 requires extensive assistance with walking and transfer and is totally dependent with mobility outside the unit. R1 resides in the secured unit of the facility that houses cognitively impaired residents. On 11/9/22 at 11:25 AM, R1 was in the dining room, sitting, and waiting for lunch. R1 was awake but confused. R1 was able to respond to simple yes and no questions. R1's left periorbital area was swollen, with black, blue, and red discoloration, as well as his left cheek. The sclera or the white area of the eye was reddened from the trauma. R1 also showed the palm of his left hand at the base of his left thumb which was also bruised. R1 stood up and started to pace around the dining room. On 11/7/22, R1 was actively wandering. On 11/10/22 at 10:55 AM, V1 (Administrator) showed where R1 was approximately found by bystanders. The area is in the ground of the neighboring independent living and is near a high traffic street. This was measured by V4 (Maintenance Director) to be 199 yards from the nursing facility. V10 (Certified Nursing Assistant/CNA) stated on 11/9/22 at 1:46 PM that R1 has dementia and has the tendency to wander and attempts to exit open doors. V10 added that on 11/07/22 R1 was being given medications by V7 (Nurse) in the dining room around 6:00 PM. V10 stated that when he returned to the dining area about 6:15 PM after giving care to another resident, R1 was not in the dining room. According to V10, R1 could not be located after checking the unit, R1's room and the bathrooms. V10 then notified V7 about R1's status. V10 did not know how R1 was able to leave the secured unit without anyone knowing. According to V10, R1 frequently attempted to open exit doors, but since R1 wears wander guard and the alarm is activated when R1 tries to leave. The unit staff then started looking thoroughly for R1 in all the bedrooms, bathrooms, and other rooms of the secured unit. V7 notified V2 (Director of Nursing/DON), and everyone started looking for R1. V11 (the other CNA) went outside the building but did not find R1. They checked the other units; they couldn't find him. Around 8 PM that same night, V7 (Nurse) informed V10 and V11 that the local hospital called to report that R1 was in the hospital. On 11/9/22 at 3:35 PM, V7 (Nurse) stated that V7 started the shift by making rounds and doing head count to make sure that everyone was present. According to V7, R1 was in and out of the dayroom and bedroom. V7 added that R1's family is very involved and visit every day during mealtime. On 11/7/22 at around 5:30 to 6 PM, V7 started checking the blood glucose level of the diabetics and administering medications to all scheduled residents. V7's medication cart was just outside the dining area because she was passing medications (From observation, the dining area is in one of the inner corners of the secured unit. It has a short hallway and does not have a direct visual access to all the hallways and exit doors). V7 gave R1 his crushed medications, he spit it all out and walked away. V7 thought that R1 went back to his room which he usually does. R1's family left after dinner. Later, V7 looked for R1 to give him his uncrushed medications, and V10 approached and informed her that he couldn't find or locate R1. V7 stated that three of them (V7, V10, V11) started looking in the hallways, bathrooms, bedrooms, and other areas for R1 and called the supervisor. V7 added that since R1 could not be located, an amber alert was called, and all units were conducting a head count and searching for R1. V10 and V11 started to search for R1 outside of the facility but did not locate R1. V7 stated that R1 is a wanderer, he is a high risk for fall and elopement. He wears a wander guard in the right wrist. V7 could not explain how R1 was able to leave the unit without setting off the alarm. On 11/9/22 at 4:05 PM, V11 (Nurse Aide) stated that on 11/7/22, prior to R1's elopement incident, R1 was with his wife who was visiting at that time. Around 6 PM to 6:15 PM that same evening, V11 was giving a shower to his resident, while V7 (Nurse) was outside the dining room passing medications. Then V10 (the other CNA) approached V7 and V11 and told them that R1 was missing. They checked all the bedrooms, and other rooms. V11 went outside and around the building, but he couldn't find R1. V11 stated that he had no idea how R1 got out of the facility. V9 (Dietary Staff) was interviewed on 11/9/22 at 12:09 PM and stated that he and V15 (Dietary Staff) noted that R1 was outside the secure unit on 11/7/22 in the adjacent (unsecured) unit. V9 stated that R1 asked them for a cigarette. According to V9, V15 recognized R1 as being a resident from the secure unit so V9 and V15 notified two nurse aides that R1 was in their hallway. V9 added that the one nurse aide told him it was fine for R1 to be in unsecured unit as R1 was just going to sit there. V9 then stated as V9 and V15 were returning to the kitchen they heard the alarm. V15 (Dietary Staff) was interviewed on 11/14/22 at 9:30 AM and stated that on 11/7/22 between 6:15 to 6:30PM, the exit door to the secure unit was beeping. According to V15, the beeping means that someone passed through the door, and it did not close on time. V15 stated V15 put in the code for the door and opened the door to leave the secure unit and found R1 outside of the secure unit. V15 stated this was reported to the two nurse aides and a short time later the alarm went off. V15 added that one of the nurses came out and asked if anyone had seen a resident leave via the exit door. V6 (Nurse) was interviewed on 11/9/22 at 1:09PM and stated that on 11/7/22 while passing medications about 6:00PM she heard the door alarm. V6 stated she asked the staff if they saw anyone leave and then conducted a head count. V6 added that all the residents on her unit were accounted for, and she then went and reset the door alarm. V6 stated that a few minutes later she was instructed to do another head count since R1 was missing. V6 was not informed by staff that R1 had been seen on her unit off the secure unit. V6 stated that if she had been informed of R1's presence on her unit, she would have returned R1 to the secure unit and notify the nurse. On 11/9/22 at 4:21 PM, V12 (CNA in the unsecured unit) stated that she was never notified that R1 was in their unit, or else she would have done something. When the alarm sounded, she was at the nurses' station. V12 didn't see anyone that was not supposed to be there except for the kitchen staff who passed by leaving with the carts. V12 did not see R1 in the hallway of their unsecured unit. When the alarm sounded, they did head count, and nobody was missing. V12 never spoke to the kitchen staff that time. On 11/9/22 at 4:30 PM, V13 (CNA) stated that she was working in the unsecured unit when she heard that someone was missing (R1) from the secured unit. When they heard it, they immediately did a head count. Prior to the sound of alarm, one of the kitchen staff (V15), asked if she knew the person (man), she noticed that there were three of them in the hallway. V13 did not know the third person, she was not sure if the person was a visitor, a staff, or a resident. V13 told V15 that she does not know the man. V13 added, she was busy at that time picking up trays. V1 (Administrator), V2 (Director of Nursing), R1's family members and facility maintenance staff all returned to the facility to look for R1. V2 then received a phone call from the local hospital to identify a person the hospital thought was the missing resident. R1's family went to the hospital to identify R1. The EMS/911 (Emergency Medical Services) documentation dated 11/7/22 shows: The EMS paramedics was dispatched to respond to a call with regards to someone bleeding. The paramedics arrived on scene with law enforcement and met a man who has no identification and was placed under a name of [NAME] Doe (Who was later identified as R1). R1 was noted having a contusion above left eyebrow and with abrasions on both hands. The paramedics and the law enforcement were unable to find out what language R1 was speaking. There was no ID or information that could be gathered from R1. R1 made a motion to the paramedics which showed that he fell on the sidewalk. The paramedics also noticed a puddle of blood that R1 made a motion that it came from his nose. R1 was brought to the hospital for further evaluation. The EMS documentation of the timeline of service shows that they received a call on 11/7/22 at 6:26 PM. They arrived at the scene of incident at 6:35 PM. They begin to transport R1 to the hospital at 6:43 PM and arrived at 6:54 PM. Hospital Emergency Department (ED) record dated 11/7/22 shows that R1 was treated for Maxillary sinus fracture and injury of the head and left sinus with internal hemorrhage. Nursing Note dated 11/8/22 at 12:48 AM documents: R1 came back from the hospital at 11: 55 PM, after an elopement and a fall incident. The staff did a head-to-toe assessment and observed swelling and hematoma around the left periorbital area with abrasion and dressing on it. R1 had discoloration near to left side cheek above the left side lip measuring 1.5-centimeter (cm) X 1.0 cm. There were scratches on both knees without any deep injury. CT scan of the head results shows left periorbital hematoma and left maxillary sinus fracture. On 11/14/22 at 10:43 AM, V3 (Assistant Director of Nursing/ADON) said that if a staff saw someone wandering in their unit and not sure if it's a resident or a visitor and that someone is not familiar to them, they should approach the person and ask question and redirect where this person is supposed to be. On 11/9/22 at 4:41 PM, V2 (DON), stated that there were 3 staff in the secured unit who were working at the time of R1's elopement. These staff were V7 (Nurse), V10 (CNA), and V11 (CNA). On the day of the incident, V2 arrived at the facility approximately past 7 PM to help search for R1. V2 was searching outside the building, and at the same time communicating with V1(Administrator) who was also looking for R1. She later received a call from V1 and informed her that the assisted living received a call from the local hospital. R1's family was in the facility at that time, and they went to the hospital to identify R1. On 11/15/22 at 11:44 AM, V5 (R1's Physician) said that if a resident who is cognitively impaired is identified as a high risk for elopement and fall then he should be in a secured unit and be closely monitored for safety. admission notes dated 10/12/22 documents, R1 has a history of dementia, he was unable to make needs known. According to family R1 wanders in the room and is a high fall risk. R1 was unable to use the bathroom, he needs 1:1 always monitoring. Nurse Practitioner notes dated 10/13/22 documents that R1 has dementia and has history of suicide attempt. R1 has decreased mobility, poor strength, muscle atrophy, all extremities examined. R1 with severe dementia, confuse. Social Service Note dated 10/19/2022 documents: R1 can express himself and understand in his native language and simple English phrases. R1 will push on unit door yet easily redirects. R1 wears wander guard as a precaution. Restorative Notes dated 10/27/22 documents: R1 is at risk for fall due to impaired functional mobility, unsteady gait, impaired cognition, and increased weakness. R1 will be assisted with activities of daily living (ADL) care as needed and all efforts will be praised. The protocol in monitoring high risk for elopement resident, is that a staff is supposed to be present in the hallway to monitor. To make sure no one goes to other people's room or try to escape through the exit door. When the nurses pass medications, they help monitor the hallway. The staff usually make unit rounds every 2 hours. R2 through R6 are residents who are on the list of the facility's elopement risk. Per documentation from the progress notes, assessments, MDS and care plan, R2 through R6 were identified as cognitively impaired, ambulatory, and displayed elopement risk behavior. These 6 residents can be potentially affected with the facility's failure of adequate supervision. Facility's Elopement and Search Policy and Procedure dated February 2014 indicates: Policy: To establish methods for protecting residents who are at risk for elopement and for conducting an organized search for a resident who cannot be located. Policy Specifications: 1. All nursing personnel are responsible for: a. Knowing the whereabouts of resident for which they are assigned. c. Staff are responsible for keeping the nurse informed of a resident's whereabouts. 7. All staff are responsible for promptly going to the location and determining the cause of the activated audible alarm. 14. All facility staff will be informed of residents at elopement risk. Through observation, interview and record review conducted on November 14, 2022, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: 1. The corrective action(s) taken for the resident(s) found to have been affected by the deficient practice: A head count was done immediately. All other residents were accounted for. All residents with wander guards were checked to make sure theirs were working. All were working as designed. The unit door alarm codes were changed. Visitors are not allowed to have the code and will be let on and off the locked unit by staff. Maintenance staff checked the wander guard system, and door alarms shortly after elopement. The systems were working as designed. 2. The corrective action(s) for other resident(s) having the potential to be affected by the same deficient practice: All residents have the potential to be affected. None were identified. 3. The measures put into place and a systemic change made to ensure the deficient practice does not reoccur: The Administrator or designee has in-serviced Nursing, CNA, Bed Maker, Housekeeping, Laundry, Maintenance, Dietary, Activity and Reception staff on the Elopement and Search Policy and Door Alarm Policy - in particular, to notify another staff member if you are unsure if it's a resident of that unit. In-servicing will be completed end of day 11/14/2022. Anyone who have not been in-serviced will be in-serviced in person or over the phone prior to their next shift by Medical Records, Nursing Scheduler, or designee prior to their next shift in this facility. This in-servicing includes staff on FMLA & PRN. All new hires will be in-serviced during their orientation on the Elopement and Search Policy and Door Alarm Policy - in particular, to notify another staff member if you are unsure if it's a resident of that unit. The Administrator or designee has in-serviced Agency Nurses and CNA staff on the Elopement and Search Policy and Door Alarm Policy - in particular, to notify another staff member if you are unsure if it's a resident of that unit. In-servicing will be completed end of day 11/14/2022. Agency staff who have not been in-serviced will be in-serviced in person or over the phone prior to their next shift by Medical Records, Nursing Scheduler, or designee prior to their next shift in this facility. Nursing, CNA, Bed Maker, Housekeeping, Laundry, Maintenance, Dietary, Activity and Reception staff were in-serviced on who is and how to identify a wanderer and an elopement risk resident. In-servicing will be completed end of day 11/14/2022. Anyone who have not been in-serviced will be in-serviced in person or over the phone prior to their next shift by Medical Records, Nursing Scheduler, or designee prior to their next shift in this facility. This in-servicing includes staff on FMLA & PRN. All new hires will be in-serviced during their orientation on how to identify residents at risk for elopement. Binders were placed by all unit nurse's stations, kitchen, therapy, and reception that contains the elopement policy and procedure and resident photos with their names. A Robo Call was sent out today on 11/14/2022 to all staff and current Agency staff on who is and how to identify a wanderer and an elopement risk resident, the Elopement and Search Policy, and Door Alarm Policy - in particular, to notify another staff member if you're unsure if it is a resident of that unit. Maintenance staff have installed motion censored lighting outside the exit door on 11/08/2022. Administrator, Maintenance Director, or designee has been auditing all door alarms, wander guards, wander guard systems daily to ensure they are working as designed. Daily checks started after the elopement on 11/7/2022. S. Electronic Services came out on 11/8/2022 to check the door alarms, magnetic locks, and wander guard system and it is working as designed. Nursing, CNA, Bed Maker, and Activity staff have been in-serviced to increase monitoring the hallway and other areas of the unit where residents who are confused and ambulatory tend to wander. In-servicing will be completed by end of day 11/14/2022. Anyone who has not been in-serviced will be in-serviced prior to their next shift. Facility will assign a bed maker daily for first (7-3) and second shift (3-11) to the locked unit to increase monitoring of the hallway and other areas of the unit where residents who are ambulatory tend to wander. 4. To ensure the deficient practice does not reoccur, the corrective actions(s) will be monitored by: Administrator, Maintenance Director, or designee will audit all door alarms, wander guards, wander guard systems daily x 4 weeks during first shift to ensure all are working as designed. The Quality Assurance Committee will monitor the facility's performance to ensure compliance and will reevaluate the duration after 4 weeks to either extend an additional 4 weeks or cease the auditing. This process will continue until compliance is achieved. The Quality Assurance Committee will meet 12/07/2022. 5. Completion date systemic changes will be completed: 11/14/2022