Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based Based on observation, interview, and record review, the facility failed to ensure residents at risk for elopement were accurately assessed and incidents of elopement were appropriately identified and thoroughly investigated for 2 (R59 and R24) of 6 reviewed for accidents and supervision in the sample of 40. This failure resulted in R59, who has a diagnosis of dementia with severe cognitive impairment, eloping from the facility on 12/29/23. Findings Include: 1. R59's Face Sheet documented R59 is a [AGE] year-old male, who admitted to the facility on [DATE] at 5:30 PM. Diagnoses listed on this document in their entirety are: Unspecified Dementia, Unspecified Atrial Fibrillation, Anxiety Disorder, Vitamin D Deficiency, Constipation, Dextrocardia, Essential (primary) Hypertension, Dorsalgia, and other Amnesia. V25 (Physician) is listed as being R59's Primary Care Physician. The only contacts listed for R59 on this document are V21 (Family Member & Power of Attorney/POA) and V22 (Family Member). R59's Minimum Data Set with an assessment reference date of 1/4/24 documented a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Section E0900 documents 0, indicating the behavior was not exhibited to the question has the resident wandered. R59's (Name of town) Primary Care record found in R59's Electronic Health Record, documented a visit on 12/7/23 with a chief complaint being to establish care. This document stated, Patient has been here in the past. It has been over 4 years since he was last seen in this clinic. He is here today with his sister to reestablish care. Over the past 2 years, she has noted a decrease in his mental status. He seems to be having problems with short-term memory. There is a family history of dementia in their father. The history of stroke is uncertain. He was hit by a semi several years ago in front of the (Store Name) here in town. He did sustain a significant head injury at that time .He does have some problems with his vision. This seems to be a problem when trying to watch TV as he cannot use his remote. He also likes to walk around town. He reports almost being hit by a semi couple days ago. According to his sister, approximately 18 months ago she became involved with his care when he showed up at her house and was quite disheveled. Since then she has worked on getting him help set up He does tend to sleep from 5 or 6:00 PM until 4:30 in the morning. At that time he does like to get up and walk around town . Local hospital Emergency Department (ED) notes dated 12/28/23 at 10:38 AM, documented R59 was seen for chief complaints of altered mental status and hallucinations. This document stated R59 was brought to the ED by family members and friends who stated R59's complaint symptoms had been going on for the last 18 months but worsened over the last 2 weeks. After workup, the Clinical Impression listed is Thoracic aortic aneurysm, unspecified part, unspecified whether ruptured; and Cardiac arrhythmia, unspecified cardiac arrhythmia type. A case management note documented report included family concerns with R59's current living apartment arrangements which state R59 has been found outside his apartment multiple times, locked out, and ultimately confused how to operate a key fob to get into the apartment. Not eating as he should and suspected hallucinations. Both R59's (Name of Town) Primary Care document and Local hospital ED documents as listed above were observed to be scanned into R59's Electronic Health Record in a folder titled, Referral Documents. R59's Elopement Risk Tool, documented as being completed by V2 (Director of Nursing/DON) on 12/28/23 at 8:14 PM, stated R59's Elopement Risk Summary was determined to be, Resident has not been found to be at risk for elopement at this time. Entries included on this same tool documented: Yes for the question, Has the family communicated that the resident has eloped or attempted to elope from home, or shared concerns that the resident may have wandering/elopement tendencies? Yes, Additional Details: Early onset of dementia for the question, Does the resident display cognitive deficits, disorientation, intermittent confusion, or any other cognitive impairments that contribute to poor decision-making skills? No for the question, Does the resident's wandering behavior affect his/her safety and well-being? R59's Departmental Notes notations include the following entries: -12/28/23 6:03 PM, Resident arrived per private auto with sister (V22). Resident went to dining room for pm meal. Alert and oriented x3 with intermittent confusion. Resident is independent in his care. Denies pain, no home meds. Was in ER today at (local hospital) and DX (diagnosis) of Afib (atrial fibrillation) but no new meds. Resident is cooperative at this time. Signed by V2 (DON) -12/29/23 6:21 AM, Resident awake and alert at 4 AM walking around asking about the exits. Approximately 5:30 during med pass got a phone call from staff stating that resident went out of backhall door. Staff (initials) (V26, Licensed Practical Nurse/LPN) stayed beside resident encouraging him to return to facility at this time resident kept walking down the street, 2nd staff (initials) (V27, Certified Nurse Assistant/CNA) ran out and assisted other staff with encouraging resident to return to facility. This point this nurse got into personal vehicle and drove down road to assist and pick up resident and other staff at which time, resident was already to his house and still refusing to return. Son (name of V20 - Family member) came outside and confirmed it was residents' home, this nurse contacted DON and returned to facility to call son (name of V21 - Family Member/POA) and inform him of residents' elopement. Signed by V28 (Licensed Practical Nurse/LPN). -12/29/23 7:23 AM, Resident returned to facility through side exit. Signed by V33 (LPN). -12/29/23 8:29 AM, Son (Name of V21) and Sister (Name of V22-Family Member) in the facility this am and discussed residents leaving the facility this AM, both agree that if he continues this behavior to leave facility they will need to consider a lock down unit and residents house is only 2 block away from the facility and he is use to walking 6 miles a day in the community. Resident voices remorse for leaving this AM and states he will not leave the facility unless one of his family members is here to sign him out. Signed by V2 (DON). -12/29/23 12:22 PM, Resident frequently up walking. Pleasant and cooperative. Alert to person and place, reorienting often. Family has been visiting and bringing belongings in throughout the day. Vital signs obtained 98% (room air), 166/82 bp (blood pressure), 97.3 F (Fahrenheit), 70 bpm (beats per minute), 19 rr (respirator rate). Resident often goes to bed early and gets up early. The resident can go out on leave with (name of V21) or (name of V22). (Name of V21) requests to be called in the morning to prevent elopements and reorient the resident. No c/o (complaints of) pain or discomfort. Continuing with the plan of care. Signed by V33 (LPN). -12/31/23 2:38 PM, .This morning he did well with adjusting to facility however became slightly restless towards the afternoon. He did not make any attempts to leave the facility but did gesture towards leaving the facility stating he was getting his warm clothes on . Signed by V35 (Registered Nurse/RN). -1/3/24 10:28 AM, Was able to speak with (Name of V21) today for resident's initial care plan meeting. Signed by V7 (LPN/MDS and Care Plan Coordinator/CPC). -1/3/24 10:40 AM, Resident has been pacing in hallways. Asking to go outside did show him the courtyard which he only walked through and returned. Is thinking that the facility is kicking him out and he has to pack his belongings. Was reassured that he is to stay here . Signed by V36 (LPN). -1/3/24 11:56 AM, Resident continues to walk in hallway and go into other residents' room. Is redirected and he states you just don't understand. Signed by V36 (LPN). -1/7/24 3:59 AM, Resident in coat and hat made 1 exit attempt within past hour, out front door facility, approached by staff redirected back into facility with 1 to 1 interaction. Signed by V37 (RN). -1/22/24 2:57 PM, Resident has been up and down hallway looking and entering other resident's room. Did explain that he does not need to be going into others rooms stated I was just looking around. Signed by V36 (LPN). -1/22/24 3:43 PM, Door alarm sounding resident was leaving building staff did approach immediately and resident did agree to re-enter the building. Was given lemonade and did sit with other residents in dining room. Signed by V36 (LPN). -1/23/24 5:30 PM, Resident was seen going out old side door alarm sounding was redirected and assisted to his room where he then watch (sic) tv. Has been pacing up and down hallway looking into other residents' room. Encouraged not to enter these rooms. Did attempt to help another resident stand was asked not to help him due to possible hurting himself or other resident. Signed by V36 (LPN). -1/26/24 11:46 AM, This DON (V2) spoke with (name of V22) residents sister. (Name of V22) and (Name of V21) who is health care POA continue to request all concerns for residents care while here at (facility initials) go through (Name of V21) or (Name of V22). Resident can speak and visit with other family members however (Name of V21) request that his father only leave the facility with (V22 or V21) . Signed by V2 (DON). -1/27/24 11:11 AM, Resident has been on and off exit seeking this morning and has been redirected multiple times by staff. Resident has not found his way outside of building. Signed by V38 (LPN). The National Weather Service documented the temperature on 12/29/23 between 4-8am was 33-34 degrees Fahrenheit with precipitation of snow. On 2/7/24 at 10:11 PM, V29 (Certified Nurse Assistant/CNA) stated that R59's cognition varies. V29 confirmed she was working the night (shift) when R59 eloped. V29 stated that herself and V30 (CNA) were doing bed checks when they heard the door alarm going off. V29 stated both herself and V30 went to the door, and saw R59 outside wearing a heavy coat, beanie, jeans, and shoes. V29 stated it was snowing, cold outside and the time they first viewed R59, he was approximately 15 feet from the facility. V29 stated herself and V30 both were trying to talk R59 into coming back into the facility, but he refused and just kept walking, stating he was going home. V29 stated staff could not get to him as R59 had squeezed through a gap and was on the other side of a fence, which they could not fit through. V29 stated she went back in the building and exited out the door near the staff time clock. V29 stated by that point R59 was halfway across the parking lot, so she ran to catch up with him. V29 stated she just kept trying to convince R59 to come back to the facility, telling him it was cold, and she was out of shape, in which R59 responded by laughing that he wasn't cold and to keep up, he was used to walking 6 miles a day. V29 stated she stayed with R59 who was not combative, but just kept walking and refusing to go back to the facility. V29 stated she had hollered at V30 as they were walking away to call V28 (LPN) and tell her to come help. V29 stated that V27 (CNA) had also ran to help and walked with herself and R59, also trying to convince R59 to return. V29 stated she is familiar with R59's family, as she went to school with them, so knows the home R59 was going to. V29 stated it was R59's home, who V20 (Family Member) now resides at, which is 2-3 blocks from the facility. V29 stated as they were approaching the house, V28 pulled up in her car and R59 walked right in the front door of the home. V29 stated V20 didn't seem upset and tried to convince R59 to return with staff, but finally stated it was fine if he stayed. V29 stated she believed that V28 (LPN) called V2 (DON) who said staff couldn't force him back, so they left R59 with V20, in the home and returned to the facility. V29 stated prior to this, also the morning of 12/29/23 around 5 AM, she witnessed R59 dressed in his coat and hat, exiting out the front door. V29 stated the alarm was sounding and R59 went out the door, stated it was cold, and came right back in the facility without redirection. When questioned about actions taken after, V29 stated she did not go report this occurrence to anyone and continued working. V29 stated R59 made a comment to her about there being all these exit signs and nowhere to go. V29 stated it was probably 10-15 minutes after she had witnessed R59 go out the front door and come back in, when the back door alarm was going off and R59 was out and walking away from the facility. V29 stated also later that morning, following R59's elopement (12/29/23), at approximately 6:15 AM, she was leaving work from her shift and saw R59 walking alone, down the road heading back towards the facility. V29 stated R59 was wearing the same attire he had left the facility in. V29 stated she called the facility and cannot recall who she spoke with but told them it looked like R59 was headed back, and they said they would go out to keep an eye out for him, so she left. On 2/7/24 at 10:29 PM, V30 (CNA) stated that she was working the front hall the night R59 eloped but was helping V29 (CNA) with her bed checks when they heard the back hall door alarm go off. V30 stated that herself and V29 went to check and R59 was observed outside, a few steps away from the door, on the other side of the fence, which staff could not fit through the tight area. V30 stated they were attempting to talk R59 back into the facility but R59 continued walking away stating 'the door says exit .that means someone can exit.' V30 stated R59 was wearing a sock hat, black winter coat, boots, and jeans. V30 stated it was cold outside that day. V30 stated she went back in the building to watch the halls and V29 ran to go out another door and catch up with R59 telling V30 to call V28 (LPN) and tell her what was going on, which she did. V30 stated she stayed outside the door watching R59 until V29 got out the other door of the facility and could catch up to R59. On 2/7/24 at 9:58 PM, V28 (LPN) described R59 as being confused when admitted , with some intermittent improvement to his cognition since being at the facility. V28 stated she was a nurse on duty when R59 eloped from the facility. V28 stated she believed R59 eloped the first night he was admitted . V28 stated she did not witness R59 leave, but from her understanding, R59 exited through the back hall door. V28 stated there is an alarm on that door and although she wasn't there to witness it sounding herself, assumes it was, since staff were with R59 outside. V28 stated she believed R59 had slept good that night (12/28/23), until he woke up around 4am (12/29/23). V28 stated R59 was walking around the facility saying things like there's a whole lot of exit's and nowhere to go. V28 said she believed it wasn't abnormal for R59 to wake up around 4am though, and that was his normal time to rise for the day. V28 stated she believes R59 was admitted to the facility with a diagnosis of a heart condition and his sister (V22) and son (V21) wanted him in a facility for his health with his diagnoses and history of walking the streets of (town name). V28 stated the night R59 eloped, she believes she received a call from V29 who stated to hurry up and get out here, that R59 had left and they couldn't get him to come back to the facility. V28 stated it was cold, so she got in her car to go try and coax him back. V28 stated V29 and V27 were both with him at the time she caught up to them and described R59 as definitely having some place he wanted to go. V28 stated V20's (Family Member) house was approximately 2 blocks behind the facility and that is where R59 went. On 2/7/24 at 11:23 PM, V28 (LPN) clarified that the V26's initials in her progress note dated 12/29/23 at 6:21 AM should have read V29's initials. V28 also stated that by the time she drove to meet R59 and staff, they were already by the house which sits on a corner. V28 stated that by the time she parked, R59 was already in the house. V28 stated that staff, along with V20 (Family Member), who was present at the time R59 entered the house were unable to coax R59 back to the facility. V28 stated she called V2 (DON) to find out what to do. V28 stated V2 called V32 (Former Administrator). V28 stated she was told they could not force R59 to come back, and it was (family) V20 he was with. V28 stated at that time, she did not reach out to R59's resident representative (V21) and is unsure if V2 or V32 reached out to (V21) to get permission for R59 to stay with V20, as V20 was not the representative for R59. V28 stated she was not present when R59 returned to the facility, but believed he walked back himself before 7 AM the same day that he had eloped. On 2/7/24 at 10:21 PM, V27 (CNA) stated that R59's cognition varies. V27 described R59's normal status as being that he will wander into other resident's rooms, bathrooms, and we will find him sleeping in other's recliners, etc. V27 stated R59 had eloped the first night he was at the facility she believes. V27 does not recall being told that R59 was any sort of elopement risk at that time. V27 stated residents are viewed at least every 2 hours during bed checks, but if (she) is walking down the halls, she looks in rooms while walking by too. V27 stated she was alerted of a resident outside by V31 (Laundry), who was coming in for her shift and saw a man she didn't recognize outside walking and wasn't sure if it was a resident. V27 stated she went to check and saw R59 and V29 halfway up the road, walking away from the facility, so she ran to them to try and help. V27 stated R59 was not being combative, was just saying over and over that he wasn't coming back. V27 stated R59 walked directly to (V20's) house which was a couple blocks from the facility. V27 stated (V20) said it was ok if R59 stayed there with him since he was refusing to return. V27 stated that R59 had been up and down a few times that night prior to eloping but was re-directable until 4am when he was wide awake and got himself dressed. On 02/08/24 at 11:54 AM, V31 (Laundry) stated that she recalls coming into work early one morning in which she observed a man outside the building that she didn't recognize. V31 stated she thought he was a predator, so she came in the facility and was talking to a co-worker about the man when she then saw two staff following behind him, making her realize it was a resident and not a predator. On 02/08/24 at 11:11 AM, V20 (Family Member) stated he believed it was approximately 3 AM when he heard a knock at his front door. V20 stated he answered the door and observed R59 standing there appearing anxious. V20 stated he saw 3 staff also with him. V20 stated he didn't know who the staff were, as he didn't realize R59 had been admitted to the facility. V20 stated that R59 used to live with him, which was originally R59's house. V20 stated that R59 had recently moved to an apartment 2-3 weeks prior to him showing up at his door with staff. V20 stated that R59 had been moved to the apartment due to his increased confusion. V20 stated that he doesn't know if R59 was experiencing any problems while residing at the apartment. V20 stated he had been told by (V22) that R59 was having continued confusion at the apartments as V20 had been told R59 was going into other people's apartments that were not his. V20 stated the morning R59 had left from the facility, R59 stayed with V20, as he was refusing to return to the facility with staff. V20 stated that he talked to R59 and reminded him of past family members who had lived at the facility and coaxed him to return. V20 stated he did not accompany R59 back to the facility or call the facility to let them know R59 was leaving his home. V20 stated that R59 walked out the front door and headed in the direction back toward the facility and he saw or heard nothing further. V20 stated he had called V22 to let her know what had happened and that he had talked R59 into heading back towards the facility. On 02/08/24 at 10:27 AM, V21 (Family Member/POA) stated that he is the Power of Attorney for R59. V21 stated that R59 was admitted to the facility after having a decline in mental status, which causes R59 anxiety. V21 stated that R59 responds to anxiety by walking and walking and walking. V21 stated R59 was continuously walking all over town which causes worry for R59's safety. V21 stated he was notified via phone that R59 had eloped from the facility. V21 cannot recall the time he was notified or by who, he just recalls the facility telling him that R59 had left and staff stayed with him the whole time. V21 stated he was told R59 walked to V20's house. V21 stated he cannot recall if the facility asked him if it was ok that R59 was left with V20 at the home, he just knows that they said they were unable to get him to come back to the facility. V21 stated he wasn't surprised knowing R59's stubbornness and assumes it would have taken physical restraint or a familiar voice to coax him back. V21 stated once he was notified of the elopement, he jumped in his car to head towards the facility, which was about an hour away to try and assist with the situation. V21 stated he believes he was close to the facility when he had received a call that R59 had returned to the facility on his own. V21 stated that he would assume knowing V20 that V20 was probably not aware that R59 had left the house and returned to the facility. V21 stated he considers the elopement an accident since he knows it was R59's first night at the facility, R59's anxiety would have been high and R59 has his normal routine history of walking. On 2/8/24 at 9:47 AM, V33 (LPN) stated that she was the nurse on duty and was also the staff member who witnessed R59 return to the facility. V33 stated R59 entered back into the facility through the side door. V33 stated she was passing medications on the hall near the door he came in. V33 stated she saw R59 walking towards the facility, alone to the door, in which he opened the door and came back in the facility. V33 stated R59 did not appear to be in any physical or emotional distress but was upset apologizing for leaving. V33 stated she believes it was around 7:15 AM, when R59 arrived back. V33 stated she notified the DON (V2) that R59 was back. V33 stated she did not notify the POA of R59's return. V33 confirmed that she is not aware of what the facility's protocol is for elopement returns, as she is newer to nursing. V33 stated that she did not conduct any head-to-toe assessment or notify the physician of R59's elopement return. During this interview, V33 stated she had not received any training or direction following R59's elopement on areas to be trained or improve on. On 2/8/24 at 12:09 PM, V22 (Family member) stated she is involved in R59's care routinely. V22 stated R59 would vent to her as R59 and V20 were fighting and to cope, R59 would take off walking and just walk around town. V22 stated that V20 was struggling with an addiction to meth and ended up incarcerated after having possession of meth with prior felony charges. V22 stated that problems seemed to escalate with V20 as R59's cognition declined. V22 stated that she determined the best option she felt at that point was to reach out to Adult Protective Services in which V24 (Adult Protective Services Caseworker) was the staff member assigned to R59's case. V22 stated that V24 got an apartment set up for R59 to get him out of the environment with V20, but that living situation also didn't work. V22 stated that R59's cognition was too poor and R59 was leaving the apartment, locking himself out, going into wrong apartments, etc. V22 stated that 4 AM seems to be R59's worst time of the day for cognition as he becomes anxious and just wants to walk. V22 stated that she became scared to death that R59 was going to get hit as he would walk around town and across busy roads. V22 stated herself and V21 met with V32, who was the administrator at the facility during that time, which was approximately 1-2 weeks prior to R59's admission to the facility. V22 stated they wanted to meet with the facility to express concerns and a plan for R59 as his cognition varied, he was walking all over and also express the history with R59 and V20. V22 stated that V32 was instructed that R59 was not to leave the facility with V20 as R59 has a history being made upset by V20. V22 stated V21 also expressed that although he is the POA, information may be shared with V22. V22 verified that she was notified of R59's elopement from the facility, in which R59 went to V20's house. V22 stated she cannot recall what time she was notified or who it was that notified her but just remembers it was the morning. V22 stated that since R59's elopement, she has not received any meeting or conference with the facility to discuss any changes in R59's plan of care. V22 stated that she did have a phone conversation with V1 (Administrator) who stated activities such as karaoke were available and maybe an activity R59 would like to participate in. On 2/8/24 at 2:45 PM, V2 (DON) described R59 as being confused intermittently with short term memory loss, easy to redirect, ambulates constantly. V2 stated that prior to R59 admitting to the facility, he walked around town a lot. V2 stated she was also told by V21 and V22 that they were to be R59's only contacts for medical information and the only contacts that R59 could leave the facility with. V2 stated that R59 has another son (V20), who lives close to the facility who they said could visit R59 at the facility or call. V2 stated approximately 1 1/2 months prior to R59 being admitted to the facility, she believes R59 had been removed from living in his home with V20 by Adult Protective Services due to financial exploitation with V20 using R59's money and not paying for utilities. V2 stated that after R59 was admitted to the facility, she slowly found out more from V22 (Family Member) that R59 did not like strangers in his house, which were frequently there with V20. This would cause R59 anxiety, so he would leave the home and just walk around town. V2 stated prior to R59 admitting to the facility, V22 and V21 had come to the facility to talk with V32 and herself about wanting to put R59 in the facility. V2 stated R59's chore girl infrequently was able to provide care services for R59 who was living in an apartment at the time, due to R59 being out walking. V2 described the chore girl as someone who had been set up to provide R59 assistance in the apartment. V2 stated the family was afraid he was not getting meals, being kept clean, and confusion was increasing which caused worry for them of him being out walking. V2 stated the family felt like if he was in the facility, he would be less lonely and respond better to care offered. V2 stated at the time of R59's admission, the family placed signs on R59's door and in his room, telling him not to leave the facility, which they thought would help remind him not to leave. V2 stated the family stated they had also placed signs such as these posted in his apartment where he lived prior to admitting the facility. V2 stated that she had approved R59's admission to the facility off of her prior conversations with R59's family (V21 & V22) along with reviewing the ER (Emergency Room) documents that R59 admitted with. V2 stated that these documents didn't say much and diagnosed R59 with A-fib. V2 stated that she completed the Elopement risk tool upon R59's admission to the facility and deemed him not to be an elopement risk, because it wasn't like he had daily routines of running or hiding. V2 confirmed she was notified of R59's elopement by V28 (LPN), who was R59's nurse that night. V2 stated that R59 had just been admitted to the facility. V2 stated an investigation of the incident was complete with all staff interviewed and stated there was no fence where he left the facility at. V2 stated that she would expect any time a resident was viewed leaving the facility, despite if they immediately returned back in, she would expect the nurse to be notified and the incident documented in the resident's record. V2 stated it would give the staff a heads up that the resident maybe trying to leave. A specific example was given to V2, which included a resident is viewed independently leaving out of the facility, but once through the door, turns around and comes back in due to reported cold temperatures. V2 confirmed the resident should be redirected back inside the facility and the nurse immediately notified. V2 stated in the incident with R59, 2 staff members, a nurse and V20 could all not convince R59 to return to the facility with staff. V2 stated she can't really say she made the call to allow R59 to stay with V20 in the home at that time and have the staff return to the facility, but V20 did say R59 could stay there and we just knew where he was at. V2 stated in reviewing her phone log, she had called V32 (Former Administrator) at 5:54 AM, which she assumes was the call where she informed V32 that R59 was at the house with V20, and again at 7:20 AM, which she assumes was the call she made to V32 that R59 was back in the facility. V2 stated that she cannot say if R59 returned to the facility alone, as she didn't see him come back, a CNA just reported to her that R59 had come back in a side door. V2 stated V33 (LPN) was R59's nurse upon his return to the facility and a head-to-toe assessment should have been conducted and assumes V33 probably did one. V2 stated that R59 came to her right away upon his arrival back to the facility and apologized for leaving. V2 stated that shortly after R59's return to the facility V21 and V22 also arrived at the facility and assumes they had come to the facility that quickly due to R59 being reported at V20's house. V2 described there being poor family dynamics. V2 stated facility staff met with V21 and V22 in which they were apologetic for what had happened. V2 stated at the time R59 returned to the facility, a 1:1 staffing status was implemented, with herself being the 1:1 until the behaviors were determined to have ceased, which would have been about 5:30 PM - 6 PM that night when she left the facility. V2 stated that elopement would have been triggered on R59's baseline care plan at the time of admission due to wandering. V2 also stated that the Minimum Data Set personnel were notified of R59's elopement on 12/29/23 as the facility holds a daily meeting with all department heads to discuss incidents which have occurred or concerns. V2 stated that Section E of R59's MDS would be a section completed by social services. On 2/8/24 at 3:25 PM, V2 (DON) was asked to show the door of the facility in which R59 exited from on 12/29/23. V2 led surveyors to a door at the end of 600 hall, which R59 resides on. The door was observed as opening into a parking lot area, butting up to two roads with no fence in the very immediate vicinity visualized. V2 was asked what door would be described as the back hall door, in which she stated oh and took surveyors to another door which is also near the employee entrance door. V2 stated that some staff refer to a hallway in the facility as the back hall. Upon exiting the back hall door from inside the building, a chain link fence was to the immediate right of the door. The fence ended at an area which adjoins to an area with concrete blocks, broken concrete, trash, down tree debris, lumber and a creek bed. There was a matted down pathway between the end of the fence post and tall weeds with a wire welded fence slanted on its side creating an uneven surface. On the other side of the slanted wire fence was the creek bed. Once on the other side of this fence you could see the employee entrance door, s[TRUNCATED]