**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide adequate supervision and provide a secure environment to prevent elopement for 1 of 16 residents (R2) reviewed for elopement in the sample of 18. This failure resulted in R2 eloping without staff knowledge and has the potential to affect all 16 residents identified as being at risk for elopement (R1, R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17 and R18). This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 04/09/23 when R2 left the facility at 4:21PM without staff knowledge and was found by the local police department at 7:10 PM. V1 was notified of the Immediate Jeopardy on 04/12/23 at 13:30pm. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 4/13/23, but noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of in-service training, interventions, and the door monitoring device. Findings include: 1. On 04/11/23 at 8:35 AM, V1, Administrator, gave a list of residents identifying R1, R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17 and R18 were at risk for elopement. 2. On 04/11/23 at 10:40 AM, R2 was observed in his room, alert and oriented, (A&O), to person only. R2's Face Sheet, undated, documents R2 has a diagnosis of Dementia. R2's Minimum Data Set, (MDS), dated [DATE], documents R2 has moderate cognitive impairment and wanders which places him at significant risk of getting into dangerous places (outside of the facility). R2's Care Plan, dated 03/01/23, documents R2 is at risk for elopement/wandering related to being disoriented to place and a diagnosis of Dementia. R2's Elopement Risk Review, dated 03/09/23, documents R2 is at risk for elopement. R2's Progress Note, dated 03/09/23, documents R3 was assessed for elopement/unauthorized leave. R2 has a history of wandering/elopement and/or verbalizes a strong desire to leave. R2 has a diagnosis of dementia and/or severe mental illness. Resident has reported or documented episodes of elopement and/or attempts to elope. The resident's representative (i.e., Health Care Power of Attorney, close family member, guardian), has not requested that the resident be monitored on the Elopement Protocol. Behavioral Observations include spends time on the first floor or wanders between floors or units. Hangs around facility exits and/or stairways. R2 has the physical ability to leave the building. Resident is at risk to elope and should be placed on the Elopement Risk Protocol. A care plan for Elopement is indicated. R2's Progress Note, dated, 04/09/23 documents R2 was assessed for elopement/unauthorized leave. The resident has a history of wandering/elopement and/or verbalizes a strong desire to leave. The resident has a diagnosis of dementia and/or severe mental illness. Resident has reported or documented episodes of elopement and/or attempts to elope. The resident's representative (i.e., Health Care Power of Attorney, close family member, guardian) has not requested that the resident be monitored on the Elopement Protocol. Behavioral Observations includes Spends time on the first floor or wanders between floors or units. Hangs around facility exits and/or stairways. Has the physical ability to leave the building. Resident is at risk for unauthorized leave due to substance use disorder and should be placed on the elopement risk protocol. A care plan for elopement is indicated. R2's Progress Note, dated 04/10/23 at 4:50 PM, documents R2 has been on 15-minute checks to prevent further elopement. R2's Progress Note, dated 04/09/2023 at 11:04 PM, documents, Resident recently admitted /readmitted to the facility. Resident left unattended, brought to hospital by local police department. No injuries found. The Facility Investigation, undated, by V1, Administrator, documents the following: On 04/10/23 the cameras were reviewed to determine which door R2 exited and how he was able to exit the facility. Due to the cameras not being close enough for detail, we were unable to determine how the door was opened. We did verify that the egress and alarm is functioning properly and that R2 was able to exit from the 200-hall door without being noticed at approximately 4:21 PM. R2 was clothed properly and was wearing shoes when he exited the facility. R2 reports he was going out to get fresh air. Staff report he was in the building for dinner, which he confirmed. The hospital notified the facility that the resident was picked up by the local police department at 7:10 PM and notified the facility that he was at the hospital (not seen in the emergency room because he had no injuries) at 7:27 PM. R2 was then brought back to the facility. No injuries were noted. All vitals were normal, no distress noted. Observation: although resident was frequently walking about the facility bare foot until last week when family brought shoes, he did not have proper attire to leave or walk outside. We are questioning that due to his previous living arrangements. We believe now that because he had proper attire, he thought it was reasonable to leave the facility and return where he wanted. V3, Agency LPN, statement, undated, documents she did not realize the resident was missing until the hospital had called. R2 was at the facility for dinner and was not due for medications until 8 PM, When the resident returned, V3 completed a skin assessment, vitals were within normal range and his skin was free of wounds or bruises. R2 stated that he was just out enjoying the fresh air. He did not appear to be in any distress and when asked if he was worried or concerned about being out, he again stated that he was just out enjoying the weather. R2 was wearing shoes and was dressed appropriately. R2 told V1, Administrator and LPN, (V3), that he ate lunch and dinner. R2 reports that he does not recall how he got out or what door he exited from. On 04/11/23 at 8:35 AM, V1, Administrator, states R2, eloped from the facility on 04/09/23. V1 states, they reviewed the cameras, and the 200-hall door was not shut, it was ajar, had something in it like a stone, that was preventing the magnet to engage/lock. V1 states, the alarm had been turned off for the smokers, so the alarm did not sound. V1 states, R2 exited the facility sometime between 4:30 PM and 5 PM. V1 states, they are unsure of the time he left the facility grounds. V1 states, R2 told her that he ate dinner and then left the facility to get some fresh air and cigarettes. V1 states, R2 was homeless and used to get food by knocking on people's doors asking for canned goods or food of some sort. V1 states, at 7:10 PM, a neighbor called the police because R2 was knocking on their door asking for canned goods, the police responded and picked up R2 at 7:30 PM by the high school, (approximately 0.5 miles from the facility). V1 states R2 is independent with care and ambulation. V1 states, R2 has a Brief Interview of Mental Status, (BIMS), of 12 and is confused at times. V1 states, R2 only gets medications twice a day. V2 states, the facility staff was not aware that he was out of the building until they received a call from the hospital. V1 states, R2 was taken to the hospital by the local police department but was never seen in the emergency room and didn't have any injuries related to his elopement. V1 states, R2 was back in the facility at 7:40 PM on 04/09/23. On 04/11/23 at 1:05 PM, V9, Certified Nurse Assistant, (CNA), states, R2 is at risk for elopement because he wanders. V9 states, if R2 is heading towards the 200-hall exit door, he, (V9), knows it is because, R2 is wanting to smoke, so he will remind him that someone will be taking him out at the next smoking time and R2 will go back to his room until that time. On 04/11/23 at 2:10 PM, V11, Resident Assistant, (RA), states, R2 paces back and forth and will say he wants to leave. On 04/11/23 at 2:18 PM, V13, Maintenance Assistant, denies concerns with the door alarms except, the 200-hall exit door because, the staff turn it off and must remember to turn it back on. On 04/11/23 at 2:40 PM, V15, CNA, states, she was working on 04/09/23, when R2 eloped. V15 states, around dinner time, unsure of exact time, R2 was walking down the 200-hall towards the exit door, she asked him what he was doing, he said he was going outside, she told him not right now and to go back to his room for dinner. V15 states, R2 went back to his room. On 04/11/23 at 3:15 PM, V3, Agency Licensed Practical Nurse, (LPN), states, she was working on 04/09/23 and came in at 6 PM. V3 states, she was working the 100 and 200-halls. V3 states, by the time she got to the 100-hall to do their medication pass, the hospital had already called stating R2 was picked up by the police and was taken to the hospital. V3 states, she was not aware R2 was not in the building until the hospital called. V3 states, she was told that a neighbor called the police around 7:10 PM and he was taken to the hospital. V3 states, the hospital notified the facility around 7:30 PM that R2 was at the hospital. V3 states, the police officer then brought the resident back to the facility. V3 states, when R2 came back, they assessed him for injuries with none noted. V3 states, R2 told her he went outside to enjoy the fresh air. V3 states, R2 wasn't sure how, which door, or what time he left the facility. V3 states, she works for agency and isn't familiar with R2 and is unsure if he is at risk for elopement. V3 states, when R2 returned to the facility he was placed on one-on-one supervision for the remainder of the evening and night. On 04/12/23 at 8:55 AM, V17, Nurse Practitioner, states, R2 is not able to make good/safe decisions, he does have some safety awareness but, not enough to navigate being out of the facility without supervision. V17 states, R2 had a wander guard at the hospital prior to coming to the facility and was at risk for elopement. V17 states, she would have expected the facility to provide a higher level of care for R2 to prevent his elopement. On 04/12/23 at 10:10 AM, V16, LPN, states, she was working days on 04/09/23 and was working on the 100-hall, where R2 resides. V16 states, she last saw R2 around 2 PM. 3. On 04/11/23 at 10:30 AM, R1 was observed and is confused. R1's Face Sheet, undated, documents R1 has a diagnosis of Dementia. R1's MDS, dated [DATE], documents R1 has moderate cognitive impairment and wanders. R1's Care Plan, dated 11/30/23, documents, R1 is at risk for elopement due to a history of attempts to leave the facility unattended. R1's Elopement Risk Review, dated 04/04/23, documents R1 is at risk for elopement 4. On 04/11/23 at 10:45 AM, R3 was observed and was alert and oriented to person, place and time. R3's Face Sheet, undated, documents R3 has a diagnosis of Schizophrenia and Major Depressive Disorder. R3's MDS, dated , 04/03/23, documents R3 is cognitively intact. R3's Care Plan, dated 07/29/18, documents R3 is at risk for elopement due to wandering the facility at times and verbalizes a desire to leave the facility without a proper discharge plan. R3's Elopement Risk Review, dated 04/03/23, documents R3 is at risk for elopement. 5. On 04/12/23 at 9:35 AM, R6 was observed and is alert to name only. R6's Face Sheet, undated, documents R6 has a diagnosis of Mild Cognitive Impairment, Schizophrenia, Anxiety and Schizoaffective Disorder of the Bipolar Type. R6's MDS, dated [DATE], documents R6 severe cognitive impairment. R6's Care Plan, dated 04/18/18, documents R6 is at risk for elopement due to being disoriented to place and wandering aimlessly. R6's Elopement Risk Review, dated 04/10/23, documents R6 is at risk for elopement. 6. On 04/12/23 at 10:15 AM, R7 was observed and is alert to name only. R7's Face Sheet, undated, documents R7 has a diagnosis of Major Depressive Disorder, Cerebral Infarction and Aphasia. R7's MDS, dated [DATE], documents R7 has severe cognitive impairment. R7's Care Plan, dated 02/01/19, documents R7 is at risk for elopement due to exit seeking, history of attempts to leave facility unattended, impaired safety awareness. R7 will push on the exit doors until the alarm sounds and the door unlocks. R7 watches staff to key in the door codes and open the doors. R7's Elopement Risk Review, dated 04/10/23, documents R7 is at risk for elopement. 7. On 04/12/23 at 9:55 AM, R8 was observed and was alert and oriented to person, place, and time. R8's Face Sheet, undated, documents R8 has a diagnosis of Dementia. R8's MDS, dated [DATE], documents R8 is cognitively intact. R8's Care Plan, dated 10/29/21, documents R8 is at risk for elopement due to wandering to the doors. R8's Elopement Risk Review, dated 04/10/23, documents R8 is at risk for elopement. 8. On 04/12/23 at 9:55 AM, R9 was observed and was alert and oriented to person, place and time. R9's Face Sheet, undated, documents R9 has an admitting diagnosis of Congestive Heart Failure. R9's MDS, dated [DATE], documents R9 has moderate cognitive impairment. R9's Care Plan, dated 06/22/22, documents R9 is at risk for elopement due to being disoriented to place. R9's Elopement Risk Review, dated 03/09/23, documents R9 is at risk for elopement. 9. On 04/12/23 at 9:48 AM, R10 was observed and was alert to self only. R10's Face Sheet, undated, documents R10 has a diagnosis of Dementia. R10's MDS, dated [DATE], documents R10 has severe cognitive impairment. R10's Care Plan, dated 01/27/21, documents R10 is at risk for elopement due to exit seeking and impaired safety awareness. R10's Elopement Risk Review, dated 04/10/23, documents R10 is at risk for elopement. 10. On 04/12/23 at 10:40 AM, R11 was observed and was alert to self only. R11's Face Sheet, undated, documents R11 has a diagnosis of Alzheimer's Disease. R11's MDS, dated [DATE], documents R11 has severe cognitive impairment. R11's Care Plan, dated 03/17/22, documents R11 is at risk for elopement. R11 will attempt to open exit doors and has a history of attempts to leave the facility unattended. R11's Elopement Risk Review, dated 03/28/23, documents R11 is at risk for elopement. 11. On 04/12/23 at 10:00 AM, R12 was observed and is alert and oriented to self and place. R12's Face Sheet, undated, documents R12 has a diagnosis of Dementia. R12's MDS, dated [DATE], documents R12 has severe cognitive impairment. R12's Care Plan, dated 01/01/15, documents R12 is at risk for elopement due to dementia and is exit seeking. R12's Elopement Risk Review, dated 03/14/23, documents R12 is at risk for elopement. 12. On 04/12/23 at 9:46 AM, R13 was observed and is alert to self only. R13's Face Sheet, undated, documents R13 has a diagnosis of Dementia. R13's MDS, dated [DATE], documents R13 has severe cognitive impairment. R13's Care Plan, dated 02/04/22, documents R13 is at risk for elopement due to impaired safety awareness. R13's Elopement Risk Review, dated 04/10/23, documents R13 is at risk for elopement. 13. On 04/12/23 at 9:45 AM, R14 was observed and is alert to self only. R14's Face Sheet, undated, documents R14 has a diagnosis of Alzheimer's Disease. R14's MDS, dated [DATE], documents R14 has moderate cognitive impairment. R14's Care Plan, dated 09/27/22, documents R14 is at risk for elopement due to a history of attempts to leave the facility unattended. R14's Elopement Risk Review, dated 04/10/23, documents R14 is at risk for elopement. 14. On 04/12/23 at 9:50 AM, R15 was observed and was alert and oriented to person, place and time. R15's Face Sheet, undated, documents R15 has a diagnosis of Paranoid Schizophrenia and Major Depressive Disorder. R15's MDS, dated [DATE], documents R15 is cognitively intact. R15's Care Plan, dated 07/11/22, documents R15 is at risk for elopement due to a history of attempts to leave facility unattended. R15's Elopement Risk Review, dated 03/17/23, documents R15 is at risk for elopement. 15. On 04/12/23 at 9:38 AM, R16 was observed and is alert and oriented to person and place. R16's Face Sheet, undated, documents R16 has a diagnosis of Dementia. R16's MDS, dated [DATE], documents R16 is cognitively intact. R16's Care Plan, dated 03/01/19, documents R16 is at risk for elopement due to dementia. R16's Elopement Risk Review, dated 04/10/23, documents R16 is at risk for elopement. 16. On 04/12/23 at 9:42 AM, R17 was observed and is alert and oriented to person and place. R17's Face Sheet, undated, documents R16 has a diagnosis of Schizoaffective Disorder of the Bipolar Type. R17's MDS, dated [DATE], documents R16 is cognitively intact. R17's Care Plan, dated 07/10/21, documents R17 is at risk for elopement due to a history of attempts to leave the facility unattended. R17's Elopement Risk Review, dated 4/10/23, documents R17 is at risk for elopement. 17. On 04/12/23 at 9:40 AM, R18 was observed and is alert and oriented to person, place and time. R18's Face Sheet, undated, documents R18 has a diagnosis of Mild Intellectual Disabilities, Disorganized Schizophrenia, Anxiety Disorder, Major Depressive Disorder, Schizoaffective Disorder of the Depressive Type, Symptoms and Signs Involving Cognitive Functions and Awareness, Transient Alteration of Awareness, Traumatic Brain Injury and Psychosis. R18's MDS, dated [DATE], documents R18 has moderate cognitive impairment. R18's Care Plan, dated 02/03/21, documents R18 is at risk for elopement due to a history of attempts to leave the facility unattended. R18's Elopement Risk Review, dated 12/15/22, documents R18 is at risk for elopement. On 4/11/23 at 3:10 PM, V2, Director of Nurses, (DON), states, all residents are to be checked on at a minimum of every 2 hours. V2 states R2 is now on 15-minute checks. The Alarm Service Company Service Order, dated 04/12/23, documents 200 and 300 doors not alarming when door propped open. Emergency - ASAP. Test, analysis, and wiring identification indicated the in place delayed egress locks did not have options for a door propped open alarm or door open/door closed status output and the existing keypads did not have a necessary optional wiring harness to connect to the central door alarm annunciator panel. Installed door position [NAME] switches on each door/frame. Installed a new monitoring keypad for each door. Programmed PRN and tested thoroughly. Tested all other doors in facility to verify that when propped open a central audio/visual alarm alerts continuously until the door is closed completely. The Unauthorized Absence policy, dated 11/2012, documents the purpose is to ensure the ongoing health and safety when a resident has eloped and/or is otherwise unable to be accounted for during occurring time of day. An unauthorized absence is one that the resident is unable to be accounted for. The Code Pink - Missing Resident/Elopement policy, dated 11/2017, documents staff are to complete a new elopement risk assessment and update the plan of care with appropriate interventions as indicated. Examples of interventions may include but are not limited to: Wander guard bracelet, increased monitoring such as 15-minute visual checks, one on one supervision, evaluation for a secured unit if available and appropriate and review and update the elopement risk binder as appropriate. On 04/14/23 the following was completed to validate the abatement plan submitted by the facility: V2, DON; V3, Agency LPN; V5, CNA; V7, CNA; V8, RN; V11, RA; V14, CNA; V13, Maintenance Assistant, V15, CNA; V16, LPN; V18, Social Services Director; V21, Maintenance Supervisor; V24, CNA; V25, Laundry; V6, Housekeeping; V27, LPN; V28, Dietary Aid; V29, Dietary Aid and V30, CNA, were interviewed and all have been educated on the elopement policy, code pink policy, door alarms and where to locate information on residents at risk for elopement. R1, R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17 and R18's elopement assessments and care plans were reviewed and have been reviewed/revised by facility staff. R4 and R5's elopement assessments were reviewed and neither resident was assessed as being at risk for elopement, therefore their care plan did not need to be updated. R2's 15-minute checks were reviewed and are being completed. The door alarm audits were checked and are being completed. The elopement/code pink policies were reviewed with changes made by the facility. The in-services for the elopement policy/code pink and door alarms were reviewed and have been completed. All exit door alarms, 100 hall, 200-hall, 300-hall, front entrance) were checked with V21, Maintenance Supervisor, all are functioning as necessary. The Immediate Jeopardy that began on 04/09/23 was removed on 04/13/23 when the facility took the following actions to remove the immediacy: A. Identification of Residents Affected or Likely to be Affected: 1. From 04/10/23 to 04/12/23 all 16 residents (R1, R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, & R18) that are at risk for elopement were reassessed by V18, Social Service Director using the Elopement/unauthorized Leave Risk. 2. On 04/12/23 all remaining residents currently residing in the facility were reassessed by V18, Social Service Director using the Elopement/unauthorized Leave Risk. 3. Newly admitted residents or residents that display a new behavior related to elopement will be assessed or reassessed. This will be ongoing. 4. Care plans were reviewed and updated by V20, MDS Nurse as indicated. On 4/12/23 all Resident's Care plans were reviewed and updated by V20, MDS Nurse as indicated. No further residents were identified as at risk for elopement. B. Actions to Prevent Occurrence/Recurrence: 1. On 04/12/2023 all staff were in-serviced by V18, Social Service Director on location of the elopement binders (nurse station, social service office) including interventions to address elopement behaviors. Any agency staff or new staff will be in-serviced prior to working the floor. This will be ongoing. 2. On 04/12/23 (Door alarm company) installed egress alarms that will alert staff when the door is left open for 20 seconds. Staff will be required to manually turn off the alarm at the door once staff manually enter the code the door will be reset. The alarm will not stop sounding until the staff member enters the code in the keypad at the door. Both 300 and 200 hall doors were updated with the new equipment. 3. On 04/12/2023 All staff have been in-serviced on the door alarm and not turning the alarm off at the control panel. Any agency staff or new staff will be in-serviced prior to working the floor. This will be ongoing. 4. 04/13/2023 100% All Staff in-service completed. Maintenance Supervisor V21, or Designee performs door alarm checks daily. This audit will continue indefinitely, and results will be reported to QAPI monthly for the next 2 months 5. On 04/12/2023 policy on Unauthorized Absence and Code Pink: Missing Resident/Elopement policy was reviewed, revised, and updated by V22, VP Clinical Operations Arcadia Care. 6. On 04/12/23 All Staff in-service initiated on revised policy on Unauthorized Absence and Code Pink: Missing Resident/Elopement policy. 04/13/23 90% completed. In-servicing will continue until 100 % completed. Staff will receive in-service prior to start of next scheduled shift. Any agency staff or new staff will be in-serviced prior to working the floor. This will be ongoing. 7. On 04/12/23 (Door alarm company) installed egress alarms that will alert staff when the door is left open for 20 seconds. Staff will be required to manually turn off the alarm at the door once staff manually enter the code the door will be reset. The alarm will not stop sounding until the staff member enters the code in the keypad at the door. Both 300 and 200 hall doors were updated with the new equipment. 8. On 04/12/23 all potential exits secured, and staff are able to recognize when a resident exits the facility.