**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to monitor and supervise a cognitively impaired resident (R1) with an identified elopement history from exiting the building during the deactivation of the facility door alarms. R1 was missing from the facility for hours and was found sleeping under a bush at a gas station on a busy street one mile from the facility. R1 was transported back to the facility by the local Police Department without injury. This failure has the potential to affect all eight Elopement Risk Residents residing in the Facility (R1, R2, R3, R4, R5, R6, R7 and R8). These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 8/23/23, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. Findings include: Facility Elopement/Missing Resident Policy and Procedure, dated 7/2017, documents: it is the policy of the Facility that reasonable precautions are taken to prevent Resident Elopement; reasonable precautions include, but are not limited to, door alarms, wrist alarms and staff intervention; and all staff shall be trained and in-serviced on an annual basis in how to operate and respond to alarms, proper intervention and search techniques. Facility Missing Resident Policy, dated 7/2017, documents: it is the Facility policy to demand immediate response to elopement attempts, door alarm activation and participation in search attempts in the event that a resident is deemed missing; a Resident shall be defined as missing when initial reasonable search of the Facility interior and immediate grounds has not rendered physical evidence of the Resident's person; and no evidence of the Resident's whereabouts upon examination of documents including but not limited to the medical record, calendar of events and sign out books/sheets and after questioning of facility staff and Residents evidence of whereabouts remains uncertain; notify the Law Enforcement Officials; facilitate/coordinate staff assistance in investigation/search under direction of the Law; the Director of Nursing/DON's responsibility is to conduct a thorough investigation using the 'Investigative Report of Missing Resident: and report the findings to the Quality Assurance Committee with a time of occurrences, interventions and responses; prepare a summary of staff performance and policy/procedure strengths and weakness; and report as required by the State and Federal regulation to appropriate regulatory agencies. Facility Door Alarm Policy, dated 7/2017, documents: it is the policy of the Facility to ensure Resident safety and security through the use of door alarms; all doors leading to the outside, MUST meet these requirements; the alarm must only be disengaged at the door itself, either by push button code or key; no alarm may be disengaged from the nurses station or any other location without physical evidence gathered by a staff member or reason for trigger reported to the person silencing the alarm; the alarm must ring continuously until physically disengaging through key or code; testing, including actual activation, and documentation of testing will be completed weekly; and any malfunctions are to be reported to the Administrator and repaired as quickly as possible. The Facility Assessment Tool, dated 6/20/22, documents: the tool is organized in three parts, Resident Profile including diseases/conditions and physical/cognitive disabilities; services and care offered are based on Resident needs; and to provide competent care for Residents, including staff, staffing plan, staff training/education and competencies, education and training, physical environment and building needs; the Facility may accept Residents with Psychosis, Impaired Cognition, Mental Disorders, Anxiety and Behavior that needs interventions; and provide person centered/directed care to prevent abuse and neglect and identify hazards and risks for Residents. Facility Psychiatric Contracted Behavioral Health Source 6/23/22, documents: the purpose of this agreement services shall include psychiatric evaluation and medication management, psychological evaluation and testing therapy and counseling sessions; shall provide licensed Psychiatrists, Psychologists, Nurse Practitioners and other mental health care professionals; Facility shall provide the Contracted Behavioral Health Source with appropriate referrals for services; and each party shall comply with the Federal, State and Local laws, rules and regulations. R1's Physician Order Sheet/POS, dated 6/1/23 through 6/30/23, documents that R1 admitted to the facility on [DATE]. R1's POS documents that R1's medications include Buspar (Anti-Anxiety), Haloperidol (Psychosis), Chlorpromazine (Anti-Anxiety), Seroquel (Psychosis) and Trazadone (Anti-Anxiety). The POS also documents diagnoses including: Dementia, Psychosis, History of Alcohol Abuse, History of Encephalopathy, Elevated Hepatitis, Tardive Dyskinesia, Hallucinations, Paranoia and Anxiety. R1's Letter of Office/Guardian of Estate of Person Form, dated 3/16/23, documents that R1 is a disabled person and has a Court Appointed Guardian (V12/R1's Mother). 1. R1's Nursing Note, dated 6/15/23 at 2:00 am, documents that R1 climbed out the window and ran down the street and that R1 was unable to be redirected back to the Facility by staff and the Police were called and R1 taken to the emergency room (ER). R1's Nursing Note, dated 6/15/23 at 5:35 am, documents a telephone call from local Hospital Emergency Department that R1 was being discharged back to the Facility. R1's local Medical Hospital Emergency Department notes, dated 6/15/23 at 2:16 am, document: R1 presents from Facility due to a mental health evaluation with the local Police Department; staff (at the Facility) report that R1 removed a screen of the window and ran away; and that R1 is alert and not oriented at baseline. R1's Police Report, dated 6/15/23 at 1:30 am, documents V10's (Police Officer) Narrative and that V10 was dispatched and responded to a call for a [AGE] year old male (R1) that had jumped out of a window' (from the Facility). R1's Police Report/Report, dated 6/15/23, documents: at 1:31 am, R1 was identified at a nearby park; at 1:38 am, V10 (Police Officer) requested Emergency Medical Services/EMS for R1; at 2:06 am, R1 was taken to the local Hospital Emergency Department, R1 was confused and was left in the care of the Hospital Emergency staff for a mental evaluation. R1's local Hospital History and Physical/H&P, dated 6/15/23, documents that R1 admitted for a Mental Evaluation to the local Emergency Department at 3:16 am and was discharged back to the Facility at 6:57 am. The H&P documents that R1 was seen by a Behavioral Health Screener and deemed appropriate for return back to the Facility and that a Psychiatric follow-up is recommended. R1's Nursing Notes and Physician Order Sheets, dated 6/15/23 through 8/18/23, do not document a scheduled Psychiatric Evaluation appointment or screening order. On 8/18/23 at 10:40 am, V2 (Director of Nursing) stated, (R1) was identified upon his 4/24/23 admission to the Facility, as an Exit Seeker, and has continued throughout his stay. In the early morning of 6/15/23, (R1) climbed out of (R1's) window in (R1's) room and staff followed him down the road. They were unable to get him to come back to the Facility, so the local Police Department was called, and the Police took him the Hospital for an evaluation. On 8/23/23 at 2:48 pm, V2 (DON) stated, Our contact at our behavioral health psychiatric services (V13) has been out on medical leave for at least two months and that no contact person had been coming to the Facility in her place and I have no idea when (V13) is coming back. On 8/24/23 at 8:25 am, V17 (behavioral health psychiatric services) stated, We received a referral for (R1) but when we were going to do the initial screen, we did not have a signed Consent and (R1) was in the hospital and we never got another referral until 8/24/23, so (R1) has not been seen yet. (R1) is now scheduled for an initial assessment on either Monday (8/28/23) or Tuesday (8/29/23). We just received a signed Consent on 8/24/23, the Facility could never send us a signed Consent prior to this. R1's Nursing Note, dated 4/23/23 at 2:17 pm, documents that R1 admitted to the Facility and that R1 was placed on one-on-one observations. R1's Nursing Note, dated 4/25/23 at 1:00 am, documents that R1 has been exit seeking throughout the evening. R1's Nursing Note, dated 4/25/23 at 7:30 pm, documents that at 6:00 pm, R1 was exit seeking. R1's Nursing Note, dated 4/25/23 at 7:35 pm, documents that R1 exited the building eight times between 4:00 pm and 5:30 pm. and R1 believes R1 is residing in another town and became angry with staff and V12 (R1's Mother). R1's Nursing Note, dated 4/26/23 at 6:40 pm, documents that R1 has left the Facility three times and Facility staff has initiated one-on-ones with the Resident for the Resident's safety. The Nursing Note documents that V1 (Administrator) and V2 (Director of Nursing) were notified. R1's Nursing Note, dated 4/30/23 at 11:00 am, documents that R1 remained on one-on-one watch. R1's Nursing Note, dated 5/13/23 at 2:00 am, document R1 trying to find car and became agitated and argued with staff. R1's Nursing Note, dated 5/25/23 at 2:45 am, documents that R1 was trying to find car keys and go home. R1 was argumentative with staff and went out the back door. R1's Nursing Note, dated 6/2/23 at 7:30 am, documents that R1 was looking for his car keys and house keys and was hoarding cigarettes in pocket. R1's Nursing Note, dated 6/7/23 a 5:00 am, documents that R1 went to bed at this time and was up all night exit seeking. R1's Nursing Note, dated 6/8/23 at 5:00 am, documents that R1 went to bed at this time, was up all night, exit seeking. R1's Interdisciplinary Team/IDT Progress Notes, dated 6/15/23 at 9:00 am, document that the IDT team met to review R1's elopement attempt and that R1 was placed on one-on-one observations while awake for 24 hours until re-evaluation of elopement risk. R1's Interdisciplinary Team/IDT Progress Notes, dated 6/16/23 at 9:00 am, document that the IDT team met to review and re-evaluate R1's risk of elopement and that one-on-one observations were discontinued. 2. Facility local Health Department State Agency Notification Form/Notification Form, dated 6/17/23, documents that R1 has a Brief Interview for Mental Status (BIMS) score of 10/15 (cognitively impaired) and diagnoses including Dementia, Psychosis and Paranoia. The Notification Form documents that R1 was last seen, by staff on 6/16/23, during the hours of 10:00 pm and 6/17/23, at 1:00 am. The Notification Form documents that R1 exited the Facility unsupervised and was returned with no injuries. The local Police Department was notified. The Notification Form also documents In-Service Training forms to check door alarms were performed on 6/19/23. The Facility local Health Department State Agency Notification Form, dated 6/17/23, documents a written timeline statement from V6 (RN) stating, on 6/17/23, at 12:30 am, R1 was last seen by V6/RN sleeping on couch and R1 seen walking back to room. On 6/17/23, at 1:00 am, R1 was not in R1's room and V6 notified all staff in Facility to search all rooms, bathrooms and closets, and R1 was not in the Facility. V6 then notified the local Emergency (911), V1 (Administrator) and V2 (DON). On 6/17/23, at 1:40 am, V1 (Administrator) and V2 (DON) came to the Facility to help search for Resident. On 6/17/23, at 2:03 am, V10 (local Police Department) or V11 (local Police Department) called the Facility for R1's diagnosis, name and date of birth . On 6/17/23, at 3:00 am, all capable staff called into Facility to help search for Resident and at 4:15 am, R1 was still missing. Facility local Health Department State Agency Notification Form, dated 6/17/23, documents interviews with V6 (Registered Nurse/RN), V7 (Certified Nursing Assistant/CNA), V8 (Registered Nurse/RN) and V9 (Unit Aide). The Facility local Health Department State Agency Notification Form documents: that V7 stated, I was at the Nurses Station and (V6/RN) asked why the lights on the panel were blinking C Door, Front Door and Back Door. Saw they were off and (V9/Unit Aide) turned them back on. Around 11:30 pm, (on 6/16/23), (V6) asked where (R1) was, because (R1) was not in (R1's) assigned room. (V6) asked if (V9) and myself could check A Hall and B Hall while (V6) checks C Hall and (R1) was nowhere to be found. It had to be between 10:00 pm and 11:30 pm. (on 6/16/23); V8 (RN) stated, At 12:25 am (on 6/17/23), I went out to smoke and put in the code (door alarm code), and nothing happened. I said man, I can come in and out and alarm is not going off' and he (R1) heard it; V9 (Unit Aide) stated, (V6) was doing rounds and asked where (R1) was at. I told (V6) probably in room [ROOM NUMBER] or room [ROOM NUMBER] and (V6) said she had already checked them, so I said we will double check. Then I said we will check all single male beds, then I checked inside and outside the Facility. I checked for any broken screens but did not find any. (R1) is always trying to find his next escape route; V9 stated that V9 last saw R1 in the hallway between 10:30 pm and 11:30 pm.; a written timeline statement from V6 (RN) stating, on 6/17/23, at 12:30 am, R1 was last seen by V6 sleeping on couch and R1 was seen walking back to room.; on 6/17/23, at 1:00 am, R1 was not in R1's room and V6 notified all staff in Facility to search all rooms, bathrooms and closets, and R1 was not in the Facility. V6 then notified the local Emergency (911), V1 (Administrator) and V2 (DON).; on 6/17/23, at 1:40 am, V1 (Administrator) and V2 (DON) came to the Facility to help search for Resident. On 6/17/23, at 2:03 am, V10 (local Police Department Officer) or V11 (local Police Department Officer) called the Facility for R1's diagnosis, name and date of birth ; on 6/17/23, at 3:00 am, all capable staff called into Facility to help search for Resident and at 4:15 am, R1 was still missing. R1's Police Report, dated 6/17/23 at 12:59 am, documents that the local Police Department was notified that R1 had left the building and was going west bound on Grant Street. On 6/17/23, during the hours of 1:05 am to 1:30 am, all Units checked area. On 6/17/23 at 1:45 am, R1 was entered into the system as a Missing Person and at 1:48 am, the Police Department contacted the local State Police (Illinois State Police) and requested a dog to search for R1. R1's Police Report, documents V10's (Police Officer) Narrative and that V10 was dispatched to the facility on 6/17/23 at 12:59 am. V10 went back to the Facility to talk with employees and was informed that the missing person was R1 who I am familiar with through previous contact of him running away from the Facility. V10 stated that staff was unsure of when R1 escaped the Facility and was last seen around 11:00 pm inside of the building. The staff were unsure how R1 was able to leave the building but did state that the alarm system had been disabled for several hours due to a death in the Facility. V10 stated that R1 had been placed into the system (LEADS) as a missing person and that Patrol Officers have continued to search area parks and high probability areas throughout the shift with negative results. On 6/17/23 at 8:09 am, V11's (Police Officer) Narrative documents that on 6/17/23 at approximately 6:30 am, V11 was dispatched to the possible location (200 block of North [NAME] Street, [NAME], Illinois) in search of R1. R1 was located at a gas station and stated he went for a walk to clear his mind and get some exercise. V11 brought R1 back to the Facility. Google Driving directions shows the distance from 200 N. [NAME] to the nursing home is 1.2 miles driving distance. R1's Nursing Note, dated 6/17/23 at 1:00 am, documents R1 not in his room or the room or the room he likes to sleep in and that staff immediately searched all rooms and (R1) not in Facility. R1's Interdisciplinary Team/IDT Progress Notes, dated 6/19/23 at 9:40 am, document that the IDT team reviewed R1's elopement from the weekend (6/17/23) and that one-on-one observations were immediately put into action and is on-going. R1's Behavior Tracking, dated 6/1/23 through 7/31/23, documents exit seeking behaviors and verbal aggression. The Facility could not provide Behavior Tracking Forms for April 24, 2023, through 5/31/23. R1's Care Plan documents that R1 has very poor memory, both short and long term, frequently exit seeks and wanders stating R1 is looking for various people or places and requires supervision. R1's Care Plan also documents that R1 is a High Elopement Risk and is known to wander and may seek to leave. R1's Care Plan also documents: an intervention on 5/14/23, that one-on-one observations and constant or continuous visual monitoring when R1 is agitated and not easily redirected from exits and wandering; R1 is known to wander and seek to leave the Facility due to diagnoses (Dementia, Psychosis, Hallucinations, Paranoia and Anxiety) and determine plan of care and need for location monitoring device and one-on-one and constant monitoring when R1 is agitated and not easily redirected from exits and wandering; and initiate behavior monitoring program to attempt to identify patterns, precursors and causes of behavior and attempt to understand the meaning of the behavior. R1's Sign Out/Acceptance of Responsibility for Leave of Absence does not document any signatures of R1 leaving the building or returning to the building. R1's Community Survival Skills Assessment, dated 4/25/23 and 8/2/23, documents: that R1 is not sufficiently oriented and coherent; is not able to navigate/negotiate safely on the community streets; does not know the Facility address, location or how to contact the Facility; is not able to refrain from self-harmful and/or socially inappropriate behavior; does not have knowledge of potentially dangerous situations, such as walking alone after dark, straying into alley, accepting rides from strangers or carrying valuable items; is not able to adhere to pass privilege, permission to leave, signing out or respecting time parameters and curfews; and is not able to behave with respect while in the community and there have been no problems/concerns with conduct over the past 30 days. R1's Elopement Evaluation, dated 4/23/23 and 6/15/23, documents: R1 is physically able to the leave the building; verbalized desire or plan to leave without proper supervision; level of agitation requires supervision; medical disorders which may lead to leaving unattended; attempts to leave undetected or without properly signing out; wandering in vicinity of exit doors; and is a high risk of elopement. On 8/18/23, at 9:00 am, the Facility Identified Resident Elopement Binder located at the Nurses Station, included documented Elopement Risk Evaluations for R1, R2, R3, R4, R5, R6, R7 and R8. On 8/18/23 at 2:00 pm, V5 (Maintenance Director) stated, (R1) got out of the building on 6/16/23 through the parking lot Exit Door. The Nurses had turned off the alarm system that night. After that, I added a momentary switch that can no longer shut it completely off, it just has like a 15 second delay. (R1) had gotten out a window right before this incident and I had to go to every exterior window in the entire building and screw the windows so that they can only open four inches. I also had to fix the [NAME] Patio Door because that door sensor needed replaced. Facility Maintenance Work Order, dated 6/19/23, documents that the East Patio door alarm sensor was not working and the wires are broken and the [NAME] Patio door alarm is not working due to wires are broken. Facility Maintenance Work Order, dated 7/5/23, documents a maintenance issue with the knobs on the door alarms and alarm toggles at the Nurses Station. Facility Maintenance Work Order, dated 7/28/23, document that the alarm toggles were replaced at the Nurses Station. On 8/18/23, 8/22/23 and 8/24/23, during the survey hours R1 had a staff member (V4) for one-on-one observations. On 8/18/23 at 9:48 am, R1, was lying in bed. R1 was talkative and moderately confused. R1 stated, I really do not remember why I left that night, but they brought me back here. I do not know how long I was gone. They did not take me to the hospital, they just checked me back in here. On 8/18/23 at 10:05 am, R2 stated, I did leave out of here, right after I came here. My daughters dumped me here about a month ago and I have not seen them since. I left out of the door, but they caught me at the picnic table and told me not to leave again. I did not know anyone here and I did not have any friends, but I am better now. I have not tried to get out since. On 8/18/23 at 9:18 am, R3 stated, There was one was one guy with a beard, named (R1), that got out of here a couple times. On 8/18/23 at 9:15 am, R9 stated, (R1) has gotten out of here more than once. I do not know where he went, but he gets out all of the time. On 8/18/23, at 9:09 am, V4 (Resident Aide) stated, I was hired to do one-on-one observations with (R1) because (R1) got out the door, over a month ago, and they ended up finding him sleeping under a bush at a gas station. From what I understand, the door alarm was off and (R1) got out of the door, so now we have to watch him all the time. We have to leave his door cracked, so I can see (R1), because before he got out the main door, he also climbed out of his bedroom window. On 8/18/23 at 9:50 am, V3 (Registered Nurse) stated, I was (R1's) nurse when (R1) was brought back by the Police that morning of 6/17/23. They found (R1) at a gas station about a mile from here and (R1) was sleeping under a bush. I did a complete body audit upon his return and (R1) did not have any injury. (R1) has gotten out of the building multiple times, now they have hired staff to watch him 24 hours a day, seven days a week. (R1) even got out of his window and was walking down the block, so now all the windows in the Facility only go up for inches because of him. On 8/18/23 at 10:40 am, V2 Director of Nursing (DON) stated, (R1) got out of the building on the night of 6/16/23, and was last seen about 10:30 pm, and the staff noticed (R1) missing on 6/17/23 around 1:00 am. My staff called me right away to tell me that they could not find (R1), and I immediately came to the building. V3 (Registered Nurse) and V8 (Registered Nurse) were working. V8 is no longer employed here now. We asked if there were any open windows, because (R1) had climbed out of a window recently and we had to get the police involved with the incident also. We looked all over the grounds and could not find him. We called the police and they found him sleeping under a bush at a gas station about 1.1 miles from here, right when it was starting to get daylight, then they brought him back here and we assessed him. We did not send (R1) to the hospital. We are not sure how (R1) got out, but the alarm was shut off at the panel or the door could have not been completely latched, and we think (R1) just pushed the door open and got out. We have cameras in the building, but most of them were not working that night and the one that was working did not record, but we have fixed all of them now. We have also fixed the door alarms to a push button, instead of a toggle, after (R1) got out the last time on 6/16/23. We now have hired staff that watch specifically (R1) with one-on-one's. V2 stated, The Elopement Binder at the nurses station has eight Residents that are elopement risks. On 8/22/23 at 9:00 am V2 (DON) stated, It was Care Planned that (R1's) intervention for the 6/15/23 elopement, was that (R1) be put on one-on-one observations, but I do not have any documentation of those one-on-one observations. After the 6/16/23 elopement, that is when we hired staff to specifically watch only (R1). The Immediate Jeopardy was identified to have started on 6/17/23, when R1, exited an unalarmed exit door and was missing from the Facility for hours. V2 (Director of Nursing/DON) was notified of the Immediate Jeopardy on 8/22/23 at 8:44 am. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. During the survey 8/18/23 through 8/24/23 R1 had an assigned staff member for the one-on-one observations. Facility Monitoring Logs, dated 6/17/23 through 8/23/23, were reviewed. 2. All Residents residing in the Facility had Elopement Risk Assessments completed. Residents were documented in the Elopement Risk Binder at the Nurse's Station. 3. The Facility Quality Assurance Team revised Care Plans for each at risk Elopement Resident. 4. Staff were in-serviced on Facility Exit Door Alarms, Elopement Policy and Procedures, Door Panel at Nurse's Station and doors that are inactivated or need repair. 5. Facility Maintenance Director is doing random door checks to ensure they are engaged and will do alarm checks.