**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to timely identify, assess and monitor, and provide treatment to prevent the worsening of pressure ulcers for 1 of 3 residents (R2) reviewed for pressure ulcers in a sample of 3. This failure resulted in R2 developing two unstageable pressure ulcers requiring debridement at the bedside and being started on an antibiotic treatment related to pressure ulcer infection. The Immediate Jeopardy began on 05/12/25 when due to the facility's failure to assess and monitor and provide progressive treatment, R2 developed an opened area to her buttocks which went untreated, worsened to R2 developing two unstageable pressure ulcers requiring bedside debridement and acquiring an infection which required antibiotic treatment. V1, Administrator was notified of the Immediate Jeopardy on 07/11/25 at 1:45 PM. The Immediate Jeopardy was determined to not be removed on 7/17/25, upon review of the implementation of the facility's abatement plan. The surveyor confirmed through observation, interview, and record review, that the facility did not assess all facility's residents' current skin condition and did not revise R2's Care Plan with interventions related to R2's pressure ulcers as per the facility's Abatement Plan. Findings include:On 07/09/25 at 10:50 AM, V7, Licensed Practical Nurse (LPN) did R2's dressing change at this time. R2's old dressing was removed from the left (Lt.) buttock/ischium with a moderate amount of bloody drainage noted to the old bandage. Wound bed was red/granular, and the wound was 5 centimeters (cm) x by 6cm. No odor or signs of infection noted. Old dressing removed from the right (Rt.) buttock/ischium with a moderate amount of drainage noted. The wound measured 14cmx9cm with yellow/tan/eschar covering the wound bed. There was a foul odor noted when the dressing was removed. R2's Face Sheet, print date of 07/11/25, documented R2 was admitted to the facility on [DATE] and has diagnoses of but not limited to chronic kidney disease, stage 4 (severe), dependence on renal dialysis, morbid obesity, hypertension (HTN), Atrial Fibrillation, and Type II Diabetes Mellitus. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 14 out of 15, she independent with most of her activities of daily living (ADLs), and is frequently incontinent of bladder and always continent of bowel. MDS section M-skin dated 04/09/25, documented R2 did not have any pressure areas at this time, a formal assessment instrument/tool should be done, clinical assessment to be done, she is at risk for developing pressure ulcers/injuries, and she should have a pressure reducing device for her chair and her bed. R2's MDS- Ancillary Assessment, dated 04/09/25, documented R2's Braden Scale Assessment score was a 17= Mild Risk (9 or below=severe risk, 10-12=high risk, 13-14=moderate risk, and 15-18=mild risk).R2's MDS- Ancillary Assessment, dated 07/02/25, documented R2's Braden Scale Assessment score was 17.R2's last Braden Scale Assessment prior to the two above was completed on 06/05/23 with a score of 19.R2's Care Plan, admission date of 05/15/23, documented Potential for skin breakdown related to (r/t) incontinence, history (Hx) weeping lower extremities (L/E's), ace wraps for edema, morbid obesity, overactive bladder (OAB), Lt. Buttock stage 3, Rt. Buttock stage: unstageable (U). (An unstageable wound, specifically referring to a pressure ulcer, means the depth of tissue damage cannot be determined because the wound bed is obscured by slough (yellow, tan, tray, green, or brown) or eschar (tan, brown, or black). These are full-thickness injuries, but the extent of the damage below the surface cannot be seen.) Goal: R2 will develop no skin breakdown thru next review. Interventions include but are not limited to reposition self every two hours and as needed (PRN), monitor for redness or discoloration, and weekly skin checks.R2's Physician's Orders, dated 04/28/25 at 4:15 PM, documented skin check 6P-6A with showers on Monday, Wednesday & Friday. No redness, open areas, or excoriation at (@) present skin integrity = within normal limits (WNL) skin impairment = abnormal (ABN) every night shift every Mon, Wed, Fri for skin management.R2's Treatment Administration Record (TAR) for the month of May 2025 regarding weekly skin checks documented on 05/12/25 ABN. R2's Progress notes were reviewed for 05/12/25 and there was no documentation regarding R2's abnormal skin assessment. R2's Shower Sheet, dated 05/12/25, documented by V10, Certified Nursing Assistant (CNA) found a small open area to the back of R2's left thigh. V6, Licensed Practical Nurse (LPN) signed off on the shower sheet. R2's Electronic Medical Record (EMR) was reviewed and there was no documentation on 5/12/25 noting if the nurse was notified of R2's opened area, the physician was notified of the new skin condition, no measurements or wound description, and no wound assessment or evaluation done. R2's TAR dated 05/26/25, documented R2's skin check for this day was WNL.R2's Shower Sheet, dated 05/26/25, documented V10, CNA noted redness and bleeding to R2's Rt. and Lt. back thigh area. V12, LPN signed off on the shower sheet.R2's EMR was reviewed and there was no documentation regarding the nurse being notified of the open areas to R2's bilateral thighs, the physician being notified, no wound measurements or wound description, and no wound assessment or evaluation done.On 05/28/25 R2's two shower sheets above were signed off by V5, Former Wound Nurse.R2's Progress Notes, dated 5/28/2025 at 2:35 PM, documented Skin/Wound Note, Note Text: while this writer was reviewing shower sheets, redness and bleeding was noted, this writer went to residents' room and talked with resident. Resident stated some discomfort to right and left under folds of coccyx, open areas noted to both right and left under folds of coccyx, contacted MD (Medical Director), MD gave order to apply cal (calcium) alg (alginate) cover with dry dressing. ETAR (electronic treatment administration record) updated at this time.R2's Physician's Orders, dated 05/28/25, documented Left under fold of coccyx and Right under fold of coccyx- Cleanse area with NS (Normal Saline) or WC (Wound Cleanser) apply Cal Alg cover with dry dressing until healed every night shift for wound and as needed (PRN).R2's TAR/weekly skin checks, for the month of June 2025 was reviewed and documented on 06/02/25, ABN skin check. There was no documentation in R2's EMR regarding the abnormal skin check. On 06/20/25, R2's TAR/weekly skin check had open written in the space provided and there was no documentation in R2's EMR regarding any skin issues. On 06/23/25, R2's TAR/weekly skin check documented the letter o in the space provided. There was no progress notes noted regarding any skin issues. R2's TAR/weekly skin check for the date of 06/30/25, documented ABN and there were no progress notes regarding any abnormal skin findings. On 07/16/25 at 12:07 PM, V6, Infection Control Preventionist (ICP)/Wound Nurse stated if there is an abnormal finding on the weekly skin check there should be a progress note attached to it explaining why it is abnormal. R2's Progress Notes, dated 06/25/25 at 10:32 AM, documented MD gave order for resident to be evaluated by wound management.On 07/07/25 at 3:15 PM, This surveyor gave V1, Administrator a list of things that would be needed the next day. The wound care log for the past three months was one of the documents requested.On 07/08/25 at 8:35 AM, V2, Director of Nursing (DON) brought in wound care log for May and July 2025. She said the June log was jammed in the printer, and she would bring it as soon as she got it printed out.Wound care log dated 05/29/25, documented R2's wound measurements to her left buttock was 2x1x0.1 and was a stage 2. Right buttock measurements were 2.2x1.4x0.1 and was a stage 2. There was no wound care log for the month of June 2025 provided to this surveyor.R2's Physician's Orders, dated 07/01/25 at 11:19 AM, documented to contact wound management for evaluation and treatment.R2's Wound Assessment Report completed by V8, Wound Nurse Practitioner (NP), dated 07/01/25, documented R2's wound to her left buttock measured 8.0 centimeters (cm) x 4.0cm x 0.2cm and was a stage three pressure ulcer. R2's wound to her right buttock measured 14cm x 13cm and was unstageable. It also documented R2's wound to her right buttock had heavy purulent exudate (drainage that is thick, opaque, and tan, yellow, green, or brown in color is purulent. This is never a normal occurrence in the wound bed and is often associated with infection or high bacteria levels). Wound Care Education Institute. R2's Weekly Wound Assessment, dated 07/01/25, in R2's EMR documented onset date of 05/28/25, Lt. Buttock measurements 8.0x4.0x2.0 and the wound was unstageable. The Rt. buttock measurements for the wound were 14x13xUTD and the wound was unstageable. R2's Physician's Orders, dated 07/01/25, documented Left lower buttock/ischium and Right lower buttock/ischium- Cleanse area with NS or WC apply Silver Alginate, cover with silicone dressing. Change daily and PRN every night shift for wound.Wound care log dated 07/02/25, documented R2's wound measurements to her left buttock was 8x4x0.2 stage 2 and her right buttock measurements were 14x13x Unable to determine (UTD).R2's Weekly Wound Assessment, dated 07/08/25, documented R2's wounds were measuring Lt. Buttock: 8x5x0.2 and it was unstageable and the Right buttock: 14x13xUTD and was unstageable.R2's EMR was reviewed and there were no other weekly wound assessments done on the wounds to R2's Rt. and Lt. buttocks for the months of May 2025 and June 2025.R2's Progress Notes, dated 07/08/25 at 8:41 AM, documented R2 was seen by wound specialist (V8). R buttock has improved and measures 14x13xUTD. L buttock has declined and measures 8x5x0.2. Both wounds were debrided with a scalpel and forceps by V8. Awaiting final culture report on wounds.R2's wound culture that was collected on 07/02/25 documented R2 has Pseudomonas Aeruginosa in her wound. (This infection is a condition that can affect your skin, blood, lungs, GI tract and other parts of your body. Pseudomonas Aeruginosa bacteria are common in the environment, especially water, soil and produce. Symptoms vary according to where the infection is in your body. Treatment usually includes at least one type of antibiotic. A Pseudomonas Aeruginosa infection can be challenging to get rid of. It's rare for a Pseudomonas Aeruginosa infection to develop in people with a healthy immune system. But it can be serious and potentially deadly if you have a weakened immune system (immunocompromised). Common causes of weakened immune system include diabetes and kidney disease. Cleveland Clinic 2025).R2's Physician's Orders, dated 07/08/25 at 11:28 AM, documented Cipro Oral Tablet 250 milligrams (MG) (Ciprofloxacin HCl) Give 250mg by mouth two times a day for seven days for Skin management; Wound until 07/15/25.On 07/08/25 at 2:35 PM, V7, LPN said skin assessments are usually done on the resident's shower days. She said the CNA will fill out the shower sheet and then the nurse will sign off on it. V7 said if she had someone with a new skin issue, she would contact the doctor and get an order for it until they can be seen by the wound nurse. She said if it an excoriation issue she will check her medication administration record (MAR) and see if they have some kind of cream ordered or if they have an anti-fungal powder ordered before contacting the doctor. She said if it was for an open wound, she would go down and assess the wound, do the initial measurements, call the doctor to get an order put into place, and then she would give it over to the wound nurse. She said the wound nurse would be the one to do all the measuring of the wounds after that and is also the one who makes rounds with wound Nurse Practitioner (NP). On 07/09/25 at 9:00 PM, V13, LPN said the last time she seen R2's wound was a long time ago. She said she usually works the other hallways, and it just so happened they put her down there that day. She thinks it was when the wounds first started but she can't remember. She said the wound on the left was smaller and the one on the right was much bigger and looked like a bruise, maybe there was an underlying wound or something but there was no open area and had no depth. She said she hasn't worked over there since and hasn't seen the wounds recently.On 07/09/25 at 9:10 PM, V10, CNA said she assisted R2 with her shower (05/12/25) and was drying her off when she noticed the towel had blood on it, so she looked and R2 had a small open area to her left buttock/thigh area. She said she always fills out the shower sheet and hands it to the nurse so she can review it. If there are any new skin issues, she lets the nurse know so they can go down and assess it and inform the wound nurse of any new wounds and that is what she did. V10 said she isn't sure if the nurse that night went down and assessed R2's wound or not. On 05/26/25 She said when she was drying off R2 and seen the blood on the towel she thought maybe the other side had opened. She said it was hard to remember because it was a while back. She said she would have done the same thing as she did for the other wound, she found on R2. V10 said she hasn't seen R2's wounds recently but she assisted R2 with her shower the day before yesterday (07/07/25) and the wounds had bandages on them, so she didn't get to see them.On 07/10/25 at 9:00 AM, V5, Former Wound Nurse said when there is a new skin issue found the CNAs are to document it on the shower sheets, the floor nurse is to assess the wound, notify the physician, get an order for a treatment, and write it on the shower sheet. She said because of the floor nurses and agency nurses it's not being done. V5 said with R2 she was reviewing the shower sheets and seen R2's. She said she called the doctor and got an order put into place. V5 said she can't check the shower sheets every day. She said they could go weeks or however long without being checked. V5 said she was having to do her job and the floor nurses' job, and she just couldn't do it all. V5 said she informed V1, Administrator and V2, Director of Nursing (DON) and they didn't pay any attention to her, and nothing was done. V5 said she was sure things would have been different if there had been a treatment order done for R2 when it was first seen.On 07/08/25 at 12:16 PM, V8, Wound Nurse Practitioner (NP) said it depends on the facility's policy on how often skin assessments are to be done. She said they usually do them on the resident's shower days. V8 said they should be doing weekly assessments on everyone and on the residents who have wounds they should be doing a weekly wound report regardless of if they receive her services or not.On 07/10/25 at 8:55 AM, V8, NP/Wounds said she wasn't aware R2's wounds started on 05/12/25. She said R2's condition could have been different if they had a treatment put into place at that time. She said she would have had a better chance of healing and a better prognosis than now. V8 said R2 also has more of a chance of getting an infection. V8 said from 05/12/25 to 05/26/25 the wound had plenty of time to get worse.On 07/17/25 at 12:33 PM, V2, Director of Nursing, DON stated the CNAs are to do head to toe skin assessments twice a week with the resident's shower. If they find a new area or worsening area they are to report it to the nurse immediately. The nurses are to do assessments whenever they do a treatment, and the other skin checks come from the CNAs. V2 said if the CNA were to find a new area, she would expect the nurse to go down and look at it then contact the doctor or the wound nurse for further treatment.The facility's policy and procedure Prevention of Pressure Ulcers, not dated, documented Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. It further documented General Guidelines: 2. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. 3. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. It also documented 5. Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. It further documented Interventions and Preventive Measures: General 9. Routinely assess and document the condition of the resident's skin per Weekly Skin Integrity form for any signs and symptoms of irritation or breakdown. 10. Report any signs of a developing pressure ulcer to the physician. 11. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. It also documented Additional Factors that Indicate Residents at Risk: The following are additional clinical conditions, treatments, and abnormal lab values that indicate that a resident is at risk for pressure ulcers: 1. Impaired/decreased mobility and decreased functional ability; 2. Co-morbid conditions, such as end stage renal disease, terminal cancer or diabetes mellitus.The facility's policy and procedure Resident Examination and Assessment, with a revised date of 02/2014, documented Purpose: The purpose of the procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. It further documented Physical Exam 8. Skin: a. intactness; b. moisture; c. color; d. texture; and e. presence of bruises, pressure sores, redness, edema, rashes. It also documented Documentation The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All assessment data obtained during the procedure. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. It also documented Reporting 2. Notify the physician of any abnormalities such as, but not limited to e. wounds or rashes on the resident's skin; and f. worsening pain, as reported by the resident. 3. Report other information in accordance with facility policy and professional standards of practice.The facility's policy and procedure Pressure Ulcers/Skin Breakdown- Clinical Protocol, revised date of March 2014, documented Assessment and Recognition 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue.The facility's policy Pressure Ulcer Risk Assessment, revised date of September 2013, documented Purpose The purpose of the procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Review current Braden Scale or facility risk assessment tool. It further documented General Guidelines 4. If pressure ulcers are not treated when discovered, they have the potential to become larger, painful and infected. It also documented 6. Once a pressure ulcer develops, it can be extremely difficult to heal. It further says 9. Pressure ulcers are a serious skin condition for the resident. 10. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation of breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. Assessment 1. Risk Assessment. A pressure ulcer risk assessment will be completed upon admission, quarterly, annually and with significant changes. 2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will perform routine skin inspections (with daily care). b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessments at least weekly to identify changes. It further documented Identifying Residents at Risk 4. Diagnoses and Conditions that increase risk for pressure ulcers: f. Chronic or end stage renal, liver, or heart disease, g. Diabetes. It also documented Documentation The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment conducted (for example, admission Assessment, Weekly Skin Integrity tool.) 2. The date and time and type of skin care provided, if appropriate. 3. The name and title (or initials) of the individual who conducted the assessment. 4. Any changes in the resident's skin (i.e., the size and location of any red or tender areas), if identified. It also documented 12. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted. 13. Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care if indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision/monitoring to prevent an elopement for 1 of 11 residents (R2) reviewed for supervision to prevent elopement in the sample of 11. This failure resulted in Immediate Jeopardy on 10/15/2024 with R2, eloping from the facility sometime between 3:00 PM to 4:00 PM. R2 was found by a passerby at approximately 4:30 PM, was assessed at the local hospital and returned to the facility. The Immediate Jeopardy began on 10/15/2024, when R2 eloped from the facility. On 10/22/2024 at 2:18 PM V1, Administrator and V30, Medical Records Director were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 10/29/24, but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R2's admission Assessment, dated 10/4/2024 at 9:45 AM, documents R2 was admitted from home. She was assessed to have clear speech and was orientated to person only, confused and agitated. Elopement Risk Assessment documents supervision with walk in room and locomotion on and off unit, decisions regarding tasks of daily life: moderately impaired. Behaviors: anger facility placement and verbalizing statements about leaving. Resident experienced new admission. Contributing diagnoses: Alzheimer's disease, dementia other than Alzheimer's disease, dementia other than Alzheimer's disease. Resident assessed as an elopement risk. R2's Late Entry Nurse Progress Note, dated 10/4/2024 at 10:31 AM, documents (R2) was admitted on [DATE] at 9:45 AM . from home. (R2) is unaware that family wants this to be a long-term placement as she is unsafe at home due to her progressing dementia. (R2) is confused and thinks she is at the hospital and will go home as soon as the doctor evaluates her. Resident is alert to self. R2's Nurse Progress Note, dated 10/5/2024 at 2:40 PM, documents (R2) has been anxious this day, pacing the hallway and voicing that she does not understand why she is here, she fears her family may be sick and why did they leave her here. She asks for mom and dad. Resident's POA (Power of Attorney) came to visit resident and resident became very upset and crying. R2's Nurse Progress Note, dated 10/7/2024 at 12:29 AM, documents 1 milligram (mg) Ativan administered for increased anxiety. R2's Nurse Progress Note, dated 10/7/2024 at 2:21 PM documents (V6), Medical Director documents (R2's) primary diagnosis is Alzheimer's disease. Currently she is generally awake, alert and pleasant, however she is adamant about going home, she cannot understand why she is here at the facility. (R2) is becoming increasingly forgetful and in addition she has had a problem with anger outburst and very hostile behaviors which previously were out of character for her. R2's Skilled Nursing admission Documentation, dated 10/8/2024, documents alert to person only and confused. (R2) was assessed independent with bed mobility, transfers, eating and toilet use. A note documents: resident alert to self, able to make needs known. Resident anxious this morning, carrying her purse saying she needs to leave, becoming agitated. PRN (As Needed) Ativan administered and effective. Ambulates independently, with steady gait. R2's Nurse Progress Note, dated 10/10/2024 at 2:03 PM, documents (R2) continues to seek exit today and asking for (V12) and husband able to redirect at this time. R2's Nurse Progress Note, dated 10/11/2024 at 1:01 AM, documents (R2) had an episode prior to HS (bedtime) that was long lasting where she was exit seeking and yelling out for her daughter, staff unable to redirect easily and PRN Ativan was given. She calmed after about an hour and the PRN dose was effective. Closely monitored by memory care staff. R2's admission Minimum Data Set (MDS) dated [DATE], documents resident understood and understands. Brief Interview for Mental Status (BIMS) score of 5 (severely cognitively impaired.) Physical, verbal, and other behavioral symptoms (hitting or scratching self, pacing, rummaging or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days. Rejection of care occurred 1 to 3 days. Change in behavior or other symptoms were worse. No mobility devices. R2's Nurse Progress Note, dated 10/14/2024 at 2:00 PM, documents completed the admission MDS and assessment with (R2). (R2) is confused as to time, place and situation. (R2) was able to answer the MDS questions without issues. The questions about her history were a little more confusing for her. She is new to the facility and is on the unit. She packs her belongings every day and waits for (V12) to pick her up. (R2) was able to talk about her past and growing up. We will continue to try to get her involved in activities. R2's Nurse Progress Notes, dated 10/15/2024 at 6:40 PM, documents (R2) returned to facility via EMS via stretcher. (R2) alert and oriented to self. Speech clear. No injuries observed from previous incident. (V8), Medical Director notified of (R2's) return. R2's admission Assessment, dated 10/15/2024 at 6:40 PM documents elopement risk assessment walk in room supervision on and off unit, moderately impaired decisions regarding tasks of daily life, behaviors include: prior exit seeking, packing belongings, repeatedly opening doors/settings off alarms of secured doors, resisting redirection from staff and verbalizing statements about leaving. Contributing diagnoses include Alzheimer's disease, depression and anxiety disorder. Interventions documented include ID bracelet on, clothing marked with identification and frequent checks. R2's Nurse Progress note, dated 10/15/2024 9:42 PM, documents frequent checks on resident. V7, CNA Written Statement, dated 10/15/2024 at 5:15 PM, documents I was on the hall working and was last in contact with (R2) around 4:00 PM. She asked about going home and I instructed her we would have dinner in about 30 minutes if she could wait. I then checked on another resident and then moved onto another resident and escorted her to the bathroom where I then began to change her. I was notified of (R2) being gone around 4:45 PM. V4, LPN Written Statement, dated 10/15/2024 at 5:44 PM, documents this nurse had just finished med pass on a (different hall than R2 resided) hall, med cart parked at nurse's station when phone rang. (V9), Unit Aide answered phone at 5:40 PM. (V9) informed this nurse that police were on the phone and (R2) was in their custody, they had found her in a field and (V9) transferred the call to Administrator's office. This nurse immediately went to Administrator's and DON's offices to notify them. This nurse then went to (the hall R2's room was located) hall, head count performed. All residents accounted for except (R2). V9, Unit Aide Written Statement, dated 10/15/2024 at 6:00 PM, documents I, (V9) was passing supper when the phone rang at 4:50 PM. I answered the call from the local police department who stated they found one of our residents in a field. I made the resident's nurse aware the Administrator the police were on the phone. R2's Care Plan, updated 10/16/2024 documents focus: the resident is at risk for elopement posing a safety concern. Goal: the resident will not leave the facility without a responsible person accompanying them. Interventions: develop a plan for immediate action if elopement occurs. Educate the family and engage resident in activities such as folding washcloths/towels, washing tables in dining room to give a sense of purpose. Have photo and description readily available. Implement continuous monitoring and whereabout tracking preform elopement risk assessment on admission and quarterly secure exits, windows and potential escape routes changing codes to locked unit train staff of elopement prevention and immediate response. V1, Administrator typed statement dated 10/16/2024, documents this writer was informed around 4:30 PM on 10/15/2024 from the local Sherriff's Office that someone had called the sheriff's department about a person that was observed at the corner South Grand and [NAME] Street. Resident had been sent to local hospital Resident did return from hospital at 6:40 PM. Hospital stated no injuries. This writer also spoke with (V12) to keep her updated and told her (R2) had returned from hospital. Prior to (R2's) returning to the facility, facility provided POA information at 5:07 PM on the 15th. This writer informed the Medical Director of incident that same day. Investigation continues. 10/16/2024 left message for IDPH (Illinois Department of Public Health) to return my call. Informed my receptionist of this. On 10/15/2024 Administrator had maintenance screw all the windows on (hall R2 resides on) hall to only open 2-3 inches. There was a window left open in a vacant room. On 10/16/2024, DON and Administrator surveyed the area where (R2) was observed at. Maintenance and Administrator also surveyed the grounds of the facility with no real findings. Spoke to (V14) at 11:00 AM on 10/16/2024, Assistant Director of Nurses at hospital to thank her and the hospital for the assistance with (R2). On 10/17/2024 at 9:00 AM, R2's door was closed. Upon opening R2's bedroom door she was observed sitting on her bed with a black purse next to her. R2 told the State surveyor she wanted to go home, and she doesn't belong here, and she didn't know where her family was. R2 didn't recall being outside or at a hospital within the last few days and she was alert to name only at that time. No identification bracelet on. On 10/17/2024 at 11:20 AM, V3 Social Service Coordinator stated that (R2) was initially admitted on [DATE], (R2) was very confused and thought this was a doctor's office and as soon as she was seen by the doctor she could go home. (R2) is severely cognitively impaired and wanders up and down the memory locked unit hall from one door to the other and constantly tries to get out of the locked unit. V3 didn't see or assess (R2) on 10/15/2024 and wasn't told (R2) was exhibiting behaviors on that day. Upon admission, (R2's) family told her (R2) is no longer safe to be at home because her husband is frail with a heart condition and can't take care of (R2) anymore and she was afraid (R2) would leave the house unsupervised and would get harmed in some way. (R2's) family voiced they were afraid she would get out of the facility and get harmed in some way. On 10/17/2024 at 12:20 PM, V4, LPN (Licensed Practical Nurse) stated she worked on 10/15/2024 and was assigned to (R2) from 6:00 AM to 6:30 PM. V4 states she works with 1 CNA (Certified Nurse Aide) on the memory care locked unit and she is also assigned to other residents on three additional halls so although she is the assigned nurse to the locked unit, she is not back on the locked unit at all times when she is off the unit administering medications to other residents there is 1 CNA assigned to the unit for 11 residents who are very active and multiple residents are ambulatory and have behaviors and it is hard for her and the CNA to keep track of the residents let alone her being off the unit and leaving 11 residents with 1 CNA. Staffing has been like that for the year she has worked at the facility and even though she doesn't agree with it, it's how her schedule is set for the day to be assigned to multiple halls. V4 recalled she administered morning medication to (R2), and she took it, but she didn't recall seeing (R2) after that. V4 left the locked unit between 3:25 PM - 3:30 PM to pass evening medications on other halls and didn't recall seeing the resident at that time. V4 found out the resident was not at the facility at approximately 4:50 PM on 10/15/2024 because she was on a hall passing evening medications and overheard (V9) talking to the police on the phone and when (V9) transferred the call to (V1), (V9) told her that (R2) was in police custody, and she was found walking in a field. When she found out (R2) eloped she went to the locked unit she went and did a head count she noted the window (in R2's room) was wide open and a recliner was propped up against the window as well. All residents were accounted for at that time except for (R2). V4 didn't know how (R2) got out of the facility or if (R2) went out the window. V4 stated she never observed (R2) playing with the windows on the locked unit or anything like that. On 10/17/2024 at 1:30 PM, V7, CNA stated he worked on 10/15/2024 from 6:00 AM to 6:30 PM and was assigned to (R2) on the locked unit. V7 was the only CNA assigned to the locked unit with (V4), LPN and when (V4) had to administer medications to residents on other hall V7 was the only employee assigned to the locked unit. V7 stated he was getting residents ready for supper and that consists of toileting residents and washing their hands. V7 assisted (R2) to the bathroom and the last time V7 saw (R2) was at 3:00 PM. V7 stated he didn't know (R2) was not at the facility until (V4), LPN came and told him to do a head count of residents because the police called and reported (R2) was found walking in a field and was in police custody. V7 assisted with the head count and (V4) showed him a window in room [ROOM NUMBER] was wide open and a recliner was propped up against the window. V7 stated there are 4 or 5 residents that are exit seekers and several are transferred via sit to stand lifts, so they need 1:1 care he has to stay there with them. V7 stated he didn't hear any door alarms while he was caring for the residents in the bathroom. While he provides 1:1 care he tries to make sure all residents are safe prior to going into the bathroom but he's only 1 person and can't leave a resident on the toilet alone so he does the best he can. No other staff are there to keep an eye on the residents when he is providing 1:1 care to a resident. V7 stated he was familiar with (R2) and her wanting to always go home but she was calmer the day of 10/15/2024, she still voiced she wanted to go home but she wasn't hanging out at the exit door like she has in the past. V7 stated (R2) is alert to name only and she is extremely confused at all times. When she exit seeks and says she wants to go home V7 tells her let's eat the next meal and go from there to redirect her. V7 recalled what (R2) wore on 10/15/2024, it was pants with a t-shirt with a sweater over the t-shirt and house shoes. On 10/17/2024 at 11:40 AM, V10, Activities/Unit Aide stated she worked on the locked unit on 10/15/2024 and left at 3:00 PM and (R2) was on the unit at that time because she recalled saying bye to her. V10 was familiar with (R2) and stated (R2) always says she's going home and she's always packing her bag. V10 stated (R2) looks out the windows often but she never saw her playing or attempting to open a window. On 10/17/2024 at 11:05 AM, V2, DON stated that (R2) was admitted on [DATE] and ever since then she has wanted to go home every minute of every day. V2 knew (R2) wanted to go home prior to her eloping from the facility. (R2) was initially admitted to the facility on the memory care locked unit due to her diagnoses of dementia and early onset Alzheimer's disease. V2 stated (R2's) family was concerned (R2) would leave the facility without anyone knowing and get harmed in some way. Prior to (R2) eloping the facility she expected staff to encourage (R2) in social activities on the unit, assist with activities and monitor for worsening behaviors. After (R2) returned from the elopement she expected staff to reassess her elopement risk to see if it changed and she wasn't aware staff didn't document a reassessment of (R2's) elopement risk. Interventions that were added to (R2's) care plan after she returned to the facility included in-servicing staff on how to prevent future elopements, educate family, involve the resident in folding wash cloths and towels, 15-minute checks for 72 hours and increase monitoring of resident as needed. Staff working on the memory care locked until on 10/15/2024 reported seeing (R2) last at 4:00 PM that day. She was aware after the police called the facility at approximately 4:40 PM that the resident was found walking in a field behind the hospital, she didn't know how the resident got out of the facility. After she was aware (R2) eloped she had the memory care locked unit do a head count to ensure all other residents were there and the nurse noted a window (in R2's room) was wide open and there was a recliner pushed against the windowsill. On 10/17/2024 at 1:10 PM, V2 stated an elopement risk assessment should be completed after a resident elopes to see if the elopement risk has changed. There is no initial care plan done upon a resident's admission and a MDS is done at days 4 and 14 then a care plan is documented at day 21 after a resident is admitted . The memory care unit is a locked unit for confused residents and there is 1 nurse and 1 CNA assigned to the unit. The nurse is also assigned to other halls as well so she's not always on the unit, but the assigned CNA is always on the unit. There are 11 residents that reside on the locked unit with 4 of the 11 residents are ambulatory and V2 didn't know how many residents exit seek or set door alarms off. (R2) was readmitted the same day she eloped which was 10/15/2024. (V2) was not at the facility when (R2) was readmitted to the facility via EMS but she knew (R2) didn't sustain any injuries. On 10/16/2024 at 1:30 PM, V5, Maintenance Man stated he just started working as the maintenance man at the facility, before that he worked in the kitchen. V5 was aware a resident was found in a field a few days ago but didn't know how she got out of the facility. The Administrator asked him to screw all the windows shut so they only open approximately 2 inches one day after (R2) was readmitted to the facility. On 10/17/2024 at 10:50 AM, V1, Administrator stated she was here at the facility on 10/15/2024 from approximately 8:00 AM to 6:30 PM. She was not aware (R2) was missing from the facility until the police called the facility at approximately 4:30 PM on 10/15/2024 and they stated the resident was found walking in a field near the local hospital. V1 stated doesn't know how (R2) got out of the facility or what time she left the facility. (R2) was seen by a staff member at 3:00 PM on 10/15/2024 and that was the last time staff saw here before she eloped. After V1 was notified that the resident was not at the facility staff did a head count on the memory until and during that it was noted a window in (R2's room) was found wide open with a recliner pushed up again the heat register. V1 and other staff don't know if (R2) went out the window to get out of the facility but since then they have screwed the windows shut on the memory unit so the windows only open 2 inches so residents cannot go out the window. (R2) was transported via EMS to the hospital and then back to the facility at approximately 6:30 PM on 10/15/2024 with no injuries. (R2's) has a low BIMS score and has diagnosis of dementia and early onset Alzheimer's disease. V1 stated R2 was found wandering in a field 0.6 mile from the facility. Review of the streets surrounding the facility showed there were multiple cars driving by a curvy busy country road with no sidewalks and deep ditches on both sides of the road. There was also a pond within 150 feet of where the resident was found. (R2) was initially admitted to the facility on [DATE] and since then she's stated she wants to go home and that's why she's on the memory locked unit because she doesn't have safety awareness and to be kept safe. When (R2) states she wants to go home she expects staff to redirect her. Since she returned to the facility staff have (R2) on 15-minute checks for 72 hours and all residents every 2 hours for 72 hours. On 10/18/2024 at 8:46 AM, R2 was observed sitting on her bed dressed with house shoes on. She was packing her clothes into a plastic hospital bag and stating to call her family because she needs to go home today. No identification bracelet on. On 10/18/2024 at 9:00 AM, R2 was observed sitting on her bed her house shoes were under the bed and she now had tennis shoes on. R2 again stated tell them I am going home today and to call her family. No identification bracelet on. On 10/18/2024 at 10:48 AM, V8, Police Officer who responded to the 911 call stated no report was made for this incident because he saw it as a medical situation. 3 police officers responded to an elderly woman (R2) walking in a bean field behind the local hospital on [DATE] at 4:31 PM. The resident stated her last name and police dispatch called the local nursing home and they stated the resident resided at the facility and they didn't know she was missing. The resident was pleasantly confused at that time and had notable dementia. V8 couldn't recall what (R2) was wearing or if she had shoes on or not. (R2) was transferred to the local hospital via EMS at that time. No police report was documented because this was considered a medical transport issue. On 10/18/2024 at 9:05 AM, V6, Medical Director stated that (R2) is alert to person only and has poor safety insight. (R2) has diagnoses including dementia and early onset Alzheimer's disease. (R2) is not safe to be outside by herself due to poor safety awareness due to being confused and has anxiety often. V6 stated (R2) never wanted to be at the facility and her family told her once the doctor sees her, she can go home, and she continues to say she wants to go home. V6 didn't know how (R2) eloped from the facility but thinks she followed a family out the locked door and went out the main door of the facility. V6 wasn't aware there was a window left wide open in room [ROOM NUMBER] on the locked unit after the resident eloped. On 10/25/2024 at 2:00 PM, V1, Administrator stated (R2) now has a Electronic wandering bracelet on her ankle. V1 stated the facility had the electronic wandering system in place when (R2) was initially admitted to the facility but no one put the Wander Guard bracelet on her. V1 expected staff to assess all new residents for elopement risk and if they are determined to be an elopement then an electronic monitoring bracelet should be applied within hours of the resident being admitted to the facility. The memory care locked unit doors are not equipped for the electronic system, but all other exit doors to the facility are protected so if (R2) had the electronic wandering bracelet on, the alarm would have sounded. The Facility's Undated and Untimed Final Investigation documents (V2) was notified on 10/15/2024 at or around 4:30 PM that the local Sheriff's Office had responded to a call regarding an individual in the area of South Grand and [NAME] Street In Nashville, Illinois. This individual was identified as (R2) a memory care resident of the facility. Sheriff's Deputies transported (R2) to the local hospital per department policy, Facility investigation began Immediately and (State Survey Agency) and the facility Medical Director were notified. Facility shared pertinent medical Information regarding the resident with local hospital, including the power of attorney Information on file at the facility, at or around 5:07 PM on 10/15/2024. The resident's family was immediately notified of the elopement and was notified again when (R2) returned to the facility at 6:40 PM on 10/15/2024. The results of the investigation are as follows: (R2) was observed by staff safe and secure in her assigned room on the locked memory care unit of the facility at 4:00 PM on 10/15/2024. Following the notification by the Sheriff's Department of the discovery of the resident at 4:30 PM, the facility conducted a search of the memory care unit and discovered a window ajar in an unoccupied resident room on the unit. While a conclusive determination cannot be made with the evidence at hand, It Is suspected that (R2) exited the facility by 1 of the 2 methods: 1. Following the check on (R2) 4:00 PM she may have at some point entered the unoccupied room on the locked memory care unit and was able to open a window and exit the facility. 2. (R2) followed a visitor through the unit's secured door, with the visitor not being aware that she was a resident. She was then able to exit the facility. A search of the facility grounds and the area that the resident was found revealed no additional findings. (R2) sustained no injuries as a result of the elopement. Facility staff have been reeducated on elopement policies and procedures. The door codes to enter the locked memory care unit of the facility have been changed and distributed to staff. A new notification system has been Implemented for families to utilize to gain entry to the locked memory care unit with posted Instructions at the entrance. The facility maintenance department as inspected all windows along the locked memory care unity of the facility as has modified their operation to only allow for the window to open 2-3 Inches, per life safety codes. (R2's) care plan was updated to reflect her current status and to include the use of a Wanderguard device which was Implemented Immediately. Beginning on 10/15/2024 all memory care residents were put on 15-minute checks to continue for a period of 72 hours. Upon the expiration of the 72 hours, (R2) wlll continue to be on 15-mlnute checks while other residents will be on 2 hour checks for a continued period of-14 days and then QA Team will review. All residents of the memory care unit were reevaluated for elopement risk and statuses were updated accordingly. Elopement policies and procedures, and this incident in particular will be included in the next QA meeting to be held on 10/20/2024. R2's Hospital Emergency Department documentation dated 10/15/2024, documents chief complaint: patient presents with altered mental status. [AGE] year-old female patient resident of local nursing home for the past 5 days only with a past medical history of dementia, high blood pressure, high cholesterol and anxiety who was found wandering in a field in heavy clothing with house shoes and socks, carrying one shoe in her hand. Patient was found by a passerby who noted that patient was confused so 911 was called. Police found out that patient was a resident of local nursing home and patient was not able to say where she lived. EMS transported to ER for evaluation. We called nursing home to request paperwork and information about contacting family. We called (V12) for more information and found out that patient was just placed into the nursing home on Friday, and she had been trying/wanting to leave ever since. Previously patient was at home being cared for by her [AGE] year-old frail husband. (V12) not able to come to ER because she was taking the patient's husband to the ER for another health matter. Physical exam: awake, alert, confused, asking about parents and her missing daughter. Neurological: mental status: she is alert. Mental status is at baseline. She is disoriented and confused. Psychiatric: perception is normal, she is inattentive. Thought content is delusional. Cognition and memory is impaired. She exhibits impaired recent memory and judgement is impulsive and inappropriate. Medical Decision Making: [AGE] year-old patient with dementia found wandering in a field several blocks from nursing home where she is a new resident in the locked dementia unit. Patient found walking by a passerby and when patient was confused, they called 911. Patient checked over with no physical abnormality noted. Patient ambulatory with steady gait and had no complaints of pain, nausea, dysuria, fever or any other complaints. Patient was disoriented which (V12) confirms is her baseline. Problems addressed: confusion: chronic illness and dementia. Risk details: called patient's (V12) to discuss findings and the decision to discharge. (V12) unable to come get patient because she is with patient's husband in another ER right now. Decision made to use EMS for transport due to high elopement risk via other means as evidenced by her escape from locked unit in the nursing home and her baseline severe dementia confusion. The facility's Elopement Prevention Policy, dated 1/1/2024, documents the facility will implement individualized interventions to strive to prevent elopement. We define elopement as follows: a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary. Procedure: upon admission, quarterly, and after an elopement event or attempt, and with a change in condition, each resident will undergo a comprehensive elopement risk assessment using a validated tool. Assessment results will be documented in the resident's medical record and used to develop an individualized care plan for residents identified to be at risk for elopement. The interdisciplinary Team (IDT) will work with the resident and/or family to identify and implement appropriate individualized elopement prevention interventions based on assessment findings to reduce the risk of elopement while maximizing dignity and independence. Interventions may include but are not limited to electronic monitoring/alarm system, environmental modifications, protected list of names and photographs of those at risk for elopement, psychosocial interventions, regular rounds, resident/family education, staff interventions, and structured group activities. Communicate interventions during shift report and daily clinical rounds to the caregiving team. Review and revise the elopement plan of care admission, quarterly and after an elopement event or attempt and with a change in condition. The IDT will educate residents and their families about fall risks and prevention strategies. Analyze elopement incident date to identify trends and develop quality improvement initiatives. Provide regular training for all staff on elopement prevention, risk assessment, and post-elopement event management. Ensure staff competency through ongoing education and practical assessments. The QAPI Committee will review elopement incidents and outcomes regularly to ensure compliance with the policy and identify areas for improvement and implement quality improvement projects based on data analysis and feedback from staff and residents. The Immediate Jeopardy that began on 10/15/24 was removed on 10/29/2024, when the facility took the following actions to remove the immediacy: Proposed Removal Plan: The following actions have been taken to abate the risk of future elopements: • The issue has been determined to have the potential to affect all memory care residents and any other residents within the facility that have been identified as an elopement risk. • (R2) was evaluated at local hospital following the elopement and again upon returning to the facility on [DATE]. No injuries were observed at that time. (R2's) responsible party, attending physician, and State Survey Agency were all notified on 10/15/2024. • All residents on the memory care unity were placed on 15-minute checks for a period of 72 hours, beginning on 10/15/2024. At the expiration of the 72 hours, residents were placed on a 2-hour check, with the exception of (R2) remained on 15-minute checks, for a time period of 14 days and QA team will review to see if any changes need to be made. • (R2) care plan was reviewed and updated to assess exit seeking triggers and none were identified. The care plan was updated to include the use of a electronic monitoring device. • The electronic monitoring device, which is present on all exterior doors of the facility, was tested and determined to be in working order. The electronic monitoring alert system was tested and determined to be functioning properly and the electronic monitoring bracelet was placed on the resident. These items were all completed on 10/15/2024. • &nbs[TRUNCATED]