**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision for cognitively impaired residents and keep hazardous disinfectant, alcohol gel, and hazardous odor eliminating spray secured and out of the reach of cognitively impaired, self-mobile residents for seven of seven residents (R1, R2, R3, R4, R5, R6, R7) reviewed for accidents in the sample of eight. These failures resulted in, on 2-14-25 R1, a cognitively impaired resident, obtaining a bottle of hazardous disinfectant (BNC-15), R1 ingesting the hazardous disinfectant, and R1 requiring emergency room services for treatment. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3-10-25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include: The facility's Housekeeping Policy dated 1-2023 documents, Purpose: To assure proper housekeeping and facility cleanliness and to have proper guidelines for housekeeping standards. Supplies and Equipment: Cleaning supplies should be kept in locked cupboards or rooms for the protection of the residents. The Chemical BNC-15 Manufacturer's Safety Data Sheet/MSDS dated 4-1-21 documents, (32 ounce) BNC-15 (Disinfectant). Hazard Statements: Harmful if swallowed. Causes severe skin burns and serious eye damage. Response: Immediately call a poison center or physician. If on skin: Rinse cautiously with water for several minutes. Take off immediately all contaminated clothing and shoes. Rinse with water or shower for at least 15 minutes. Ingestion: Rinse mouth. Do not induce vomiting. Storage: Store locked up. Toxicology Information: Skin Contact: Pain, redness, blistering, and possible chemical burn. Ingestion: Damage or chemical burns to mouth, throat and stomach, pain, nausea, vomiting and diarrhea. The Manufacturer's Fresh Odor Eliminators Spray Safety Data Sheet dated 11-9-22 documents, Precautions for Safe Handling: Store at normal room temperature away from reach of small children. Keep container closed. Ingestion: Do not induce vomiting unless directed to do so by medical personnel. Never give anything by mouth to an unconscious person. If potentially dangerous quantities of this material have been swallowed, call a physician immediately. Acute Toxicity: Exposure to solvent vapor concentrations from the component solvents in excess of the stated occupational exposure limits may result in adverse health effects such as mucous membrane and respiratory system irritation and adverse effects on the kidneys, liver, and central nervous system. Symptoms may include headache, nausea, dizziness, fatigue, muscular weakness, drowsiness, and in extreme cases, loss of consciousness. Repeated or prolonged contact with the preparation may cause removal of natural fat from the skin resulting in dryness, irritation, and possible non-allergic contact dermatitis. Solvents may also be absorbed through the skin. Splashes of liquid in the eyes may cause irritation and soreness with possible reversible damage. The Manufacturer's Spectrum Advance Hand Sanitizer Gel dated 7-23-24 documents, Storage: Keep containers tightly closed in a dry, cool and well-ventilated place. Store locked up. Eye Contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Remove contact lenses, if applicable, and continue flushing. If symptoms persist, call a physician. Skin Contact: In the case of skin irritation or allergic reactions see a physician. Inhalation: Move to fresh air. Get medical attention immediately if symptoms occur. If breathing has stopped, contact emergency medical services immediately and give artificial respiration. Ingestion: If swallowed do not induce vomiting. Clean mouth with water and afterward drink plenty of water. Never give anything by mouth to an unconscious person. Consult a physician if necessary. Most important symptoms/effects: Burning sensation. Itching. Rashes. Hives. Coughing and/or wheezing. May cause breathing difficulties if inhaled. The facility's current Centers for Medicare and Medicaid Services Form 802 documents R1-R7 have the diagnoses of either Alzheimer's or Dementia and can either self-propel a wheelchair or self-ambulate. R1's current Face Sheet documents R1 is an [AGE] year-old with the diagnoses of Dementia, mild, with Anxiety, Dysphagia, Anxiety Disorder, Alzheimer's Disease, Insomnia, Restlessness, and Agitation. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is severely cognitively impaired. R1's Progress Notes dated 2-14-25 at 7:06 PM and signed by V3 (RN/Registered Nurse) document, This writer was sitting at nurses' station when another resident (R8) alerted me to Stop him (R1). (R1's) going to drink that. This writer then stood up to see (R1) sitting in wheelchair at nurses' station with lid to purple disinfectant cleanser labeled BNC-15 in hand and liquid coming from (R1's) mouth. (R1) then asked for water and the writer immediately notified (R1's) nurse (V4/LPN/Licensed Practical Nurse) and located MSDS (Material Safety Data Sheet) for BNC-15 in MSDS manual in cabinet at nurses' station and followed sheet advice for ingestion of BNC-15. R1's Progress Notes dated 2-14-25 at 7:31 PM and signed by V4 (LPN) document, (V3) came up to writer and stated that (R1) was possibly observed drinking cleanser. (R1) alert to baseline not showing any signs of distress at this time. (V2/DON/Director of Nursing) immediately notified. EMS (Emergency Medical Services) called for further evaluation and MSDS sheet for cleanser (R1) ingested sent with paramedics. All emergency contacts were attempted to be notified with no response. Voicemail left to return call back to facility. (R1) taken to (local) hospital. R1's emergency room Provider Notes dated 2-14-25 and signed by V9 (emergency room Physician) document, Chief Complaint: (R1) present with accidental ingestion. (R1) presents to ED (Emergency Department) from (facility) after drinking about six oz (ounces) of a cleaning chemical, BNC-15 one step disinfectant cleaner, about 30 minutes ago. Accidental ingestion of caustic alkali (highly corrosive bases that can cause severe burns and damage to living tissues). (R1) has a history of Dementia. Chemical was left sitting on the counter. (R1) did not appear to do this in an attempt to harm himself but did not understand what he was doing. Discharge Instructions: Four to six hours observation. Strict NPO (Nothing by Mouth). GI (Gastro-intestinal) referral for EGD (Esophagogastroduodenoscopy) per poison control. R1's Report of Incident dated 2-14-25 and signed by V1 (Administrator) documents, On 2-14-25 around 7:07 PM, (V1) was notified by (V2) that the nurse on duty reported to her that (R1) long-term resident with a history of advanced Dementia was reported by (R2) to have something (R1) shouldn't have. Nurse (V3) stated that she was sitting at the nursing station when another resident (R8) said to her You better take that from (R1). (R1) is going to drink it. The nurse reports to have looked over the countertop and saw (R1) sitting in his wheelchair with the lid of a bottle of disinfectant in his hand. The nurse states (R1) did not have the bottle of cleaner in his hand, only the sprayer lid, which she reports (R1) took out of his mouth. (V3) immediately notified the nurse assigned to (R1) and they immediately assessed (R1). (R1) has advanced Dementia, very poor hand dexterity, and is unable to communicate clearly, therefore the clinical decision was made to error on the side of caution and send (R1) to the ER for evaluation since no one could say with certainty that (R1) did not ingest the disinfectant. The bottle was around 90 percent full. EMT transported (R1) to (hospital) emergency room where they observed (R1) for around four and a half hours and then returned (R1) to the facility around 2:00 AM on 2-15-25 with orders to follow-up with gastroenterology. R2's MDS assessment dated [DATE] documents R2 is severely cognitively impaired. R3's MDS assessment dated [DATE] documents R3 is moderately cognitively impaired. R4's MDS assessment dated [DATE] documents R4 is severely cognitively impaired. R5's MDS assessment dated [DATE] documents R5 is severely cognitively impaired. R6's MDS assessment dated [DATE] documents R6 is severely cognitively impaired. R7's MDS assessment dated [DATE] documents R7 is severely cognitively impaired. R8's MDS assessment dated [DATE] documents R8 is cognitively intact. On 3-7-25 from 9:45 AM through 11:00 AM a two-ounce bottle of fresh odor eliminators spray was located on top of a handrail in the middle of the hallway and two eight-ounce bottles of spectrum advanced hand sanitizer gel were sitting on top of a cart located in the hallway outside of room [ROOM NUMBER]. There were no staff present during these times, and R2 was walking aimlessly up and down the hallway. On 3-7-25 at 11:10 AM R2 was at a cart located in the hallway outside of room [ROOM NUMBER]. There were two eight-ounce bottles of spectrum advanced hand sanitizer gel and a box of tissues sitting on top of the cart. R2 was standing in front of this cart, pulling tissues out of the box, and placing them on top of the cart. R2 then picked up one bottle of the alcohol gel and sat it back down. On 3-7-25 at 11:15 AM R8 was lying in bed. R8 stated, On (2-14-25) I saw (R1) take the lid off of a cleaner and drink the cleaner. (R1) had the nozzle to the cleaner in his other hand. I was yelling at the nurse look! Look! Look! (R1) is drinking that! The nurse sent (R1) to the hospital and (R1) had to have his stomach pumped. On 3-7-25 at 10:05 AM V4 (LPN) stated, I was (R1's) nurse and was not at the desk when (R1) had drank the disinfectant. Another nurse told me (R1) drank the disinfectant. (V3) came into to me and reported it to me. I called (V2/Director of Nursing) and asked how much (R1) drank and I told (V2) I was not sure. (R1) had the cap off the disinfectant and drank some of it. There was at least a half of a cup of the disinfectant missing out of the container. I called 911 and all emergency contacts. I found the Safety Data Sheet and sent it with EMS. (R1) was being observed the entire time until the ambulance came. I did not rinse (R1's) mouth or skin. I just observed (R1) until EMS arrived. On 3-7-25 at 10:30 AM V7 (RN) stated, (R1) is extremely confused and would not know if he was drinking a chemical. (R1) gets up late every day and self-propels his wheelchair around the facility, using his hands to propel the wheelchair. (R1) is not aware of his surroundings. On 3-7-25 at 10:40 AM V5 (Housekeeper) stated, For some reason (V6/RN) would always ask me for the BNC-15 disinfectant. There were several days before (R1) got ahold of the disinfectant that (V6) would get the disinfectant when I was not aware and leave the disinfectant on top of the nurses' desk. No staff would be around when the disinfectant was being left on top of the nurses' desk. Every time I would find the disinfectant, I would lock it up. I would tell (V6) the disinfectant must be locked up. I know residents can drink the cleaners. That is why the cleaners have to be locked up at all times. On 3-7-25 at 11:56 AM V10 (Housekeeping Supervisor) stated, (V6/RN) asked for a chemical that day and was refused the chemical BNC-15. (V6) would ask for this chemical frequently and was the only nursing staff that would ask for that chemical. (V6) worked that day and (V6) left the BNC-15 chemical on top of the nurses' station and did not lock the chemical back up. All chemicals are to be locked up at all times and the housekeeping cart is to be always visible to keep residents from getting to the chemicals. (R2) observes the housekeeping carts frequently and could try to open a housekeeping cart. Staff should always pay attention to their surroundings. On 3-7-25 at 12:10 PM V6 (RN) stated, On 2-14-25 I got the disinfectant (BNC-15) to clean up a spill that had happened on the nurses' desk and floor. I got busy that day and I forgot to lock the disinfectant back up after I used it. I got told that was part of the reason why I was terminated. On 3-7-25 at 1:00 PM V11 (R1's Family Member) stated, (R1) has no idea what he is doing and is not safe around chemicals. On 3-7-25 at 2:40 PM V3 (RN) stated, On 2-14-25 around 7:00 PM, I heard (R8) yelling, Stop him (R1)! Stop him! I saw (R1) had the top off the chemical BNC-15 and had the tube that goes down into the chemical in his mouth, licking the chemical off the tube. (R8) yelled, (R1) drank that! I saw a very light purple liquid in (R1's) mouth and running out of (R1's) mouth. The BNC-15 chemical is a purple color. The bottle had about four to six ounces missing out of it. I immediately told (V4) and (R1) was sent to the hospital. Whoever left the chemical on top of the nurses' desk should know better. All chemicals should be locked up at all times. On 3-7-25 at 2:30 PM V2 (Director of Nursing) confirmed that all chemicals should be always locked up. V2 also confirmed R1-R7 are cognitively impaired and either self-propel a wheelchair or self-ambulate throughout the facility. The Immediate Jeopardy started on 2-14-25 when V6 (RN/Registered Nurse) left a bottle of BNC-15 hazardous disinfectant unsecured on top of the nurses' desk and R1, a cognitively impaired resident, obtained the bottle of BNC-15, ingested the disinfectant, and required emergency room services for treatment. V1 (Administrator), V2 (Director of Nursing), and V13 (Regional Manager) were notified of the Immediate Jeopardy on 3-10-25 at 10:30 AM. On 3-12-25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 3-10-25 department heads conducted a facility wide walk through to assure all chemicals and hazardous materials were securely stored and out of reach of the residents. On 3-12-25 this surveyor conducted a facility wide walk through to assure all chemical and hazardous materials were securely stored in the housekeeping carts, clean storage utility room, and out of reach of the residents. 2. On 3-10-25 a list of identified residents who are cognitively impaired and self-mobile was placed as the nurses' station by V2 (Director of Nursing). 3. On 3-10-25 all care plans of residents who are cognitively impaired and self-mobile were revised. 4. On 3-10-25 V1 (Administrator), (V2 (Director of Nursing), and V14 (Human Resource Director) in-serviced all staff on which residents are cognitively impaired and self-mobile, where to find the list that indicates residents who are cognitively impaired and self-mobile, proper securement of chemicals and all other hazardous materials, location of the SDS (Safety Data Sheets) and how to read a SDS sheet. All new employees will be in-serviced by V14 prior to their first shift. 5. On 3-10-25 an audit tool was developed and implemented by V1 to track compliance of proper storage of chemicals and all other hazardous materials. Completion Date: 3-10-25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to interview the family of a confused resident to accurately assess elopement risk prior to admission, screen for supervision needs and develop an elopement care plan, failed to provide adequate supervision to prevent an elopement, failed to ensure all exit doors were secured and/or alarmed and the exit door alarm system was in working order, and failed to investigate an elopement for one of three residents (R27) reviewed for wandering in the sample of 27. These failures resulted in R27, a severely cognitively impaired resident with a diagnosis of Dementia, who is normally independent with ambulation and with a known history of eloping prior to admission to the facility, eloping from the facility on 5/30/22 and being found outside in the back of the building, walking across the grass heading towards the facility, from an unknown location. The facility was unaware that R27 was missing until V20 (Dietary Aide) observed R27 outside and notified facility staff. R27 was found and required extensive assistance of two staff members to return inside of the facility due to R27 being physically exhausted. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 6/15/22, the facility remains out of compliance at a severity Level II as the facility Maintenance Director and Administrator continue to monitor all exit doors to ensure they are alarmed and functioning. Residents identified as an Elopement Risk/identified as high risk for elopement were added to Quality Assessment and Assurance/Quality Assurance and Performance Improvement plan for ongoing monitoring. The facility is also awaiting a local electronic maintenance company that has been scheduled to provide service to evaluate and repair keypad and magnetic-locking door system on the fire door leading into the assisted living. In addition to this, parts have been ordered for adding an announcer speaker to sound the front door alarm when it is breached. This installation will be scheduled as soon as parts arrive. Findings include: The facility's Missing Resident policy dated 2/25/19, states, Purpose: To provide 24-hour supervision of the resident's safety. Staff responsible: 1. Administrator 2. Maintenance 3. Director of Nursing 4. All Staff; Missing Resident: the following criteria shall be met prior to determining whether a resident is missing: The resident is not capable of making safe decisions regarding their safety and welfare and they are unattended. Procedure: All exterior doors shall be equipped with a signal that will alert staff if a resident leaves the building. Any exterior door that is supervised during certain periods may have a disconnect device. 2. Residents at risk for wandering shall be assessed and addressed on the Care Plan. Immediately following the alarm signal, staff shall check the alarm panel and respond to the door indicated. Prevention: Check and test door alarms regularly, Identify and monitor residents at risk; Response to Resident Leaving the Building: Assist back to building, When resident returns to facility, a thorough exam should be completed, to assess for injuries; Missing Resident Protocol: The facility shall notify the resident's Physician and the legal representative or family member; Once the resident is found, an internal investigation will be conducted by the Administrator. R27's electronic medical record documents R27 was admitted to the facility on [DATE] with diagnoses which include, Dementia with behavioral disturbances, Cerebral Infarction with left sided weakness, Insomnia, Unsteadiness on feet, and Aphasia. R27's MDS (Minimum Data Set) assessment dated [DATE], documents the following: R27 has severely impaired cognition with short and long-term memory problems, wanders daily which places R27 at significant risk of getting to a potentially dangerous place (such as stairs, outside of the facility); and R27's wandering also significantly intrudes on the privacy or activities of others. This same MDS assessment documents R27 ambulated once or twice with one staff assistance. R27's Elopement Risk assessment dated [DATE] at 3:56 p.m., and completed by V13 (Activity Director), documents R27 is not at risk for elopement. R27's Care Plan initiated on 5/4/22, does not address R27 being a risk for elopement or wandering until it was revised on 6/1/22 (after R27 eloped on 5/30/22). This same Care Plan states, Activities: R27's barriers are cognitive decline due to Dementia, physical and verbal behaviors to other residents and staff when upset about wanting to go home or see husband. R27's Behavior Tracking dated 5/10/22 through 5/30/22, does not document R27's exit seeking/wandering. R27's Progress Notes dated 5/14/22 9:50 a.m., state R27 has continual supervision in waking hours. Unable to reorient. R27 does not remember fall occurring earlier in day. R27 self ambulates often raising her voice and cussing at staff. R27's Progress Notes dated 5/15/22 at 11:05 a.m., state, R27 has to have one-on-one supervision at almost all times (due to) her behaviors and fall risk. R27's Progress Notes dated 5/16/22 at 10:19 a.m., state, R27 states, 'My husband is not here yet. You hate me and I am not listening to you. I am tired of this bulls**t. I am leaving, maybe I will die'. On 6/06/22 at 12:53 p.m., V25 (R27's Husband) stated that R27 lived at home with him prior to her hospitalization and admission to the facility on 5/4/22. V25 stated R27's Dementia was progressing, and she was no longer safe to stay at home with V25. V25 stated R27, got lost three times in our hometown after she wandered off from home. Luckily, it's a small town and people knew who R27 was. R27 even went to (her old place of employment) and walked in like she was going to work. R27 can walk independently, and I take her on a lot of walks when I'm here. R27 has tried to leave this facility at least twice, according to staff. R27 says she wants to go home so she is frequently trying to get to an exit door. I can't remember the date that she tried to elope. R27's Nursing Progress Note dated 5/31/22 and completed by V2 (Director of Nursing) states, Spoke with V25 that (R27) is an elopement risk and R27 had wandered out of the facility on 5/30/22 at approximately 7:20 p.m. and found by (the apartments down the street) and brought back by dietary staff member. No injury noted. R27 placed on frequent checks by night shift nurse and wander guard placed. R27's Nursing progress Note dated 5/31/22 at 12:42 p.m., states Nursing implemented (wander management device) this morning. On 6/8/22 at 11:48 a.m., V20 (Dietary Aide) stated V20 was sitting outside of the service door (the exit door located by the kitchen) at the end of his shift on 5/30/22. V20 stated R27 came walking towards the facility, through the grass in the back of the building. V20 stated, I have no idea where R27 came from or how she got out of the facility. I knew she needed help, so I ran inside the building and got V21(Cook) to come outside to help me with R27. I quickly tried to call nursing staff when V21 headed outside but no one answered the phone, so I went back outside to help V21 get R27. R27 was walking but appeared exhausted. It took V21 and I both taking R27 by the arms to assist her back inside to the nurse's station. R27 was worn out. I'm glad I saw her when I did, or I don't know what would have happened to her. There were no alarms heard from the kitchen. The (service door exit) does not have an alarm on it. On 6/8/22 at 10:30 a.m., V21 (Cook) stated, I was in the kitchen when V20 came running in telling me that R27 was outside by herself. V20 tried to call nursing staff for help, and I ran outside to R27. When I got to R27 she was completely exhausted. I have no idea where all she had been or how long she was outside. It took both V20 and I to hang on to R27 and help her to get back inside to the nurse. I didn't ever hear any alarms. The service door (exit by the kitchen) is not alarmed. The door that comes from the hallways to the kitchen area is unlocked by kitchen staff in the morning and not locked until approximately 8:00 p.m. at night. On 6/8/22 at 9:34 a.m., V2 (Director of Nursing/DON) stated, I was notified on 5/30/22 at approximately 8:00 p.m., that R27 had somehow gotten outside of the facility. R27 has a diagnosis of Dementia and cannot make safe decisions. Her cognition is severely impaired. I did not do any type of investigation after R27's elopement on 5/30/22. I just had nursing staff attach a (wander management device) on her clothes the next morning. R27's nurse V22(Registered Nurse/RN) did not document R27's elopement, an assessment of R27 to check for any type of injuries, or that R27's Physician or husband were notified of the elopement. I don't recall hearing R27 verbalize that she wanted to go home or that she had made attempts to leave the facility. I did call V1 (Administrator) on 5/30/22, after I was notified of R27 being found outside. We (facility staff) had been trying to find her alternative placement due to her behaviors. I did not know that R27 had a history of eloping when she was still living at home. I don't do the elopement risk assessments. Those assessments are completed by the Activity Director in this facility. The elopement risk assessment should have been completed with the assistance of R27's husband since R27 is confused. I have no idea if R27's Care Plan addressed her risk for elopement prior to 5/30/22. I have not watched any video surveillance or conducted any interviews with the staff that found (R27) outside or any other staff on duty on 5/30/22. I cannot say where she exited the building or how long she was outside. I screened R27 for admission to the facility. I don't recall reading anything about her history of elopement. I don't have any documentation of my screening that was completed prior to accepting R27. I don't recall what all I reviewed from the hospital. There is no specific form that I follow. I probably wouldn't have taken (R27 as a resident) if I had known she had a history of eloping at home. We aren't a locked unit. I absolutely would have made sure R27 had a (wander management device) in place on admission at the very least. On 6/8/22 at 9:50 a.m., V13 (Activity Director) stated R27 is very impulsive and easily becomes agitated. V13 stated, I do a lot of one on one's with R27 and at times she is very hard to re-direct. I take her for a lot of walks because that seems to keep her content. She likes to be up moving. R27 was admitted on [DATE] and I completed her Elopement Risk Assessment. I don't know why this facility has the Activity Director doing those assessments. I don't have access to residents' medical records or anything like that. I was not formally trained on completing the Elopement Risk Assessments. I don't recall involving V25 while completing R27's Elopement Risk assessment. I wasn't aware that R27 escaped from her home prior to admission. I would have made her high risk for elopement if I had known that. I don't make the decision to put a (wander management device) on residents. R27 is always telling staff she wants to go home and asking where V25 (R27's Husband) is. I know she has tried to get out the exit doors and she has done a lot of wandering since she was admitted . On 6/8/22 at 11:20 a.m., V1 (Administrator) stated V2 notified her of R27's elopement from the facility on the night of 5/30/22. V1 stated V1 did not consider it an actual elopement because R27 was still on (facility owned property). V1 stated R27 has severely impaired cognition and is not safe to be outside of the facility without supervision. V1 stated, I thought V2 (DON) was handling the elopement issue. I told V2 to put a (wander management device) on R27 and do frequent checks. I have not completed any sort of investigation of R27's elopement on 5/30/22. I don't know what happened. V2 was responsible for the investigation at that point. We don't know what door R27 exited from or how long she was outside unsupervised. I do not have access to video surveillance and I'm not sure what is monitored by the video surveillance. I doubt the exit doors are on video. All exterior doors should be alarmed. Staff should have been aware of R27's history of elopement when she was admitted if they had interviewed V25 (R27's Husband) or properly screened R27 prior to admission. On 6/6/22, at 11:10 a.m., R27 was ambulating independently towards the nurses' station, with no staff supervision. On 6/7/22 at 9:50 a.m., R27 was ambulating independently in the main hallway. On 6/8/22 at 9:47 a.m., R27 ambulated into V2's office and sat at the table. On 6/8/22 at 10:07 a.m., R27 was up independently ambulating in the common area with only socks on her feet. A staff member assisted R27 back to the wheelchair and took R27 to her room. On 6/08/22 at 10:40 am, R27 was ambulating on the main hall of the facility with standby assistance from staff. R27 repeatedly stated get me out of this place and when am I going home. R27 had a small device attached with a clip to the hood of her sweatshirt. V2 (DON) was questioned as to what that device was. V2 stated the device was a wander guard that would alert staff if R27 passed through an exit door. V2 stated that the facility typically uses a wander guard that is placed on the resident's wrist or ankle as a bracelet, but they only have two of those devices and they are being used by other residents. On 6/8/22 at 3:30 p.m., R27 was walking outside with her husband. On 6/08/22 at 10:37 am, the facility was toured with V2 (DON) to identify all exterior doors and if they were secured and alarmed. The corridors that separate the Skilled Nursing side of the facility from the Assisted Living Side of the facility were not alarmed. V2 explained, at that time, that the only way a staff member would know if a resident went through those doors, was if they had a wander guard bracelet/alarm on. V2 then stated, R27 did not have a wander guard on when she eloped from the facility on 5/30/22, so R27 likely went through those doors into the Assisted Living portion of the facility. Once on the Assisted Living side of the building, the Service Entry door that leads to the Kitchen and another exterior door, was not locked, or alarmed. That exterior door led to the parking lot behind Assisted Living. At 10:45 am, V21 (Cook) stated that Service Entry door is unlocked and not alarmed from the time Kitchen staff arrive early in the morning, until they are gone at 8:00 pm. An additional exit door on the [NAME] Hall, which led directly to the parking lot in the front of the facility was able to be opened without an alarm sounding. V2 stated, at that time, that the exit door on [NAME] Hall should alarm when opened. The Immediate Jeopardy was identified on 6/8/22. The Immediate Jeopardy began on 5/4/22 (R27's admission date) upon admission when the facility failed to identify R27's risk for elopement and implement interventions to help prevent R27 from eloping from the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 6/9/22 at 8:55 a.m. On 6-13-22 from 9:45 AM through 10:15 a.m., it was confirmed through interviews that V30 (Agency Licensed Practical Nurse/ Agency LPN), V31 (Physical Therapy Assistant), V32 (Occupational Therapy Assistant), and V33 (Housekeeper) had not been in-serviced as stated on the abatement plan, the facility's abatement plan was not completely executed. On 6/14/22 at 5:00am, the same fire doors that separate the Skilled Nursing Unit from the Assisted Living Unit were not alarmed, as outlined in the Abatement Plan for F689. On 6/14/22 at 5:05 am, V22 (Registered Nurse/RN) was the only Licensed Nurse working 3rd shift. V22 was unable to reiterate any of the education provided by V2 (DON) and V1 (Administrator) regarding the Immediate Jeopardies identified the week prior. V22 was unaware of the Elopement Book, that was outlined in the Abatement Plan for F689. Upon further interview, V22 (RN) explained that R27 had attempted to elope two times the evening of 6/13/22, once out the front door and once out of the corridor that connects the Assisted Living Unit to the Skilled Nursing Unit. V22 verified that R27 was supposed to be on one-to-one supervision due to the elopements throughout the evening; however, V22 stated that the facility did not have the staff to provide 1:1 supervision and R27 was not on 1:1 supervision at the time. At 5:15 am, two additional staff, V36 (Agency Certified Nursing Assistant/ Agency CNA) and V38 (Cook) stated they had not received education as identified in the Abatement Plans. On 6/14/22 from 6:35 a.m.-6:37 a.m., The fire doors that separate the Skilled Nursing Unit from the Assisted Living Unit did not alarm on two separate instances when one visitor and one staff member V11(Registered Nurse/RN) came through those doors. On 6/14/22 at 5:21 a.m., review of the Shift Door Check sheet dated 6/13/22, did not document any of the 19 listed doors were checked to ensure they were properly functioning on the 2nd and 3rd shift. On 6/14/22, R27, R119, and R194's Care Plans had not been revised with resident specific interventions related to their elopement risk. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 6/8 and 6/9/2022 V17 (Maintenance Director) verified that all exit doors were alarmed when opened and reported findings to V1 (Administrator). 2. On 6/13/22, R27s elopement investigation from 5/30/2022 completed by V1 (Administrator). 3. On 6/9/22, R27s Care plan and interventions were reviewed and updated by V24 (Minimum Data Set/MDS Care Coordinator) and the Interdisciplinary Team. 4. On 6/9/22, V2 (Director of Nursing) In-serviced all staff on R27's Elopement Interventions. Staff members not in attendance of in-servicing held on 6/9/22 will be in-serviced prior to the start of their next shift, by phone or in person by V1 or designee. 5. On 6/9/22, V2 (DON) and Department Heads In-serviced all staff on all residents at risk for elopement, individualized resident interventions, and monitoring needs, and Missing Resident Protocol. Staff members not in attendance of in-servicing held on 6/9/22 will be in-serviced prior to the start of their next shift, by phone or in person by V1 or designee. 6. On 6/9/2022, V2 (DON) and V24 (MDS Coordinator) completed new Elopement Risk Assessments on all residents. On 6/15/22, the Care Plans for those residents Identified as high risk for elopement were updated adding resident specific interventions to meet the resident's needs. 7. On 6/9/2022, all nursing staff, including V2 and V24 were in-serviced on Elopement Risk Assessments needed for all new admissions, to include reviews on a quarterly basis and with significant changes. Staff members not in attendance of in-servicing held on 6/9/22 will be in-serviced prior to the start of their next shift, by phone or in person by V1 or designee. 8. On 6/9/2022, V1 (Administrator) and V2 (Director of Nursing) verified that the appropriate information on residents with exit seeking behaviors were properly placed in binders and at designated locations. All staff were in-serviced on the locations of binders. 9. On 6/9/2022, V17 (Maintenance Director) activated an alarm on fire doors directly leading to the Assisted Living Facility. 10. On 6/9/2022, V17 (Maintenance Director) in-serviced exit doors needing checked by staff every shift to assure they are alarmed and functioning. These Logs will be reviewed by the Maintenance Director and presented to the Administrator daily with issues being addressed as they occur. 11. On 6/9/22, the residents identified as an Elopement Risk/identified as high risk for elopement were added to Quality Assessment and Assurance/Quality Assurance and Performance Improvement plan by V1 (Administrator) for ongoing monitoring. 12. On 6/14/22, all staff were provided additional in-servicing on the above-mentioned trainings by the Regional Nurses along with a post-test for proof of training and understanding. Abatement completion date: 6/15/2022 Based on observation, interview, and record reviews conducted on 6-15-22 the facility completed all measures including the in-servicing of working staff and updating care plans for high-risk elopement residents as stated on the abatement plan.