**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to prevent a resident that exhibited signs of cognitive impairment from eloping from the facility. Elopement means a resident that leaves the facility without staff knowledge or permission. On 10/29/22, staff failed to thoroughly investigate when the front door alarm had been activated. Resident #14 eloped and was found a quarter mile from the facility on the side of the road, near the entrance to the interstate. The resident wore a wanderguard alarm that failed to work properly at the front door. These findings constituted an Immediate Jeopardy (IJ) to resident health and safety. The facility reported a census of 84 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] showed that Resident #14 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficits). The MDS revealed the resident remained independent with transfers, locomotion, toilet use and dressing. The care plan dated 1/8/19, identified Resident #14 as at risk for wandering and had diagnoses that included: Alzheimer's disease, wandering, anxiety disorder and major depressive disorder. An update on 5/15/22 documented an addition that directed staff to stay with the resident if she exhibited wandering behaviors. A Wandering Evaluation dated 2/20/22 at 4:07 PM showed Resident #14 scored 26 points (high elopement risk). On 9/8/22 at 12:03 PM, she scored 20 points (also high risk). The nursing notes contained the following documentation: 1) On 2/22/22 at 3:17 PM, Resident #14 exit seeking and trying to the leave the facility. The census tab showed that on 2/22/22 after these behaviors, resident moved to the 500 hallway (locked memory unit). 2) On 5/13/22 at 5:56 PM Resident #14 involved in an incident in the memory unit, so staff moved her out of the locked department. The Medication and Treatment Administration record showed she wore wanderguard (WG) alarm that staff checked twice daily. From 5/14- 21, wanderguard was on her left ankle; on 5/22/22, staff attached it under the tray of her walker. 3) On 8/5/22 at 5:07 PM Resident #14 agitated, exited via the front door and started down the driveway. Staff convinced her to come back inside at that time. Another note dated 10/19/22 at 11:15 AM showed the resident attempted to leave through the front door. 4) On 10/29/2022 3:10 PM, Resident #14 approached the nurse at main nurses station and asked the nurse to find her a ride home. The nurse redirected the resident with conversation and snack, resident calmed with redirection and walked hall where she lived. She no longer made statements of wanting to leave. 5) On 10/29/2022 at 4:00 PM, Resident #14 found outside of facility walking in the grass on Clay Street at 3:50 PM. Resident assisted back to facility. Staff conducted a head-to-toe assessment, found no injuries, and then provided 1:1 supervision. On 11/15/22 at 3:13 PM the Director of Nursing (DON) said she was not working the day that Resident #14 left the building unattended. She reported she lived close by and while driving down the road, she saw the resident walking in the grass. The DON stated she the resident had crossed Clay Street and left her walker on the sidewalk where there was a curve. She continued to walk through the grass up the hill toward the interstate (according to a fitness application, the resident was found a quarter of a mile from the facility). The resident recognized the DON right away and she agreed to get into the car with her and she was brought back to the facility. On 11/15/22 at 2:42 PM, Staff D, Certified Nursing Assistant (CNA) verified she had worked the day that Resident #14 got outside undetected. She said that there was an agitated resident in the 400 hallway that afternoon, so they had closed the fire doors to keep her confined. Staff D was on the other side of the doors so it was difficult for her to hear the alarms and announcements regarding what door was open. She said that when she came into work at 2:00 on 10/29/22, Resident #14 had been at the nurse's station talking to the nurses. That was the last time she saw her before she left the facility. Staff D said that the alarms had gone off many times that afternoon because there were many people in and out for a party for another resident. She said that since the elopement, the staff were more diligent in investigating an alarm. Before the elopement, if there was a door alarm going off, we didn't think much of it. On 11/15/22 at 2:33 PM, Staff A, Licensed Practical Nurse (LPN) reported she worked on the afternoon of 10/29/22 - Resident #14 had been at the nurses station, acted agitated and said wanted to go home. The resident asked Staff A to call a cab for her. Staff A redirected the resident with a snack and the resident headed back down the hallway toward her room. She later learned that the resident had been outside when the Director of Nursing (DON) contacted the facility and told them she found the resident outside. Staff A said that she had heard alarms earlier in the afternoon. She had shut off the alarm at the front door once, then checked the perimeter but didn't see any residents outside at the time. The alarms went off a couple more times, but other staff members responded and had turned it off. Staff A said that she did not do a head count to account for all residents. Staff A added there were many family members at the facility that day for a party in the 300 hallway; they do not always push the red button before entering, therefore the alarm had sounded many times. On 11/17/22 at 11:29 AM, Staff C, Certified Nursing Assistant (CNA) said that there was a resident at the facility that was having a party on 10/29/22 and there were many family members in and out of the front door. She said that she had turned the alarm off several times and she didn't see any residents around. She said that staff were always expected to investigate when an alarm had sounded, but it was not enforced and many did not follow through with this expectation. On 11/17/22 at 9:50 AM, LPN Staff B reported that she had been instructed by the facility to go to the door when that alarm sounded was sounding and to look for any residents that may have exited. If there were no residents observed at the door, she would check the perimeter of the building. On 11/17/22 at 6:40 AM the DON explained that the keypad on the wall wired to the door alarm would not work if a resident with a WG was nearby. If the code had been punched into the key pad the door could be opened without the alarm going off, but, if a resident with a WG alarm walked through the doorway, the alarm would then be activated. She said that this was the point that failed when they tested the WG later in the afternoon of 10/29/22 after Resident #14 had been brought back to the facility. They then went to other doors throughout the building with the same WG and it worked at those doors. She said that they called the service provider for the alarms and he inspected the wiring. He determined that they would need to do some rewiring. In the meantime, the facility put an extra alarm on the front doors. On 11/16/22 at 6:43 AM the DON checked the WG at the front door and it was working. On 11/16/22 at 3:39 PM the administrator said that the facility did not have a policy related to door alarm response. She said that it was expected that staff would go to the door that is alarming and if they did not see who set it off, they would not turn the alarm off until they determine how it was set off. Staff were then expected to do a headcount of all residents. According to the facility policy: Emergency Procedure - Missing Resident, dated August 2018, a resident at risk for wandering and/or elopement would be monitored and staff would take necessary precautions to ensure their safety. The immediate jeopardy was removed on 10/29/22 and the IJ was identified as past noncompliance when the facility took the following actions: 1) All residents were assessed via a wandering evaluation. If not current, the evaluations were completed. 2) Posted signs on the handicap exit button for visitors to wait for staff to assists. 3) Posted sign on front entrance door for visitors to call the facility before entering and exiting so a staff member could assist with entry and exit until wander guard alarm could be serviced. 4) Elopement binder with listing of high-risk residents placed at nurses stations 5) Maintenance supervisor checked for functioning of all exit door alarms and wander guard alert. 6) Call to RF Technologies to schedule a service call to address inconsistent functioning of front door wander alerts. 7) Residents with wander guards in place had tested and were check for placement, functioning and expiration date. 8) Resident #14 was moved to the locked memory unit on 10/29/22. 9) Secondary alarms were added to the front door 10) Missing resident drills conducted randomly. 11) Education to staff regarding the door alarm response with resident at risks 12) Staff educated on outside check around outside of the building when door alarmed. 13) Attention signs at exit doors reminding visitors to not allow residents to exit. 14) Door alarm and missing resident protocol added to the agency orientation checklist.