**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 42 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to provide adequate supervision for Resident (R) 4 who was independent with ambulation and required staff supervision for safety due to a diagnosis of schizoaffective (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations [perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there] or delusions [altered reality that is persistently held despite evidence or agreement to the contrary], and mood disorder symptoms, such as depression [persistent feeling of sadness and loss of interest] or mania [abnormally elevated, extreme changes in your mood or emotions, energy level or activity level]) disorder, intellectual disabilities, and a personal history of physical, sexual, and psychological trauma. The resident's care plan directed R4 should not be allowed to leave the facility without supervision and was to be protected from any interaction with specific individuals. On 08/15/22 at 09:30 PM staff observed R4 in the common area of the facility. At approximately 10:06 PM the county Sheriff's Office notified facility staff that R4 was in police custody. R4 left the facility without staff awareness and supervision and walked nine blocks through town to the gas station. R4 called 911 and reported she left the facility without telling anyone. Police returned R4 to the facility. R4's face was flushed and R4 was upset. R4 reported she punched the code in the door and since no one saw her, she kept walking. Facility staff failed to provide adequate supervision to prevent an elopement (when a resident leaves the facility without staff knowledge and/or supervision) and failed to identify the resident was not in the facility until reported by law enforcement. This placed R4 in Immediate Jeopardy. Findings included: - R4's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder bipolar (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), intellectual disabilities, and a personal history of physical and psychological trauma. R4's Annual Minimum Data Set (MDS) dated 06/04/22 recorded R4 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS recorded R4 admitted to the facility on [DATE] from a psychiatric hospital. The MDS recorded R4 had no behaviors or wandering during the look back period. She required supervision with set up help from staff for locomotion on and off the unit, supervision with assistance of one staff for personal hygiene; she required supervision with no physical assistance for all other activities of daily living (ADL). The MDS recorded R4 had medically complex conditions and referenced her diagnosis of schizoaffective disorder. The MDS documented R4 had psychiatric /mood disorders of anxiety and schizophrenia (e.g., schizoaffective) disorder. The MDS recorded the resident received scheduled pain medication and was a current tobacco user. The MDS recorded no falls. R4 received antipsychotic medications (medications for psychotic disorder) daily during the look back period. The MDS documented R4 had no active plan to discharge into the community. Review of R4's 'Wandering/Elopement Risk Assessment revealed on 01/26/22 R4 received a score of nine which indicated she was at risk for wandering/elopement. The assessment indicated that a score between zero and eight indicated low risk for wandering/elopement. R4 assessment revealed a low risk for wandering/elopement on 03/12/22 (4), 03/30/22 (2), 06/30/22 (4) and again after the elopement event on 08/16/22 (8). R4's Care Plan dated 07/01/21 recorded R4 had a past traumatic event or experience of abuse (sexual), severe human suffering (pregnancy through sexual assault with subsequent adoption of child that was conceived), and sexual assault (sex trafficking by her father). The care plan directed staff R4 should have no contact with her father an dR4 should not leave the facility with any family without the guardian's consent. The care plan further directed staff to redirect R4 if she reached out to others in an inappropriate way (wanting to cuddle or offering sex or to show them her body. It further directed staff that due to R4's sexual trauma, R4 may reach out in a sexual way and desire that kind of attention from others; the care plan directed staff to remind R4 to respect her body and to also respect other's bodies. R4's Care Plan revised on 10/05/21 documented R4 had a diagnosis of schizoaffective disorder and anxiety. She enjoyed visiting with staff and sought desired staff members for 1:1. The care plan directed staff R4's physician and guardian felt it was in R4's best interest not to have visits or phone calls from her father due to allegation for sex trafficking. The care plan directed staff to monitor and record occurrences of pacing, wandering, disrobing, inappropriate response to verbal communications, and violence and/or aggression towards staff or others. R4's Care Plan dated 11/20/21 (and revised only after the event on 08/16/22) documented R4 was at risk for elopement. It directed staff to perform frequent visual checks to verify R4's location and safety. It further instructed R4 had a Wanderguard (a device that is used to alert staff when a resident is near an exit door) on her right wrist. Interventions were added on 08/16/22 after the elopement which directed staff to perform hourly visual checks for two weeks and remind R4 not to leave the facility without supervision and to remind R4 she was not to leave the facility without supervision. On 11/20/2021 at 04:50 PM a Plan of Care Note Late Entry recorded R4 approached the nurse and stated she (R4) was leaving to go walk around town and find a job. R4 had her coat on, and her book bag. Staff informed R4 that the businesses were not open on Saturdays and that she cannot leave facility on her own. R4 then returned to her room. Staff applied a Wanderguard to R4 at that time and placed R4 on 30-minute visual checks as well. On 03/12/22 at 05:56 PM the Nurses Notes documented R4 cut off her Wanderguard bracelet. R4 stated to staff the bracelet smelled bad. Staff noted the metal clasp on the bracelet had irritated the back of R4's right hand, Staff reassessed R4 and noted R4 was no longer at risk to wander as she had not wandered in the previous six months and did not try to leave without assistance. On 08/15/22 at 10:21 PM the Nurses Notes documented the County Sheriff called the facility on the phone and stated they had R4 in their custody. R4 had called 911 from the convenience store and informed them she had left the facility without anyone knowing. The County [NAME] reported to the facility they were in route back to the facility. Staff notified the (unidentified)on-call nurse who came to the facility and provided one to one supervision for R4. On 8/15/2022 at 10:54 PM a Health Status Note documented R4 was last seen by the Certified Medication Aid at 09:30 when the CMA gave R4 water from the kitchenette that R4 requested. The note further recorded the (unidentified) CMA and Certified Nurse Aid (CNA) were putting a resident to bed. The police officer was just leaving at that time. R4 sat on the recliner, sweating and her face was red. R4 wore a long sleeve shirt, long pants, and purple tennis shoes. R4 was upset and stated she left because no one wanted her at the facility and people were blaming her for everything. Staff told R4 that staff wanted to keep R4 safe and asked R4 if she was safe when she left. The note recorded R4 stated she did not feel safe and was scared and asked the police officer to bring her back to the facility. R4 stated that she punched the code in the door to get out and no one saw her, so she left and kept walking. The note documented R4 did not have a wanderguard on; R4 stated that she had taken it off at some point. R4 stated the staff member was her friend and she knew staff wanted her to stay; R4 stated that she was sorry and knew she should not have left. R4 stated that she would not leave again. Staff placed a Wanderguard on R4's wrist and dated it. The charge nurse assessed R4's vital signs and R4 had calmed down, stopped sweating, and her face went back to normal color. R4 rested in bed with a Wanderguard in place. The note recorded the CNAs were educated to do frequent visual checks along with the charge nurse. Staff notified the director of nursing, the physician and Administrative Staff A was notified by Administrative Nurse D. The note further recorded R4 had no new issues, no injuries and had no interactions other than with the employee at the convenience store and the police officer that brought her back to the facility. On 08/16/2022 01:59 PM a Health Status Note Late Entry recorded R4 was educated that she may not leave the facility without supervision. She verbalized understanding. The note further recorded R4 was placed on frequent visual checksR4's Conservator asked if R4 could ride along with the transportation driver one day a week as that might help R4 with her continued feeling of needing to leave the facility. On 08/16/2022 at 04:35 PM a Psychosocial Note Late Entry recorded Social Services X spoke to R4 about R4's elopement. R4 stated that a family member of another resident kept telling her to leave; the note also noted Social Services X was unable to confirm or deny this. The note documented R4 stated that she knew that she should not have done that. The note further recorded Social Services X asked R4 if she realized that bad things could have happened to her and R4 said yes and that she will not be leaving by herself anymore. A Witness Statement dated 08/18/22 from CNA P noted the last time CNA P saw R4 on 08/15/22 was at 08:00 PM when R4 sat in the chairs in the nursing place. The statement recorded CNA P left the facility at 09:00 PM on Monday. A Witness Statement dated 08/19/22 from CNA Q recorded CNA Q saw R4 at 09:00 PM outside smoking and then again at 09:30 PM in the sitting area. A Witness Statement dated 08/19/22 from CNA M recorded CNA M saw R4 in bed reading a book at 09:10 PM. A Witness Statement dated 08/18/22 from CNA N recorded on 08/15/22 around 09:00 PM CNA Q, CMA R and CNA N went outside to the courtyard to smoke and took R4 out with them to smoke. Around 09:15 PM, the staff members went back inside and Licensed Nurse (LN) H came outside and smoked and sat with R4. Around 09:25 PM both R4 and LN H went inside. CNA N sat by the nurse's station and charted. CNA N noted at 09:35 PM she last saw R4 in a recliner by the nurse's station. A Witness Statement dated 08/19/22 from CMA R recorded CMA R saw R4 at 09:30 PM when R4 asked CMA R for fresh water. CMA R filled R4's cup and R4 left the area. CMA R saw R4 again when R4 reentered the building around 10:00 PM. On 12/07/22 at 10:30AM, observation revealed R4 laid on her bed in her room. On 12/08/22 at 07:00 AM observation revealed the convenience store R4 walked to was nine blocks away from the facility. There area did have sidewalks. There was a four way stop with a flashing red light on the way to the convenience store from the facility. On 12/08/22 at 09:00 AM review of Wunderground.com revealed the temperature on 08/15/22 between 09:30 and 10:00 PM was 87 degrees Fahrenheit. On 12/8/22 9:30AM, Administrative Staff A verified R4 does require frequent one on one from staff and is an elopement risk. Administrative Staff A reported the door code was posted at the door as required by the state Fire Marshall. Administrative Staff A reported that R4 was assessed and found not to be at risk for elopement, so her Wanderguard had been removed. He stated that staff were unable to watch the residnet 24 hours a day. The facility's Elopement policy, dated 12/2021, states to ensure the safety of those residents who have been identified as being at risk for elopement. It is the policy of this facility to identify those residents at risk for elopement and take precautions to ensure their safety and well-being. A Wanderguard door locking system is provided. Upon admit each resident is assessed for the potential for elopement risk. Consideration will be given to the residents prior to history of wandering, impaired decision making or impaired cognition. All other residents will be accounted for at least every two hours. All exit doors are alarmed with audible alerts, In the case of a door alarm sounding, staff will immediately go to the door indicated on the enunciator system and check both inside and outside the door to determine who/why the door alarm sounded. Facility staff failed to provide adequate supervision to prevent an elopement and failed to identify the residnet was not in the facility until reported by law enforcement. This placed R4 in Immediate Jeopardy. 1. On 08/16/22 the facility completed the following corrections: 2. Staff reassessed R4 as a low risk for elopement and placed a Wanderguard on R4. 3. CNA and nurse staff were educated to do frequent visual checks on R4; R4 placed on hourly checks. 4. Wanderguard devices on all elopement risk residents were assessed for function. All residents were reassessed for risk for wander and appropriate actions were implemented. 5. Staff received education on Elopement policy and procedures. 6. The door code was changed and posted higher in effort to prevent R4 from reading and exiting again. 7. Facility staff coordinated so R4 could ride along with the transportation CNA one time weekly to assist R4 with her continued feeling of need to leave the facility. The deficient practice was cited as past non-compliance.