**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 128 residents. The sample included three residents, with three residents reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). Based on observations, record review, and interviews, the facility failed to ensure staff provided adequate supervision to prevent an elopement for Resident (R) 1 and further failed to provide a thorough search in response to a WanderGuard (sensors that monitor doors and a technology platform that sends safety alerts in real-time) alert. On 04/13/25 at 07:15 PM, R1 who was severely cognitively impaired and at high risk for elopement, set off the WanderGuard alert system. Staff responded to the alarm 36 seconds later but did not see R1. Staff started searching for R1 but did not immediately open the staircase door and search the staircase where the WanderGuard alert system sounded. By the time the staff searched the staircase, R1 had exited the building through the staircase and walked around the sidewalk in the back of the facility. The facility located R1 approximately five to six minutes later near the parking lot on the ground. She had visible injuries including an abrasion to her forehead and right ankle swelling. The facility called an ambulance and R1 was transported to the hospital for evaluation and treatment. She returned later that evening with no fractures. The facility's failure to provide adequate supervision and implement a thorough search in response to the WanderGuard alert placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), abnormalities of gait and mobility, dementia (a progressive mental disorder characterized by failing memory and confusion), need for assistance with personal care, and restlessness and agitation. R1's Significant Change Minimum Data Set (MDS) dated 09/18/24, documented a Brief Interview for Mental Status (BIMS) was not conducted due to R1 being rarely or never understood. R1 had no behaviors and used a wander alarm daily. R1 was independent with bed mobility, transfers, and walking and had no falls since the last assessment. R1's Quarterly MDS dated 02/26/25, documented R1's BIMS score was 99, which indicated severe cognitive impairment. R1 had rejection of care and wandering behaviors for one to three days in the assessment period. R1 was independent with bed mobility, transfers, and walking and had no falls since the last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 09/19/24, documented R1 had short-term and long-term memory deficits and moderately impaired cognitive skills for daily decision-making. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 09/24/24, documented R1 required assistance with ADLs and mobility. R1 ambulated independently and used no devices for locomotion. The Falls CAA dated 09/24/24, documented R1's balance was sometimes slightly impaired, and she had wandering behaviors reported almost daily. R1 had two falls since her last MDS. R1's Care Plan dated 12/22/22, documented R1 had problems with remaining safe in her environment due to dementia and a history of wandering. R1's Care Plan documented R1 had a WanderGuard bracelet (a bracelet that helps monitor residents who are at risk of wandering) on her left ankle and staff redirected R1 when she was exit seeking or took a walk. R1's Care Plan dated 03/26/25, documented R1 had an impaired ability to take care of herself and needed help performing ADLs. The plan directed R1 was independent with transfers and ambulation with no devices. R1's Fall Risk assessment, dated 02/26/25 but created on 03/26/25, documented a high fall risk score of 17. R1's Elopement Risk Assessment dated 02/26/25 but created on 03/26/25, documented R1 was at risk for elopement with a score of 10 and wore a WanderGuard bracelet. The facility's Investigation dated 04/18/25, documented on 04/13/25 at 07:31 PM, Administrative Nurse E notified Administrative Staff A and Administrative Nurse D of an incident that occurred. Administrative Nurse E reported that R1 got out of the doors and staff found her in the parking lot; R1 had apparently fallen after losing her balance on the rocks next to the sidewalk. Administrative Nurse E initially reported R1 got out of the facility doors around 07:15 PM and staff responded to the door where her WanderGuard alert sounded. Staff started searching for R1 and when they were unable to find R1, they reported her missing. Staff notified Administrative Nurse E at 07:19 PM and she notified security at 07:20 PM to drive the campus while staff continued to search inside the facility. At approximately 07:21 PM, a staff member stated they saw R1 in the parking lot on the ground and staff headed to her. At about the same time, security noticed R1 and pulled up next to her. It appeared R1 walked around the backside of the building on the sidewalk towards the Independent Living entrance but lost her balance on the rocks near the sidewalk and fell. Upon nursing assessment, the staff called for an ambulance due to possible injuries to R1's ankle. R1 returned a few hours later with no fractures. R1's EMR revealed the following notes: A Nursing Notes dated 04/13/25 at 11:33 PM, documented around 07:10 PM, R1 eloped through the Heritage door. The WanderGuard alarm went off and staff started looking for her. Staff found R1 sitting on the ground, and it appeared R1 fell in the parking area. R1's ankle was swollen. Staff called an ambulance and kept R1 on the ground until the paramedics arrived. The facility notified R1's representative, provider, and hospice. A Nursing Notes dated 04/14/25 at 12:20 AM documented R1 returned to the facility at 11:45 PM, accompanied by R1's representative. R1's representative stated the hospital completed a computed tomography (CT scan - a test that uses X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) scan with no abnormal findings. R1 had a forehead contusion (an injury where blood and tissue damage occur beneath the skin without breaking the skin's surface), multiple bruises, and right ankle swelling. On 04/22/25 at 01:42 PM, R1 laid in bed with her eyes closed. Observation revealed an abrasion on her left forehead. Additionally, there was a high back wheelchair in R1's room. On 04/22/25 at 01:48 PM, Administrative Staff A walked the surveyor down the route that R1 took during her elopement on 04/13/25. Per Administrative Staff A, R1 exited through the Heritage stairwell doors that opened after 15 seconds of pushing on them. Observation revealed the Heritage stairwell double doors opened up into a hard-floor staircase with two flights of stairs descended to get to the first level with outside door access. The outside door opened up to the back of the building where generators and Independent Living parking were. The sidewalk from the door turned right towards an Independent Living entrance and there was a staircase to the right side of the sidewalk as one walked towards the entrance. Once past the Independent Living entrance, the sidewalk continued to the left. There were rocks on the right side of the sidewalk and sometimes on the left side as well. A dog park was located near the area R1 was found on the ground. The area where staff located R1 was all parking for the facility with no public streets per Administrative Staff A. On 04/22/25 at 01:58 PM, review of the camera footage provided from R1's elopement on 04/13/25 revealed at 07:14:05 PM, R1 was seen on camera wearing a long-sleeved shirt, pants, and shoes while she walked down the hallway. At 07:14:35 PM, R1 walked around the corner to the Heritage stairwell door and was out of camera view. Certified Nurse Aide (CNA) M exited the kitchen at 07:15:00 PM in response to a door alarm and she went to the elevator door. CNA M and CNA N realized it was the Heritage stairwell door and walked to that door at 07:15:36 PM. It was not seen whether or not the door was opened for staff to check the stairwell for R1. CNA M and CNA N started walking away from the Heritage stairwell door when the nurse walked down the hall asking where R1 was. On the camera, R1 was seen turning the corner of the stairwell at 07:16:17 PM while staff started searching for her. Staff went down the Heritage stairwell door to check for R1 who had already exited the stairwell and was off camera at 07:19:00 PM. There was no camera footage of the area where R1 was found. On 04/22/25 at 01:22 PM, CNA M stated on 04/13/25, she heard the door alarm go off and she called another aide to help assist her as she did not know how to reset the alarm. She stated CNA N typed in the code, but the alarm did not turn off. CNA M stated they looked out of the first door because it had a window but the second door they responded to did not have a window. She stated the door had an alarm code on it, but she did not know what it meant. CNA M stated she did not open the second door to check the stairwell and that was the door R1 exited from. She stated as soon as staff found out R1 was missing, staff immediately started looking. CNA M stated she saw R1 standing outside when she was upstairs and ran outside to find her but went out the wrong door. She stated she last saw R1 about two minutes prior to the alarm going off. CNA M stated R1 walked up and down the halls all the time but she had not seen R1 trying to go out of any doors. On 04/22/25 at 02:18 PM, Administrative Nurse D stated on 04/13/25, she received a call saying there was a fall and an elopement. She stated she arrived at the facility and started trying to figure out what happened while obtaining witness statements. She stated she believed the staff did everything correctly in response to the alarm but there was some confusion on where staff needed to look. She stated she expected staff to open the door and check the stairwell immediately. Administrative Nurse D stated she expected staff to check the back of the [NAME] (nursing tool that gives a brief overview of the care needs of each resident) with the alarm code to see which resident could set the alarm off and if they did not locate that resident, staff were not able to clear the alarm until the resident was found. On 04/22/25 at 02:42 PM, Licensed Nurse (LN) G stated if a WanderGuard alarm went off, the code would show up on the screen with the location of the alarm and staff responded to that location. She stated once at the location, there was a number that staff identified the resident with, and they went through the doors to make sure a resident did not go through those doors. LN G stated once staff found the resident and knew they were safe, they cleared the WanderGuard alarm. She stated if a stairwell door alarm went off and the resident was not immediately seen, the staff were to go through the doors to search for the resident. On 04/22/25 at 04:15 PM, Administrative Staff A stated on 04/13/25, he received a call from Administrative Nurse E about R1 and drove to the facility. Administrative Staff A stated he was not sure what had happened when he arrived, but he started reviewing door codes and cameras. Administrative Staff A stated he expected staff to always check the immediate area and if staff had walked through the door, they could have seen her down the stairs. He stated he expected staff to open the door and search for the resident. The facility's Missing Resident policy, dated 05/18/18, directed the facility staff to act promptly and thoroughly to investigate and determine the whereabouts of any resident who was unable to be located. On 04/22/25 at 04:25 PM Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed that the failure to provide adequate supervision to prevent an elopement for R1 placed R1 in immediate jeopardy. The facility put the following interventions into place prior to the onsite visit: The facility sent R1 to the hospital for evaluation and treatment on 04/13/25. The facility completed a post-incident review with immediate education with staff working on 04/13/25. The facility sent out an email and an alert to all staff with education on the elopement on 04/14/25. The facility started ongoing elopement education with all staff on 04/14/25. The facility updated R1's Care Plan on 04/15/25. The facility reviewed the WanderGuard list on 04/15/25. Due to the facility having completed all corrective actions by 04/15/25, prior to the onsite survey event, this deficient practice was cited as past noncompliance at the scope and severity of a J.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 113 residents. The sample included three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to provide adequate supervision to prevent Resident (R) 1, who was cognitively impaired and at risk for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff), from exiting the facility without staff knowledge or supervision on 11/26/23 at 01:23 PM. R1 pushed on a door leading to the stairwell for 15 seconds and was able to open the door. The door alarm sounded but the roam alert system (system which alerts when a linked roam alert bracelet is near) did not alert even though R1 wore a roam alert bracelet. Staff reset the door alarm but did not check the stairwell. R1 then went down a flight of stairs and exited through an outside door in the stairwell. R1 walked along the sidewalk around the building, to the front of the building where he entered the front door at 01:39 PM and was intercepted by Dietary BB then escorted back to long term care. The facility failed to provide adequate supervision and appropriate response to door alarms to prevent an elopement. These failures placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance. The admission Minimum Data Set (MDS) dated 10/20/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of five which indicated severe cognitive impairment. R1 had physical behaviors directed towards others and wandering behavior one to three days in the assessment period. R1 required substantial/maximal assistance with walking 10 feet. He had one noninjury and one injury fall since admission. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/26/23, documented R1 had a BIMS score of five, physical behaviors directed towards others, and wandering behavior. R1's factors that placed him at risk for a problem included modified independence, moderate impairment or severe impairment in decision making which may result in unsafe behavior and potential for injury, and difficulty with performance of activities of daily living (ADLs). The ADL Functional/Rehabilitation Potential CAA dated 10/26/23, documented R1 needed help with ADLs and mobility. The Falls CAA dated 10/26/23, documented R1 had a history of falls and he received staff support for transfer and safety needs. The Behavioral Symptoms CAA dated 10/26/23, documented R1 had rejection of care and wandering behavior. R1 became physically aggressive with staff while toileting and was observed wandering on the unit. R1's Care Plan, dated 11/01/23, documented R1 had problems with remaining safe in his environment due to history of wandering and a diagnosis of dementia. The care plan directed he wore a wandering bracelet on his right ankle and staff redirected him when exit seeking or took him for a walk. R1's Care Plan, dated 11/01/23, documented R1 was at risk for falling related to history of falls and muscle weakness. The care plan directed R1 may attempt to self-transfer and staff offered assistance. R1's Care Plan, dated 11/01/23, documented R1 had an impaired ability to take care of himself and needed help with performing ADL. The care plan directed staff to provide assistance with one staff for bathing, dressing/grooming, and transfers. R1's EMR revealed an Elopement Risk Assessment, dated 10/13/23, that documented R1 had an elopement risk score of six, which indicated he was not at risk for elopement. R1's EMR revealed a Behavioral Documentation note on 11/12/23 at 09:21 AM that documented R1 had been up wandering about both neighborhoods that morning and was easily redirected. R1's EMR revealed a Behavioral Documentation note on 11/26/23 at 01:07 PM that documented after lunch, R1 walked around carrying his house shoes without his walker. Staff attempted to remind him he needed to use his walker and he needed to leave his shoes in his room. R1 stated he was leaving town for two to three weeks and where he was going, he would not be able to use the walker. R1 walked away carrying his shoes and refused to take his walker. R1's EMR revealed a Nursing Notes note on 11/26/23 at 03:07 PM that documented staff reported R1 almost got out and the Wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) needed to be checked for function. The nurse went to R1 in the living room and checked his Wanderguard, which was working. The staff notified the weekend supervisor and removed R1's Wanderguard to check it for function. The Wanderguard did not alarm when going out of the care center but did when staff brought the alarm back into the care center. Staff changed R1's Wanderguard tag and placed it on his right ankle. Administrative Staff A came to facility and reviewed the camera and saw that R1 had opened the door and exited. R1 refused to allow the nurse to complete vital signs, he was cool to the touch, but did not have any shivering or jaw shaking to alert staff to him being cold. R1 was dressed in a long-sleeved shirt with an undershirt, casual pants, tennis shoes, and socks. In a notarized witness statement on 11/26/23, CNA M stated she heard the door alarm and went to check the area. As she approached, she saw R2 turn from the door and walk back down the hall. CNA M stated she checked to ensure the door was closed/latched, which it was, and reset the door alarm with the impression it was R2 who triggered it as she had several times that day. She stated the alarm never sounded so she assumed no one had passed through the exit door. CNA M stated she had seen R1 wandering all over the halls off and on all day, including that afternoon but did not recall the last time she saw him. In a notarized witness statement on 11/28/23, Dietary BB stated R1 was walking toward the front doors when she saw him on 11/26/23 at about 01:30 PM. She stated R1 was one of her residents and had just moved to the second floor. She knew he was not to be out alone, so she asked him where he was headed. Dietary BB stated R1 said he was going to see his friend and needed to get to the elevators. She stated she showed him the elevators and took him to the second floor. Dietary BB stated he did not want to go back to his room. She notified staff about what happened. The facility's investigative report, dated 12/05/23, documented on 11/26/23 at approximately 01:23 PM, R1 was seen in the lobby by Dietary BB who escorted R1 back to the second floor of LTC and notified the charge nurse. The charge nurse reported the incident to the supervisor who informed Administrative Nurse D and Administrative Staff A. Administrative Staff A arrived at the facility to investigate the incident. Initially, staff reported they thought R1 possibly followed a family member off of the floor. The facility reviewed camera footage and identified that was not the case. R1 ambulated to the exit door, pushed the door for 15 seconds until the door/magnetic lock released, and walked down the stairs. The releasing of the door magnetic lock activated the door alarm. R1 ambulated to the lobby where Dietary BB recognized him and assisted him back to the second floor of LTC. The egress exit alarm activated when the door opened; however, the roam alert did not activate/alarm. Certified Nurse Aide (CNA) M immediately responded to the egress door alarm and reset the door alarm. Since the roam alert was not activated and another resident was standing by the door, CNA M indicated she believed that resident activated the door alarm. She reset the door alarm and directed the resident away from the door. Video footage showed the following: at approximately 01:23 PM, R1 pushed on the door until the door releases. CNA M walked to the door, as she was already headed towards the door prior to the door sounding because she saw R2 by the door, immediately when the alarm sounded. She was observed resetting the door alarm at 01:24 PM. CNA M redirected R2 away from the door. At approximately 01:29 PM, R1 ambulated independently in through the front doors from outside. He wore pants, shoes, and a long-sleeved shirt at that time. Investigation of the incident indicated the roam alert at that door did not alarm. R1's roam alert tag was functioning appropriately. It was identified that the door alarm did not activate until the magnetic lock released after 15 seconds. R1 ambulated independently. The temperature outside at the time of the incident was approximately 36 degrees and the sidewalks were shoveled and salted. When questioned about the incident, R1 stated he was headed to his villa/home, which was on campus. In closing, the investigation indicated the incident was related to failure of equipment. The equipment did not activate at the time of the incident. The circuit board had not and did not display a warning signal to alert staff and/or maintenance. R1 was away from the neighborhood for a total of six minutes. According to the Kansas State University Historical Weather website, the temperature on 11/26/23 at 01:00 PM was 32.2 degrees Fahrenheit (F). On 12/19/23 at 12:50 PM, the outside door R1 left out of exited onto a sidewalk. The sidewalk was in good repair and continued around the building to the front entrance. There was parking lots located to the side and in front of the facility with a street that ran in front of the facility with a posted speed limit of 25 miles per hour. On 12/19/23 at 02:25 PM, the second-floor door R1 exited led to a stairwell. The stairs were made of cement/concrete and R1 had to walk down one flight of stairs to leave through the outside exit door. On 12/19/23 at 12:45 PM, Administrative Staff A stated R1 was identified as a wanderer and he had a roam alert bracelet staff checked every shift for placement and checked weekly for functioning. He stated on 11/26/23, R1 pushed on the door and set the alarm off but the roam alert alarm did not go off. R2 was also there, and she wore a roam alert which triggered in the alarm window but did not sound. Administrative Staff A stated Dietary BB saw R1 in the front entrance and escorted him back inside. He stated R1 exited out a stairwell door then walked around the sidewalk to the main entrance where he was able to enter the front door. Administrative Staff A stated the circuit board for the roam alert was failing and intermittently sending signals. On 12/19/23 at 02:24 PM, Administrative Staff A stated the door alarm did sound after the magnetic lock released when pushed for 15 seconds and if it had alarmed immediately when the door was pushed then staff would have answered right away. He stated R1 did go down a flight of stairs to exit. On 12/19/23 at 02:32 PM, Administrative Nurse D stated on 11/26/23, she was notified around 01:30 PM that R1 was brought back in through the front doors. She stated it was not reported to her that he had any wandering behaviors that day. Administrative Nurse D stated when a door alarm sounded, staff were expected to go to the door alarm, open the door to check and find the person, verify the roam alert number that popped up in the alarm window with the number in [NAME] (CNA care plan) before resetting the alarm. On 12/19/23 at 04:05 PM, Administrative Staff A stated he expected staff to always respond to door alarms immediately, open the door and check the area, then account for all the residents. He stated he expected this every single time the alarm went off. On 12/20/23 at 10:43 AM, CNA M stated she was not aware that R1 was a wanderer or exit seeker. She stated on 11/26/23, she was documenting at the computer when she saw R2 going towards the exit door at the end of that hallway. She stated she jumped up from charting but did not take her [NAME] with her as she wanted to get to R2 before she got to the end of the hall. CNA M stated by time she got to the end of the hall, R2 had made a U-turn and she passed her. While she was at the end of the hall, CNA M checked the door and saw it was closed and latched. She stated she did not see anybody and the only resident she saw in that direction was R2. CNA M stated since the door was latched and R2 was safely inside, she checked the roam alert window to see what number was on the code display but because she did not have her [NAME] on her, she memorized the last three digits to check against the papers at the desk. CNA M stated the last three numbers were the same as R2's roam alert. She stated the roam alert alarm did not go off and staff relied on the roam alert alarm to go off. CNA M stated besides checking the roam alert number, there was no roam alert alarm going off to indicate a reside had went through that exit. She stated the door alarms went off frequently throughout the day if someone pushed on a door or left it open too long. CNA M stated the roam alert alarm sounded through the computer as well and indicated a resident passed over a threshold. She stated if a roam alert alarm went off, everybody, no matter who it was, went to assist. She stated staff always carried the [NAME] and pulled it out to check the roam alert number with the screen. CNA M stated she did not take the [NAME] with her to get R2 because she thought it was more important to go to R2. She stated if she knew there was another resident in that area, she would have gone through the doors and down the stairs asking if anyone had seen him. CNA M stated the [NAME] was updated every day and new ones were printed every shift and listed which residents were wanderers with their roam alert numbers on the back. She stated she had assigned residents that she received report on and R1 was not one of her assigned residents, so she did not receive report on him. On 12/20/23 at 12:50 PM, Licensed Nurse (LN) G stated on 11/26/23, R1 was restless, was walking without his walker, and kept saying he was leaving. She stated staff kept telling him he needed to stay at the facility and wait for his wife to come get him. LN G stated she talked to R1 about 10 to 15 minutes before he had got out of the door, and he stated he was going to leave but she told him to wait for his wife. She stated another resident had asked for her to step into their room and that was when another nurse told her R1 had got out then was brought back in. LN G stated when a door alarm went off, staff were supposed to respond and if there was a code in the Wanderguard box, they looked at the [NAME] to find the number and make sure the resident was still in the building. She stated everyone carried a [NAME] which were reprinted at least every day and were supposed to be updated every day. LN G stated she had not observed R1 trying to push on any doors, but he would go look out of the front door to the care center then would turn around and sit down in the lobby area then back up to wandering again. She stated R1 wore a Wanderguard at the time. She stated R1 was not easily redirected that day because he was very agitated and had started cussing at staff for telling him to wait for his wife. LN G stated staff offered him food, offered him rest, and offered to call his wife but none of that seemed to work for him that day. She stated she did not feel like he needed to be one-on-one or closer observation because he had not tried to actually push on any doors to go out, he just walked up to them to look out then walked away. The facility's Elopement Prevention policy, last revised 06/18/12, directed specific interventions were developed and implemented for residents at risk for elopement such as increased frequency of checks to ensure safety, wander bracelet may be placed on resident, and resident may be moved to the 2nd floor care center. The policy directed it was the responsibility of all personnel to report any resident attempting to leave the care center to the charge nurse as soon as practical. The facility's Wandering Resident policy, dated 02/17/08, directed every effort was made to prevent wandering episodes while maintaining the least restrictive environment for residents who were at risk for elopement. The policy directed if a resident repeatedly attempted to wander off the neighborhood, a monitoring schedule was implemented to ensure resident safety. The facility failed to provide adequate supervision to prevent R1 from eloping out of the facility on 11/26/23 at 01:23 PM when the temperature was near freezing. This deficient practice placed R1 in immediate jeopardy. The facility put the following corrective actions into place by 12/05/23: All elopement risk residents were placed on 15-minute checks until the roam alert system was fixed beginning 11/26/23. R1's Care Plan was updated on 11/27/23. The security system company replaced the circuit board and changed door alarm to sound when doors were pushed on 11/27/23. An elopement drill was completed 11/28/23 and two more were completed on 11/30/23. Staff were educated on responding to door alarms from 11/27/23 to 12/05/23. CNA M received a final written warning for responding to door alarms on 12/01/23. Due to the corrective measures implemented and completed prior to the onsite survey, this deficient practice was cited as past noncompliance. The scope and severity remain a J.