The facility identified a census of 63 residents with three reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to provide adequate supervision and failed to respond appropriately to door alarms to prevent an elopement (when a cognitively impaired resident leaves the facility without staff knowledge and /or supervision) for Resident (R)1. On 06/13/23 at approximately 02:05 PM, R1, a severely cognitively impaired resident at high risk for elopement, exited the facility's [NAME] door without staff knowledge and/or supervision. Prior to R1 exiting the building, a family member of another resident exited the same door with their resident and set off the alarm. Certified Medication Aide (CMA) R entered the code to cancel the alarm and, during that time, R1 walked out the door without CMA R's knowledge. CMA R did not check the area in response to the alarm or check to ensure all residents at risk for elopement were accounted for. R1 walked around the block and down the street approximately one block away from the facility until she encountered members of the community. The community members visited with R1 for a few minutes and then put her in their car and took her back to the facility. The facility staff did not know R1 was outside of the building until the community members alerted the facility staff of the incident. Staff went outside and verified R1 was a resident at the facility and staff accompanied R1 back into the building at 02:30 PM. The facility failures which resulted in an elopement placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS), dated 05/11/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The MDS documented R1 had exhibited verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others) one to three days during the look back period. The MDS documented R1 had other behavioral symptoms not directed towards others (hitting or scratching self, pacing, disrobing in public, or verbal/vocal symptoms like screaming) for one to three days during the look back period. The MDS documented R1 exhibited wandering behavior during one to three days during the look back period. The MDS documented R1 required supervision of one staff for bed mobility, transfer, walking in her room, walking in the corridor, locomotion on and off of the unit, and personal hygiene. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/12/23, documented R1 could not participate in the BIMS, exhibited short- and long-term memory problems, often misunderstood communication from others, and displayed increased irritability with others. The CAA documented R1's activities of daily living (ADL) were supervised due to R1's impaired balance. The Fall CAA, dated 02/12/23, documented R1 had two falls during the last 90 days due to impaired balance with transitions. The Elopement Care Plan, dated 05/05/23, documented R1 would remain safe and directed staff to engage R1 in purposeful activity, provide clear and simple instructions, provide orientation to surroundings and environment, and Wander Guard (bracelet to alert staff when a resident gets close to an exit door) number 12 applied to her left wrist. The nursing staff were to verify the placement and function of the Wander Guard, every shift. The Elopement Assessment, dated 05/05/23, documented R1 had an elopement score of two which indicated R1 was at risk for elopement. The evaluation documented R1 expressed the desire to go home, packed belongings to go home, and/or stayed near exit doors. The evaluation documented R1's wandering behavior was patterned or goal-directed, likely to affect the safety or well-being of others and likely to affect the privacy of others. The Health Status Note, dated 05/05/23 at 10:12 AM, documented R1 was exit seeking with a packed bag and staff applied a Wander Guard. The Behavior Note, dated 05/06/23 at 10:59 AM, documented R1 was pacing and exit seeking that morning. R1 carried around her personal belongings, and cursed at staff when R1 did not get the answer she wanted. The Behavior Note, dated 05/06/23 at 01:57 PM, documented R1 changed her clothes and wrapped things in other clothes and carried it around with her. The Behavior Note, dated 05/06/23 at 09:07 PM, documented R1 tried to empty her room out and leave. The nurse redirected R1 back to her room but R1 continued to bring out her belongings. The Behavior Note, dated 05/07/23 at 09:43 AM, documented R1 was up and had two sacks full of her belongings at 07:00 AM. Staff were able to redirect R1 back to her room and placed the sacks in R1's closet and accompanied R1 to breakfast. R1 paced and would not sit still even in her room. R1 stated to staff she was moving out. The Alert Note, dated 06/13/23 at 02:40 PM, documented the receptionist alerted staff R1 got out of the facility and was brought back to the facility by personal car. R1's vital signs were obtained and recorded, and her skin was checked with no problems noted. R1 wore a purplish colored sweater and blue pants. The Alert Note, dated 06/13/23 at 02:52 PM, documented R1's Wander Guard was blinking red at that time. The Health Status Note, dated 06/13/23 at 03:02 PM, documented the nurse was notified at 02:29 PM that R1 exited the building. A community member observed R1 down the street and returned R1 to the facility by private vehicle. The temperature was 81 degrees and humid. R1 wore a purple sweater, black slacks, socks, and shoes. Staff notified the director of nursing immediately and initiated an investigation. The charge nurse observed R1's skin and reported no new skin areas. A charge nurse notified R1's primary care physician, hospice, and family. The facility's Information Technology (IT) employee checked the cameras in the facility for further information. R1's Wander Guard had a blinking red light, which indicated the battery was working and the Wander Guard was tested at the door and was in working order. Maintenance was notified to ensure all door checks were performed and maintenance confirmed the Wander Guard system was checked on all doors that morning and functioned properly. The Facility Incident Report, dated 06/21/23, documented on the afternoon of Tuesday, 06/13/23, R1 exited the facility without supervision at approximately 02:05 PM. R1 returned to the facility at 02:26 PM by private vehicle accompanied by two community members. One of the community members came into the building and notified the front receptionist she and her husband had R1 in their car. Medical records personnel notified nursing staff and went out to the car at 02:28 PM and confirmed R1 was a resident at the facility. Nursing staff accompanied R1 back into the building at 02:30 PM. The community member stated he was mowing his lawn when R1 stopped to talk to him. The community member and his wife conversed with R1 and then drove R1 back to the facility. R1 wore a purple sweater, black slacks, socks and shoes. Staff assessed R1's skin and found no issues. After reviewing the cameras, it was noted a family member took another resident out of the facility through the [NAME] door. CMA R then entered the code to clear the alarm to the [NAME] door and R1 walked behind CMA R out the door. On 06/21/23 at 10:30 AM, R1 sat in a resident led exercise group sleeping with her chin on her chest. Her Wander guard bracelet was on her left wrist. On 06/21/23 at 11:00 AM, CNA M stated R1 wandered and would exit seek frequently. On 06/21/23 at 12:00 PM, Administrative Nurse E stated that a lot of things went wrong on 06/13/23 including CMA R not checking to see if any residents had exited when canceling the door code, the resident's family not seeing R1 walking out of the building, and no one seeing R1 walking around the outside of the building. Administrative Nurse E stated CMA R had a plan for improvement in place that stated she should always evaluate which resident caused the alarm to sound and observe residents until the doors lock, and to always check surrounding, inside and outside, prior to overriding the alarm, to assure residents safety. On 06/21/23 at 12:30 PM, CMA R stated that she knew family just left out the [NAME] door with their resident and she figured the alarm went off because they left the door open too long, so she cleared the alarm. CMA R stated she did not see R1 exit behind her and did not go outside looking for any resident. CMA R stated she knows now to let the alarm continue to sound and stay by the door to ensure resident safety. On 06/21/23 at 02:00 PM, Administrative Staff A stated it was a perfect storm and everything that could have gone wrong, went wrong, and the facility was just happy R1 returned to the facility without any injury. The facility Elopement Policy, reviewed 06/14/23, documented all staff that hear an audible door alarm will respond immediately. A door alarm will never be reset until the source of the alarm has been identified and if a resident has exited through the door the alarm will be disengaged only after the resident has been re-directed back to a safe location or with appropriate supervision. The facility failed to provide adequate supervision and failed to respond appropriately to door alarms to prevent an elopement for R1 which placed R1 in immediate jeopardy. The facility implemented corrective actions to address the deficient practice including staff education regarding responding to door alarms, supervision of residents, and elopement protocols and policies. The facility Quality Assurance and Performance Improvement (QAPI) team evaluated the occurrences, identified causative factors, and implemented facility and individual performance improvement plans. The corrective actions were completed on 06/16/23, prior to the onsite survey event, therefore the deficient practice was cited as past noncompliance at the scope and severity of a J.