**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's Accident/Incident report, and review of the Resident Assessment Instrument User Manual, it was determined the facility failed to ensure that the Minimum Data Set (MDS) assessment for one (1) of seventeen (17) sampled residents (Resident #37) accurately reflected the resident's wandering status. Record review and interviews with staff revealed Resident #37 wandered daily and attempted to leave the facility through exit doors. In addition, on 01/25/18, Resident #37 left the facility without staff knowledge and a passing motorist had to alert the facility that the resident was outside. However, the facility failed to accurately assess the resident's wandering and the resident's risk for getting in potentially dangerous places when the facility completed an MDS assessment on 02/05/18 (refer to F656 and F689). The facility's failure to ensure residents were accurately assessed for wandering has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/02/18, and determined to exist on 01/25/18 at 42 CFR 483.20 Resident Assessment (F641), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 03/02/18. An acceptable Allegation of Compliance was received on 03/16/18, which alleged removal of the Immediate Jeopardy on 03/09/18. The State Survey Agency determined the Immediate Jeopardy was removed on 03/09/18, prior to exit, which lowered the scope and severity to D at 42 CFR 483.20 Resident Assessment (F641), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Resident Assessment Instrument User Manual, Version 3.0 revealed wandering is the act of moving from place to place with or without a specified course or known direction. Wandering may or may not be aimless and the wandering resident may be oblivious to his or her physical or safety needs. The user manual stated some residents who wander are at potentially higher risk for entering an unsafe situation. When completing the Minimum Data Set (MDS), staff should consider the previous review of the resident's wandering behaviors identified in the seven day look-back period and should determine whether those behaviors place the resident at risk for getting in potentially dangerous places. If it is determined that the wandering places the resident at risk, staff should code a 1 on the MDS. Observation of Resident #37 on 02/28/18 at 4:43 PM and on 03/01/18 at 1:44 PM revealed the resident was self-propelling his/her wheelchair in the hallway. Review of Resident #37's medical record revealed the facility admitted the resident on 02/03/17, with diagnoses that included Dementia with Behavioral Disturbance, Cognitive Communication Deficit, Muscle Weakness, Diabetes Mellitus Type II, Hypertension, and Chronic Kidney Disease. Review of Resident #37's admission Minimum Data Set (MDS) assessment dated [DATE], and the quarterly assessment dated [DATE], revealed the resident exhibited no wandering behavior. However, review of the resident's care plan dated 04/22/17 revealed the facility developed a care plan due to the resident being at risk for elopement related to wandering and propelling his/herself up and down the hallways going to exit doors. Review of the 07/31/17, 10/22/17, and 01/15/18 Quarterly MDS Assessments revealed the facility assessed the resident to have wandering daily. Review of a Resident Accident/Incident Report revealed the facility received a call from a passing motorist on 01/25/18, who stated a resident was unattended outside the facility. Review of the report revealed the resident exited the facility without staff knowledge and was returned to the facility and assessed to have an abrasion/bruise to the right knee. Review of Resident #37's Elopement Risk Assessments dated 01/12/18 and 02/05/18 revealed the facility assessed the resident to be cognitively impaired with poor decision-making skills, confusion, and anxiety and wandered aimlessly with decreased safety awareness. The Elopement Risk Assessments further indicated the resident was a possible risk for elopement and wore a code alert bracelet on the right ankle related to attempts to exit the facility by pushing on exit doors looking for [the resident's] mom and stating, I want to go home, I want my mom. Review of Behavior Tracking for Resident #37 dated January 2018 revealed the resident displayed wandering behavior and tried to exit the facility daily with the exception of 01/15/18 and 01/22/18. Review of Resident #37's Behavior Tracking for February 2018 revealed the resident wandered daily with the exception of 02/02/18. Interview with State Registered Nurse Aide (SRNA) #9 on 03/02/18 at 9:30 AM, Kentucky Medication Aide (KMA) #2 on 03/02/18 at 9:15 AM, Registered Nurse (RN) #3 on 03/02/18 at 9:35 AM, Licensed Practical Nurse (LPN) #1 on 03/02/18 at 11:25 AM, and SRNA #5 on 03/01/18 at 3:30 PM revealed Resident #37 frequently wandered to exit doors in the facility. Interview with SRNA #4 on 03/01/18 at 3:25 PM, SRNA #7 on 03/02/18 at 9:20 AM, and RN #2 on 03/01/18 at 4:58 PM revealed Resident #37 propelled him/herself to exit doors more often when the resident was agitated. RN #2 stated agitation was an indication that the resident would have increased exit-seeking behavior. According to SRNA #10 on 03/02/18 at 9:40 AM, Resident #37 attempted to leave the facility through an exit door approximately twenty (20) or more times per day. Review of Resident #37's Annual MDS assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was severely cognitively impaired and not interviewable. The facility assessed Resident #37 to wander one to three days during the previous seven days, even though facility staff had documented the resident wandered six of seven days during the look-back period. In addition, the MDS assessment revealed the resident's wandering behavior did not place the resident at significant risk of getting to a potentially dangerous place such as outside the facility, despite the resident trying to exit facility according to the Behavior Tracking, and having successfully eloped from the facility on 01/25/18. Interview with the Social Services Director (SSD) on 03/06/18 at 2:10 PM, revealed she assessed Resident #37's wandering on the 02/05/18 MDS assessment. She stated the resident's MDS should have indicated the resident wandered four to six days during the seven day look-back period ending 02/05/18, not one to three as stated on the MDS. However, the SSD did not feel that Resident #37's wandering placed the resident at significant risk of getting to a potentially dangerous place, such as outside the facility, and did not foresee dangers for the resident due to the alarms helping protect the resident. *The facility alleged removal of the Immediate Jeopardy as follows: 1. The resident's care plan was updated on 01/25/18 to include the actual elopement from the facility and every fifteen (15) minute checks were implemented with interventions to redirect the resident to common areas as much as possible, offer snacks, and monitor the resident's code alert placement and functioning every hour. Activities were added to the resident's activity plan which includes one to one activity, pictures, newspaper and magazines, snack socials, talking and reminiscing, nail care, and pillow stuffing. 2. Following the elopement a check of all residents was conducted, specifically the eleven (11) residents identified as elopement risks. All residents were safe. 3. Immediately (01/25/18) an in-service was conducted by the Director of Nursing (DON) for all staff working on 01/25/18 and the remainder of the staff were educated the following day re-enforcing that when door alarms sound, staff members are to always check outside before clearing the alarm at the door and panel. In addition, key elements of the elopement protocol were reviewed on 01/25/18 and 01/26/18 with staff. The facility practice related to responding to alarms has always been that the employee closest to the alarm responds to the door alarm, and checks outside to make sure no resident has exited the facility. When the staff member is certain no one has left the building the door alarm can be cleared. As a secondary security measure, the alarm panel at the nurses' station sounds even when a code is entered at the exit door. This alerts staff that someone has entered or exited the door. This is a secondary level of security for residents and staff. The Administrator and DON will oversee the process of responding to alarms Monday through Friday, 9:00 AM to 5:00 PM, and the Charge Nurse will oversee the process after hours and on weekends. 4. The DON immediately (01/25/18) held a meeting with the family member who offered to turn off the alarm at the door. The family was informed of the dual alarms for resident and staff protection. These exits are to be used by only authorized personnel. Staff members were educated on 01/25/18 and ongoing that if unauthorized personnel are seen using this exit, staff were required to notify the Administrator or DON immediately. 5. It has been a practice of this facility to periodically change the codes to the exit doors; however, a log has not been maintained to this point. In the future, the code changes will be logged monthly. 6. Care plans were reviewed for all residents at risk for elopement to ensure each had a care plan for potential elopement and interventions. No problems were identified. 7. An elopement manual is maintained at the nurses' station and front desk. This manual includes a list of residents at risk for elopement and a wander risk identification sheet which includes a picture of each resident at risk. This manual contains recommended diversional activities for each resident who is at risk for elopement. This manual is maintained daily by the Assessment Nurse and reviewed quarterly and is available to all staff. 8. All residents at risk for elopement are checked hourly per protocol. 9. As part of the facility's ongoing Quality Assurance/Performance Improvement (QA/PI) program, the facility will conduct an elopement/missing resident drill at least monthly to ensure staff reacted to alarms by checking all exit doors and accounting for all residents. These drills will be made part of the monthly QA/PI meeting. Members of this committee include the Administrator, Director of Nursing, Maintenance, Housekeeping, Activities, Social Services, and the Medical Director. Drills will be conducted by the Administrator and Director of Nursing and assisted by their designee. The facility conducted a drill on 03/08/18, and staff responded appropriately. 10. In addition to elopement/missing resident drills, the DON began interviewing staff on 01/26/18, following the in-services to ensure the staff was competent related to alarm response/missing resident drills and diversional activities. Approximately fifty (50) percent of staff members have been interviewed on all three (3) shifts by the DON. Monthly, ten (10) percent of staff will be interviewed by the DON to determine proper responses to elopement drills, missing resident, unauthorized personnel using the ambulance entrance, and location of the elopement risk notebook. **The SA verified the removal of Immediate Jeopardy as follows: 1. Review of resident #37's care plan revealed the facility updated the care plan on 01/25/18 to reflect the resident's elopement and an intervention was implemented to include checking on the resident every fifteen (15) minutes for twenty-four hours, attempt to redirect the resident to a common area as much as possible, offer snacks, and monitor the code alert bracelet placement every hour and functioning daily. Record review revealed the facility checked on the resident every fifteen (15) minutes on 01/25/18, for twenty-four hours. Review of the resident's activity log revealed activities were documented. 2. Review of facility documentation revealed the DON documented that all residents were accounted for on 01/25/18, after Resident #37 eloped from the facility 3. Review of in-service rosters dated 01/25/18 and 01/26/18, revealed all staff had attended an in-service given by the DON related to action to be taken when an alarm sounds. Review of an in-service dated 03/05/18 revealed the DON educated all staff that nursing was required to conduct a check of the alarm panel each shift with the oncoming nurse to ensure the alarm had not been bypassed and exit doors were working properly. Nurses were required to document the check was completed on the shift report. SRNAs were also required to do a walking round with the oncoming SRNA each shift to visualize each resident and ensure their safety. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed if an alarm sounded, the employee closest to the alarm was responsible for responding to the door alarm. Two (2) staff members were required to split up and walk completely around the building to ensure no resident had exited the building. The staff stated the alarm could only be cleared when all the residents were accounted for. The staff stated the Administrator, DON, or the Charge Nurse responded to all alarms to oversee the process. Continued interviews with nursing staff revealed they were required to check the alarm panel to ensure it had not been bypassed and to document the information on the shift report every shift. They stated they were also required to check the door alarms to ensure they were working correctly. The SRNAs stated they were required to do walking rounds with the oncoming SRNA each shift to visualize each resident and to ensure the resident's safety. 4. Interview with the DON on 03/16/18 at 3:16 PM, revealed she spoke with the family member on 01/25/18 and instructed him/her not to turn off alarms at the doors. The DON stated she had also in-serviced staff regarding not giving door codes to families and visitors. The DON stated staff was required to notify her or the Administrator immediately if a family member or visitor was observed turning off a door alarm. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed staff were knowledgeable that they were required to notify the DON or the Administrator immediately if any family member or visitor was observed to enter the code to turn off a door alarm. 5. Review of a Code Alert Door Check revealed the door exit codes were changed on 03/02/18. The log also revealed the door alarms were checked weekly by the Maintenance Department. Interview with the Maintenance Supervisor on 03/16/18 at 3:11 PM, revealed she changed the door codes on 03/02/18 and would be changing them every month. The Maintenance Supervisor stated she documented the changes on the Code Alert Door Check log. 6. Review of elopement assessments revealed the MDS Nurse assessed all residents' elopement risk on 03/05/18. The assessments revealed the facility assessed eleven (11) residents to be at risk for elopement (Resident #2, Resident #7, Resident #8, Resident #14, Resident #17, Resident #19, Resident #29, Resident #37, Resident #44, Resident #47, Resident #50, Resident #56, and Resident #210). A review of the residents' care plans revealed the care plans were reviewed and updated on 03/05/18. Interview with the MDS Nurse on 03/16/18 at 2:10 PM revealed she assisted with completing elopement risk assessments for all residents in the facility. The MDS Nurse also revealed she and the MDS Coordinator, who was not at the facility on 03/16/18, had reviewed all residents' care plans who had been assessed by the facility to be at risk for elopement to ensure each had interventions to address the potential for elopement. The MDS Nurse stated she was responsible for ensuring the Elopement Notebook was reviewed quarterly and remained available for staff. 7. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed an elopement book was kept at the nurses' stations and the front desk that contained the face sheet, picture, and a list of activities that had been developed for every resident who had been assessed by the facility to be at risk for elopement. Staff stated they were required to redirect a resident if they attempted to leave the facility. Staff further stated they were also required to check the elopement book, turn to the resident's name, and use one of the interventions listed to redirect the resident. Review of the Elopement Notebook at the nurses' station and at the front desk, revealed all residents who had been assessed by the facility to be at risk for elopement were included in the book and a list of interventions were documented. In addition, the elopement notebook also was observed to contain a picture of the resident and the resident's face sheet. Interview with the MDS Nurse on 03/16/18 at 2:10 PM, revealed she was responsible for ensuring the Elopement Notebooks were reviewed quarterly and remained available for staff. 8. Review of the record for the residents who were assessed to be at risk for elopement (Resident #2, Resident #7, Resident #8, Resident #14, Resident #17, Resident #19, Resident #29, Resident #37, Resident #44, Resident #47, Resident #50, Resident #56, and Resident #210) revealed staff documented that they checked their whereabouts at least once every hour. Interviews with SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, and SRNA #14 on 03/16/18 at 2:46 PM, revealed they monitored all residents who were at risk for elopement every hour and more often if needed. 9. Review of Elopement Drills revealed on 03/08/18 the facility had an individual attempt to exit the facility and the alarm sounded. Staff responded promptly and the door did not open because staff reached the resident before the door could open. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed they had participated in an elopement drill on 03/08/18. 10. Interview with the DON on 03/16/18 at 3:16 PM and review of documentation revealed she interviewed fifty percent of the staff after the in-services were completed to ensure staff were competent. The DON stated she would be interviewing ten (10) percent of the staff every month to ensure staff gave the proper response regarding elopement drills, missing residents, unauthorized personnel using the door codes, and the location of the elopement notebook.

Based on observation, interview, record review, review of the facility's Accident/Incident report, and review of the facility's policy, it was determined the facility failed to develop a comprehensive person-centered plan of care for one (1) of seventeen (17) sampled residents (Resident #37). Due to the facility's failure to accurately conduct a comprehensive assessment for Resident #37, the facility failed to develop a care plan with interventions which minimized the resident's risk for leaving the facility without staff knowledge. On 01/25/18, facility staff was unaware that Resident #37 had exited the facility and was outside unattended until a passing motorist notified them that the resident was outside. The facility's failure to ensure resident care plans were developed to minimize elopement risk has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/02/18, and determined to exist on 01/25/18 at 42 CFR 483.20 Resident Assessment (F641), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 03/02/18. An acceptable Allegation of Compliance was received on 03/16/18, which alleged removal of the Immediate Jeopardy on 03/09/18. The State Survey Agency determined the Immediate Jeopardy was removed on 03/09/18, prior to exit, which lowered the scope and severity to D at 42 CFR 483.20 Resident Assessment (F641), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Care Plan Goals and Objectives and Using the Care Plan policies dated 08/01/13, revealed the facility's goal for developing a care plan was to achieve the desired outcome for a specific resident problem. Information would be derived from the resident's comprehensive assessment and be resident oriented and measurable. The policies also stated that the care plan would be developed utilizing the resident's daily care routines and would be available to all staff that were responsible for providing care or services to the resident. Review of the Resident Assessment Instrument User Manual, Version 3.0 revealed wandering could be the pursuit of exercise, pleasurable activity, or it may be related to tension, anxiety, agitation, or searching; therefore, the care planning process should include an assessment of the resident's wandering to determine the frequency of the occurrence and to identify any factors that triggered the behavior or decreased the episodes in order to ensure an individualized, person-centered plan of care was implemented. Review of Resident #37's medical record revealed the facility admitted the resident on 02/03/17, with diagnoses that included Dementia with Behavioral Disturbance, Cognitive Communication Deficit, Muscle Weakness, Diabetes Mellitus Type II, Hypertension, and Chronic Kidney Disease. Observation of Resident #37 on 02/28/18 at 4:43 PM and on 03/01/18 at 1:44 PM revealed the resident was self-propelling his/her wheelchair in the hallway of the facility. Review of the resident's care plan dated 04/22/17 revealed the facility identified that the resident was at risk for elopement due to wandering in the facility and to exit doors. However, the facility only developed interventions to monitor equipment utilized to alert staff when the resident exited a door. Staff were to ensure the device was in place and functional. The facility failed to develop interventions, including adequate supervision and specific diversional activities consistent with the resident's needs and goals, in order to eliminate/reduce the risk if possible, of the resident exiting the facility or being placed at risk for harm. Review of a Resident Accident/Incident Report revealed on 01/25/18, a passing motorist notified the facility that a resident was outside unattended. Review of the Report revealed Resident #37 had exited the facility without staff knowledge, was assisted back into the facility, and assessed to have an abrasion/bruise to the right knee. Review of RN #1's witness statement dated 01/25/18, and interview with RN #1 on 03/01/18 at 4:43 PM, revealed on 01/25/18 she last observed Resident #37 at approximately 4:30 PM, just prior to the resident leaving the facility. Although RN #1 redirected the resident from the Hall 3 door, the RN took no further action to ensure Resident #37's safety or prevent the resident from further attempts to exit the facility. RN #1 stated she had called out to [Resident #37] from the nurses' station, but implemented no further interventions such as diversional activities or increased supervision. Review of Resident #37's care plan dated 01/25/18 revealed the facility revised the resident's care plan to include the resident's elopement from the facility. The facility developed interventions to prevent the resident from exiting the facility that included fifteen (15) minute safety checks for twenty-four hours; attempt to redirect the resident to a common area as much as possible; offer snacks; and monitor the code alert bracelet placement every hour and functionality daily. However, there was no evidence the facility developed interventions that described the specific steps staff should implement to achieve the resident's goals that could be measured, quantified, and/or verified. The care plan stated staff should conduct fifteen-minute safety checks for twenty-four hours; however, the care plan did not address the potential need for future increased supervision, or who should implement increased supervision when the resident's behavior warranted. The facility also developed an intervention to attempt to redirect the resident to a common area as much as possible. However, the intervention did not direct staff on the steps to take should redirection of the resident not be possible; and the interventions did not include diversional activities consistent with the resident's activity preferences. In addition, interviews with State Registered Nurse Aide (SRNA) #6 on 03/02/18 at 9:10 AM, Kentucky Medication Aide (KMA) #2 on 03/02/18 at 9:15 AM, SRNA #7 on 03/02/18 at 9:20 AM, KMA #1 on 03/02/18 at 9:00 AM, RN #2 on 03/02/18 at 4:58 PM, SRNA #4 on 03/01/18 at 3:25 PM, and SRNA #5 on 03/01/18 at 3:30 PM, revealed they were aware that Resident #37 had exit-seeking behavior. They stated they were all made aware that the resident should be redirected; however, specific redirection for Resident #37 was not detailed on the resident's care plan for the staff to follow or what staff should do if redirection was not possible. In addition, SRNA #4, KMA #2, SRNA #4, and RN #2 stated when Resident #37 was agitated, the resident's exit-seeking behavior increased. However, there was no evidence the facility identified this trigger for the resident and no interventions were developed to prevent/address the increased likelihood that the resident may elope from the facility when this behavior occurred. Interviews with the MDS Coordinator and the MDS Nurse (LPN #1) on 03/02/18 at 11:25 AM, revealed if a resident was at risk for elopement, an assessment was completed and interventions were implemented to offer the resident snacks and activities, and to redirect the resident. *The facility alleged removal of the Immediate Jeopardy as follows: 1. The resident's care plan was updated on 01/25/18 to include the actual elopement from the facility and every fifteen (15) minute checks were implemented with interventions to redirect the resident to common areas as much as possible, offer snacks, and monitor the resident's code alert placement and functioning every hour. Activities were added to the resident's activity plan which includes one to one activity, pictures, newspaper and magazines, snack socials, talking and reminiscing, nail care, and pillow stuffing. 2. Following the elopement a check of all residents was conducted, specifically the eleven (11) residents identified as elopement risks. All residents were safe. 3. Immediately (01/25/18) an in-service was conducted by the Director of Nursing (DON) for all staff working on 01/25/18 and the remainder of the staff were educated the following day re-enforcing that when door alarms sound, staff members are to always check outside before clearing the alarm at the door and panel. In addition, key elements of the elopement protocol were reviewed on 01/25/18 and 01/26/18 with staff. The facility practice related to responding to alarms has always been that the employee closest to the alarm responds to the door alarm, and checks outside to make sure no resident has exited the facility. When the staff member is certain no one has left the building the door alarm can be cleared. As a secondary security measure, the alarm panel at the nurses' station sounds even when a code is entered at the exit door. This alerts staff that someone has entered or exited the door. This is a secondary level of security for residents and staff. The Administrator and DON will oversee the process of responding to alarms Monday through Friday, 9:00 AM to 5:00 PM, and the Charge Nurse will oversee the process after hours and on weekends. 4. The DON immediately (01/25/18) held a meeting with the family member who offered to turn off the alarm at the door. The family was informed of the dual alarms for resident and staff protection. These exits are to be used by only authorized personnel. Staff members were educated on 01/25/18 and ongoing that if unauthorized personnel are seen using this exit, staff were required to notify the Administrator or DON immediately. 5. It has been a practice of this facility to periodically change the codes to the exit doors; however, a log has not been maintained to this point. In the future, the code changes will be logged monthly. 6. Care plans were reviewed for all residents at risk for elopement to ensure each had a care plan for potential elopement and interventions. No problems were identified. 7. An elopement manual is maintained at the nurses' station and front desk. This manual includes a list of residents at risk for elopement and a wander risk identification sheet which includes a picture of each resident at risk. This manual contains recommended diversional activities for each resident who is at risk for elopement. This manual is maintained daily by the Assessment Nurse and reviewed quarterly and is available to all staff. 8. All residents at risk for elopement are checked hourly per protocol. 9. As part of the facility's ongoing Quality Assurance/Performance Improvement (QA/PI) program, the facility will conduct an elopement/missing resident drill at least monthly to ensure staff reacted to alarms by checking all exit doors and accounting for all residents. These drills will be made part of the monthly QA/PI meeting. Members of this committee include the Administrator, Director of Nursing, Maintenance, Housekeeping, Activities, Social Services, and the Medical Director. Drills will be conducted by the Administrator and Director of Nursing and assisted by their designee. The facility conducted a drill on 03/08/18, and staff responded appropriately. 10. In addition to elopement/missing resident drills, the DON began interviewing staff on 01/26/18, following the in-services to ensure the staff was competent related to alarm response/missing resident drills and diversional activities. Approximately fifty (50) percent of staff members have been interviewed on all three (3) shifts by the DON. Monthly, ten (10) percent of staff will be interviewed by the DON to determine proper responses to elopement drills, missing resident, unauthorized personnel using the ambulance entrance, and location of the elopement risk notebook. **The SA verified the removal of Immediate Jeopardy as follows: 1. Review of resident #37's care plan revealed the facility updated the care plan on 01/25/18 to reflect the resident's elopement and an intervention was implemented to include checking on the resident every fifteen (15) minutes for twenty-four hours, attempt to redirect the resident to a common area as much as possible, offer snacks, and monitor the code alert bracelet placement every hour and functioning daily. Record review revealed the facility checked on the resident every fifteen (15) minutes on 01/25/18, for twenty-four hours. Review of the resident's activity log revealed activities were documented. 2. Review of facility documentation revealed the DON documented that all residents were accounted for on 01/25/18, after Resident #37 eloped from the facility 3. Review of in-service rosters dated 01/25/18 and 01/26/18, revealed all staff had attended an in-service given by the DON related to action to be taken when an alarm sounds. Review of an in-service dated 03/05/18 revealed the DON educated all staff that nursing was required to conduct a check of the alarm panel each shift with the oncoming nurse to ensure the alarm had not been bypassed and exit doors were working properly. Nurses were required to document the check was completed on the shift report. SRNAs were also required to do a walking round with the oncoming SRNA each shift to visualize each resident and ensure their safety. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed if an alarm sounded, the employee closest to the alarm was responsible for responding to the door alarm. Two (2) staff members were required to split up and walk completely around the building to ensure no resident had exited the building. The staff stated the alarm could only be cleared when all the residents were accounted for. The staff stated the Administrator, DON, or the Charge Nurse responded to all alarms to oversee the process. Continued interviews with nursing staff revealed they were required to check the alarm panel to ensure it had not been bypassed and to document the information on the shift report every shift. They stated they were also required to check the door alarms to ensure they were working correctly. The SRNAs stated they were required to do walking rounds with the oncoming SRNA each shift to visualize each resident and to ensure the resident's safety. 4. Interview with the DON on 03/16/18 at 3:16 PM, revealed she spoke with the family member on 01/25/18 and instructed him/her not to turn off alarms at the doors. The DON stated she had also in-serviced staff regarding not giving door codes to families and visitors. The DON stated staff was required to notify her or the Administrator immediately if a family member or visitor was observed turning off a door alarm. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed staff were knowledgeable that they were required to notify the DON or the Administrator immediately if any family member or visitor was observed to enter the code to turn off a door alarm. 5. Review of a Code Alert Door Check revealed the door exit codes were changed on 03/02/18. The log also revealed the door alarms were checked weekly by the Maintenance Department. Interview with the Maintenance Supervisor on 03/16/18 at 3:11 PM, revealed she changed the door codes on 03/02/18 and would be changing them every month. The Maintenance Supervisor stated she documented the changes on the Code Alert Door Check log. 6. Review of elopement assessments revealed the MDS Nurse assessed all residents' elopement risk on 03/05/18. The assessments revealed the facility assessed eleven (11) residents to be at risk for elopement (Resident #2, Resident #7, Resident #8, Resident #14, Resident #17, Resident #19, Resident #29, Resident #37, Resident #44, Resident #47, Resident #50, Resident #56, and Resident #210). A review of the residents' care plans revealed the care plans were reviewed and updated on 03/05/18. Interview with the MDS Nurse on 03/16/18 at 2:10 PM revealed she assisted with completing elopement risk assessments for all residents in the facility. The MDS Nurse also revealed she and the MDS Coordinator, who was not at the facility on 03/16/18, had reviewed all residents' care plans who had been assessed by the facility to be at risk for elopement to ensure each had interventions to address the potential for elopement. The MDS Nurse stated she was responsible for ensuring the Elopement Notebook was reviewed quarterly and remained available for staff. 7. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed an elopement book was kept at the nurses' stations and the front desk that contained the face sheet, picture, and a list of activities that had been developed for every resident who had been assessed by the facility to be at risk for elopement. Staff stated they were required to redirect a resident if they attempted to leave the facility. Staff further stated they were also required to check the elopement book, turn to the resident's name, and use one of the interventions listed to redirect the resident. Review of the Elopement Notebook at the nurses' station and at the front desk, revealed all residents who had been assessed by the facility to be at risk for elopement were included in the book and a list of interventions were documented. In addition, the elopement notebook also was observed to contain a picture of the resident and the resident's face sheet. Interview with the MDS Nurse on 03/16/18 at 2:10 PM, revealed she was responsible for ensuring the Elopement Notebooks were reviewed quarterly and remained available for staff. 8. Review of the record for the residents who were assessed to be at risk for elopement (Resident #2, Resident #7, Resident #8, Resident #14, Resident #17, Resident #19, Resident #29, Resident #37, Resident #44, Resident #47, Resident #50, Resident #56, and Resident #210) revealed staff documented that they checked their whereabouts at least once every hour. Interviews with SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, and SRNA #14 on 03/16/18 at 2:46 PM, revealed they monitored all residents who were at risk for elopement every hour and more often if needed. 9. Review of Elopement Drills revealed on 03/08/18 the facility had an individual attempt to exit the facility and the alarm sounded. Staff responded promptly and the door did not open because staff reached the resident before the door could open. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed they had participated in an elopement drill on 03/08/18. 10. Interview with the DON on 03/16/18 at 3:16 PM and review of documentation revealed she interviewed fifty percent of the staff after the in-services were completed to ensure staff were competent. The DON stated she would be interviewing ten (10) percent of the staff every month to ensure staff gave the proper response regarding elopement drills, missing residents, unauthorized personnel using the door codes, and the location of the elopement notebook.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's Accident/Incident report, and review of the facility's policy, it was determined the facility failed to provide supervision to prevent accidents for one (1) of seventeen (17) sampled residents (Resident #37). On 01/25/18 at approximately 4:30 PM, an alarm sounded to the exit door on the facility's 200 Unit for several minutes. Facility staff and a visitor turned off the alarm; however, staff failed to ensure that a resident had not exited the building. Subsequently Resident #37, who had a diagnosis of Dementia and was cognitively impaired, was outside unattended until a passing motorist notified the facility that a resident was outside the facility. Staff determined that Resident #37 had exited the building without staff knowledge, assisted the resident back inside, and assessed the resident to have an abrasion/bruise to the right knee. The facility's failure to ensure residents were supervised to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/02/18, and determined to exist on 01/25/18 at 42 CFR 483.20 Resident Assessment (F641), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 03/02/18. An acceptable Allegation of Compliance was received on 03/16/18, which alleged removal of the Immediate Jeopardy on 03/09/18. The State Survey Agency determined the Immediate Jeopardy was removed on 03/09/18, prior to exit, which lowered the scope and severity to D at 42 CFR 483.20 Resident Assessment (F641), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's protocol titled Elopement/Wander Risk, undated, revealed it was the expectation that the facility would ensure that each resident received adequate supervision and assistance to prevent accidents. Residents who were identified through the Elopement Risk Assessment process as being at risk for elopement, would have interventions in place to minimize such risk. Interview with the Director of Nursing (DON) on 03/02/18 at 2:48 PM, and the Minimum Data Set (MDS) Coordinator on 03/02/18 at 9:42 AM, revealed when an exit door alarm sounded, staff were required to check outside the door to ensure a resident had not exited the building. Observation of Resident #37 on 02/28/18 at 4:43 PM and on 03/01/18 at 1:44 PM revealed the resident was self-propelling his/her wheelchair in the hallway. Review of Resident #37's medical record revealed the facility admitted the resident on 02/03/17, with diagnoses that included Diabetes Mellitus Type II, Hypertension, Cognitive Communication Deficit, Muscle Weakness, Dementia with Behavioral Disturbance, and Chronic Kidney Disease. Review of Resident #37's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4), indicating the resident was cognitively impaired. The facility also assessed the resident to wander daily (Wandering is the act of moving from place to place with or without a specified course or known direction. Wandering may or may not be aimless and the resident wandering may be oblivious to his or her physical or safety needs.). The MDS Assessment further revealed Resident #37 required the extensive assistance of two (2) staff members for all activities of daily living (ADLs) with the exception of locomotion on and off the unit, which required the supervision/oversight of one individual. The assessment further revealed Resident #37 was unsteady and utilized a walker and a wheelchair for mobility. Review of Resident #37's Elopement Risk assessment dated [DATE] revealed the facility assessed the resident to be physically able to leave the facility on his/her own. Further review of the Elopement Risk Assessment revealed the resident was cognitively impaired with poor decision-making skills, confusion and anxiety, and wandered aimlessly with decreased safety awareness. The Elopement Risk Assessment further indicated the resident was a possible risk for elopement and wore a code alert bracelet on the right ankle related to attempts to exit the facility by pushing on exit doors looking for [the resident's] mom and stating, I want to go home, I want my mom. Review of Resident #37's Comprehensive Plan of Care dated 02/03/17 revealed the facility identified the resident had an alteration in thought processes related to dementia. The facility developed interventions for staff to provide frequent cues, reminders, and supervision and to invite and encourage daily activities for the resident. The facility also developed a care plan dated 02/03/17 related to the resident's potential for impaired physical mobility; attempted self-transfers at times; and wheelchair utilization for long distances. The Comprehensive Plan of Care dated 04/22/17 further revealed the facility identified that Resident #37 had the potential for elopement related to wandering, propelling independently in hallways and to exit doors, and removing his/her code alert bracelet. The facility developed interventions to monitor the resident's code alert bracelet and check functioning daily, and to check placement every hour. Review of a Resident Accident/Incident Report revealed the facility received a call from a passerby on 01/25/18 at 4:30 PM, informing them that a resident was outside the facility. The Report stated two (2) staff members found Resident #37 outside the facility and assisted the resident back into the building through the door on Hall 2. According to the investigation, the alarm for the Hall 2 door sounded and a visitor reset the door code. The State Registered Nurse Aide (SRNA) stated the door was bypassed and only the small alarm sounded. The Report stated staff did not check outside the Hall 2 door to determine why the alarm sounded. Review of the weather history for 01/25/18 at 4:15 PM for the area where the facility was located revealed the temperature was 45.5 degrees Fahrenheit (F). At 4:35 PM, the temperature was 45.7 degrees F with a wind chill of 43.4 degrees F. Interview with SRNA #2 on 03/01/18 at 4:19 PM revealed on 01/25/18 she heard an alarm sounding, and was instructed by Registered Nurse (RN) #1 to enter the door code to silence the alarm. SRNA #2 stated as she went down the Unit 200 Hallway, a visitor stepped out into the hallway near the alarming door and asked the SRNA if she wanted her to enter the code to stop the alarm from sounding, and the SRNA said yes. The SRNA stated after the door alarm was silenced, she then turned the alarm off at the nurses' station, and resumed her previous duties, without checking to determine why the alarm had sounded. According to SRNA #2, Resident #37 was found outside the facility between the creek and the road approximately 10-15 minutes later, after someone passing by the facility reported a resident was outside unattended. According to SRNA #2, Resident #37 was wearing pants, a shirt, sweater, and shoes. Review of RN #1's witness statement dated 01/25/18, and interview with RN #1 on 03/01/18 at 4:43 PM, revealed on 01/25/18 when she heard the alarm sounding, she instructed SRNA #2 to check the alarm. RN #1 stated she observed the SRNA turn off the alarm at the nurses' station, but RN #1 did not take any action to determine why the alarm sounded. RN #1 stated she had redirected Resident #37 from both the 300 and 400 Hallway doors earlier in the shift. Continued interview and review of RN #1's statement revealed she had last observed Resident #37 at approximately 4:30 PM, attempting to exit the facility via the Hall 3 exit door by pushing on the door handle. The statement revealed RN #1 called out to [Resident #37] from the nurses' station and instructed the resident to come toward the nurses' station. Interview with a Facility Visitor on 03/02/18 at 11:30 AM revealed she heard the alarm sounding from her mother's room. She stated the alarm sounded for several minutes. The Visitor stated she normally ignored alarms at the facility but the alarm went off so long that she walked into the hallway to see what was happening. She stated she saw SRNA #2 trying to turn off the alarm at the nurses' station and asked the SRNA if she wanted her to turn off the alarm at the door. The Visitor stated she turned off the alarm, but she did not see anyone outside the door. She stated she did not know a resident went out the door until a nurse came back several minutes later and asked her not to enter the code to turn off the door alarm again. Interview with RN #2 on 03/01/18 at 4:58 PM, revealed she was assigned to provide care for Resident #37 on 01/25/18. She stated Resident #37 was more agitated than usual, which was an indication that the resident would have increased exit-seeking behavior. However, there was no evidence the RN took any action to supervise the resident when the resident's agitation and exit-seeking behavior increased. Interview with SRNA #10 on 03/02/18 at 9:40 AM revealed Resident #37 attempted to leave the facility through an exit door approximately twenty (20) or more times per day. *The facility alleged removal of the Immediate Jeopardy as follows: 1. The resident's care plan was updated on 01/25/18 to include the actual elopement from the facility and every fifteen (15) minute checks were implemented with interventions to redirect the resident to common areas as much as possible, offer snacks, and monitor the resident's code alert placement and functioning every hour. Activities were added to the resident's activity plan which includes one to one activity, pictures, newspaper and magazines, snack socials, talking and reminiscing, nail care, and pillow stuffing. 2. Following the elopement a check of all residents was conducted, specifically the eleven (11) residents identified as elopement risks. All residents were safe. 3. Immediately (01/25/18) an in-service was conducted by the Director of Nursing (DON) for all staff working on 01/25/18 and the remainder of the staff were educated the following day re-enforcing that when door alarms sound, staff members are to always check outside before clearing the alarm at the door and panel. In addition, key elements of the elopement protocol were reviewed on 01/25/18 and 01/26/18 with staff. The facility practice related to responding to alarms has always been that the employee closest to the alarm responds to the door alarm, and checks outside to make sure no resident has exited the facility. When the staff member is certain no one has left the building the door alarm can be cleared. As a secondary security measure, the alarm panel at the nurses' station sounds even when a code is entered at the exit door. This alerts staff that someone has entered or exited the door. This is a secondary level of security for residents and staff. The Administrator and DON will oversee the process of responding to alarms Monday through Friday, 9:00 AM to 5:00 PM, and the Charge Nurse will oversee the process after hours and on weekends. 4. The DON immediately (01/25/18) held a meeting with the family member who offered to turn off the alarm at the door. The family was informed of the dual alarms for resident and staff protection. These exits are to be used by only authorized personnel. Staff members were educated on 01/25/18 and ongoing that if unauthorized personnel are seen using this exit, staff were required to notify the Administrator or DON immediately. 5. It has been a practice of this facility to periodically change the codes to the exit doors; however, a log has not been maintained to this point. In the future, the code changes will be logged monthly. 6. Care plans were reviewed for all residents at risk for elopement to ensure each had a care plan for potential elopement and interventions. No problems were identified. 7. An elopement manual is maintained at the nurses' station and front desk. This manual includes a list of residents at risk for elopement and a wander risk identification sheet which includes a picture of each resident at risk. This manual contains recommended diversional activities for each resident who is at risk for elopement. This manual is maintained daily by the Assessment Nurse and reviewed quarterly and is available to all staff. 8. All residents at risk for elopement are checked hourly per protocol. 9. As part of the facility's ongoing Quality Assurance/Performance Improvement (QA/PI) program, the facility will conduct an elopement/missing resident drill at least monthly to ensure staff reacted to alarms by checking all exit doors and accounting for all residents. These drills will be made part of the monthly QA/PI meeting. Members of this committee include the Administrator, Director of Nursing, Maintenance, Housekeeping, Activities, Social Services, and the Medical Director. Drills will be conducted by the Administrator and Director of Nursing and assisted by their designee. The facility conducted a drill on 03/08/18, and staff responded appropriately. 10. In addition to elopement/missing resident drills, the DON began interviewing staff on 01/26/18, following the in-services to ensure the staff was competent related to alarm response/missing resident drills and diversional activities. Approximately fifty (50) percent of staff members have been interviewed on all three (3) shifts by the DON. Monthly, ten (10) percent of staff will be interviewed by the DON to determine proper responses to elopement drills, missing resident, unauthorized personnel using the ambulance entrance, and location of the elopement risk notebook. **The SA verified the removal of Immediate Jeopardy as follows: 1. Review of resident #37's care plan revealed the facility updated the care plan on 01/25/18 to reflect the resident's elopement and an intervention was implemented to include checking on the resident every fifteen (15) minutes for twenty-four hours, attempt to redirect the resident to a common area as much as possible, offer snacks, and monitor the code alert bracelet placement every hour and functioning daily. Record review revealed the facility checked on the resident every fifteen (15) minutes on 01/25/18, for twenty-four hours. Review of the resident's activity log revealed activities were documented. 2. Review of facility documentation revealed the DON documented that all residents were accounted for on 01/25/18, after Resident #37 eloped from the facility 3. Review of in-service rosters dated 01/25/18 and 01/26/18, revealed all staff had attended an in-service given by the DON related to action to be taken when an alarm sounds. Review of an in-service dated 03/05/18 revealed the DON educated all staff that nursing was required to conduct a check of the alarm panel each shift with the oncoming nurse to ensure the alarm had not been bypassed and exit doors were working properly. Nurses were required to document the check was completed on the shift report. SRNAs were also required to do a walking round with the oncoming SRNA each shift to visualize each resident and ensure their safety. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed if an alarm sounded, the employee closest to the alarm was responsible for responding to the door alarm. Two (2) staff members were required to split up and walk completely around the building to ensure no resident had exited the building. The staff stated the alarm could only be cleared when all the residents were accounted for. The staff stated the Administrator, DON, or the Charge Nurse responded to all alarms to oversee the process. Continued interviews with nursing staff revealed they were required to check the alarm panel to ensure it had not been bypassed and to document the information on the shift report every shift. They stated they were also required to check the door alarms to ensure they were working correctly. The SRNAs stated they were required to do walking rounds with the oncoming SRNA each shift to visualize each resident and to ensure the resident's safety. 4. Interview with the DON on 03/16/18 at 3:16 PM, revealed she spoke with the family member on 01/25/18 and instructed him/her not to turn off alarms at the doors. The DON stated she had also in-serviced staff regarding not giving door codes to families and visitors. The DON stated staff was required to notify her or the Administrator immediately if a family member or visitor was observed turning off a door alarm. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed staff were knowledgeable that they were required to notify the DON or the Administrator immediately if any family member or visitor was observed to enter the code to turn off a door alarm. 5. Review of a Code Alert Door Check revealed the door exit codes were changed on 03/02/18. The log also revealed the door alarms were checked weekly by the Maintenance Department. Interview with the Maintenance Supervisor on 03/16/18 at 3:11 PM, revealed she changed the door codes on 03/02/18 and would be changing them every month. The Maintenance Supervisor stated she documented the changes on the Code Alert Door Check log. 6. Review of elopement assessments revealed the MDS Nurse assessed all residents' elopement risk on 03/05/18. The assessments revealed the facility assessed eleven (11) residents to be at risk for elopement (Resident #2, Resident #7, Resident #8, Resident #14, Resident #17, Resident #19, Resident #29, Resident #37, Resident #44, Resident #47, Resident #50, Resident #56, and Resident #210). A review of the residents' care plans revealed the care plans were reviewed and updated on 03/05/18. Interview with the MDS Nurse on 03/16/18 at 2:10 PM revealed she assisted with completing elopement risk assessments for all residents in the facility. The MDS Nurse also revealed she and the MDS Coordinator, who was not at the facility on 03/16/18, had reviewed all residents' care plans who had been assessed by the facility to be at risk for elopement to ensure each had interventions to address the potential for elopement. The MDS Nurse stated she was responsible for ensuring the Elopement Notebook was reviewed quarterly and remained available for staff. 7. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed an elopement book was kept at the nurses' stations and the front desk that contained the face sheet, picture, and a list of activities that had been developed for every resident who had been assessed by the facility to be at risk for elopement. Staff stated they were required to redirect a resident if they attempted to leave the facility. Staff further stated they were also required to check the elopement book, turn to the resident's name, and use one of the interventions listed to redirect the resident. Review of the Elopement Notebook at the nurses' station and at the front desk, revealed all residents who had been assessed by the facility to be at risk for elopement were included in the book and a list of interventions were documented. In addition, the elopement notebook also was observed to contain a picture of the resident and the resident's face sheet. Interview with the MDS Nurse on 03/16/18 at 2:10 PM, revealed she was responsible for ensuring the Elopement Notebooks were reviewed quarterly and remained available for staff. 8. Review of the record for the residents who were assessed to be at risk for elopement (Resident #2, Resident #7, Resident #8, Resident #14, Resident #17, Resident #19, Resident #29, Resident #37, Resident #44, Resident #47, Resident #50, Resident #56, and Resident #210) revealed staff documented that they checked their whereabouts at least once every hour. Interviews with SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, and SRNA #14 on 03/16/18 at 2:46 PM, revealed they monitored all residents who were at risk for elopement every hour and more often if needed. 9. Review of Elopement Drills revealed on 03/08/18 the facility had an individual attempt to exit the facility and the alarm sounded. Staff responded promptly and the door did not open because staff reached the resident before the door could open. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed they had participated in an elopement drill on 03/08/18. 10. Interview with the DON on 03/16/18 at 3:16 PM and review of documentation revealed she interviewed fifty percent of the staff after the in-services were completed to ensure staff were competent. The DON stated she would be interviewing ten (10) percent of the staff every month to ensure staff gave the proper response regarding elopement drills, missing residents, unauthorized personnel using the door codes, and the location of the elopement notebook.