**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' baseline care plan which provided instructions needed to provide effective and person-centered care for each resident was implemented for 1 of 5 (Resident (R) 9) sampled residents reviewed for elopement risk. Resident 9, who had major neurocognitive impairment, was care planned to be monitored frequently for his whereabouts, however, on 07/27/2025, the Resident left the facility by removing his bedroom window and climbing through it without staff knowledge/supervision. The Resident walked approximately 1.3 miles, in the dark. The failure to implement R9's baseline care plan to prevent R9's elopement during 81-degree heat with 90-degree heat index created Immediate Jeopardy with the likelihood for serious harm or death.Immediate Jeopardy (IJ) was identified on 08/13/2025 and was determined to exist on 07/27/2025 in the areas of 42 CFR S483.25, F689 Free of Accident/Hazards/Supervision/Devices and 42 CFR S 483.21, F656 Develop/Implement Comprehensive Care Plan. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25, F689 Free of Accident/Hazards/Supervision/Devices. The facility was notified of the IJs on 08/13/2025.On 08/13/2025 at 4:00PM, the Director of Nursing, Administrator and the Regional Director of Clinical Services were notified of the Immediate Jeopardy (IJ) and provided a copy of the Center for Medicare & Medicaid Services (CMS) IJ Template and was notified that R9's elopement from the facility on 07/27/2025 constituted an IJ.The facility provided an acceptable plan for removal of the IJ on 08/15/2025, alleging removal on 08/04/2025. The State Survey Agency (SSA) survey team validated the IJ was removed on 08/04/2025, prior to the SSA entrance on 08/07/2025, according to the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice was determined to be past non-compliance. The findings include:Review of the facility's policy, Safety and Supervision of Residents ((C) 2001 MED-PASS, Inc.) revealed the facility used a facility and resident oriented approach to environmental safety. Per review, their systems approach considered hazard identified and individual resident risk factors and adjusted interventions accordingly. Per review, the facility mitigated safety and accident hazards with an individualized, resident-centered approach which included: identifying specific hazards by analyzing assessments and observations, provide targeted interventions, which may include adequate supervision.Review of the facility's policy Wandering and Elopements ((C) 2001 MED-PASS, Inc.) revealed the facility would identify residents at risk for unsafe wandering and elopement and strive to prevent harm while maintaining the lease restrictive environment. Per review, those identified at risk would have identified strategies and interventions included in their plan of care to maintain resident safety. Closed Record review of R9's Face Sheet, revealed the facility admitted R9 into its secure memory loss unit on 07/24/2025 with diagnoses including moderate dementia, cataracts and unilateral hearing loss.Review of R9's admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 07/28/2025 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment. Per this MDS, R9 required supervision and/or touch prompts, throughout or intermittently, for indoor ambulation and he displayed wandering behaviors for 1-3 days during the assessment period. Review of R9's baseline care plan initiated on 07/24/2025 revealed the Resident was at risk for elopement. Multiple interventions were assigned; admission to secure memory loss unit, medications as ordered, document/notify physician if behavior interferes with daily function, monitor for environmental hazards - which may increase supervision requirements, check exit/stairwell/door alarms on a routine schedule for operability, monitor whereabouts frequently, redirect as needed, wander alarm (a device, usually placed on resident's ankle which triggers an alarm if exiting doors with companion equipment) checking placement and functionality every shift. Additionally, explain all care before providing to reduce resident tension and promote a comfortable experience, observe for behavior/cognitive status change and notify physician if they occur.Review of a Nursing note dated 07/24/2025 at 4:15 PM revealed R9 was pleasant but confused. Continued review revealed the resident started looking for his keys saying it was time to go. Per review of the note, the resident was placed on a wander alarm to his left ankle.Review of a Nursing note dated 07/24/2025 at 10:12 PM, revealed R9 stated he was ready to go home and wanted his keys. Review of a Nursing note dated 07/26/2025 at 5:00 AM described R9 as increasingly anxious the prior evening, 07/25/2025. R9 stated he was leaving the facility, packed up his personnel belongings in paper bags and approached the exit. Per review of the note, the Resident stayed near the exit door of the unit waiting to leave. However, there was no documentation to support the Resident's care plan was implemented to monitor his whereabouts frequently.Review of a Nursing note dated 07/27/2025 at 4:50 AM revealed R9 eloped and his Power of Attorney (POA) was notified.Review of a Nursing note dated 07/30/2025 at 7:20 PM revealed R9 had become increasingly agitated with staff and was verbally threatening to fight staff if they prevented him from leaving. R9 was transferred to the Veterans Administration hospital for evaluation and treatment. The Resident did not return to the facility. Observation on 08/11/2025, at 1:00 PM traveled by car on the path R9 followed to the church, revealed a heavily wooded primarily residential area, with scattered sidewalks. The streetlights were present, but the tree canopy would limit their effectiveness and there was no active crosswalk. An interview on 08/11/2025 at 3:11 PM with R9's family member revealed she recalled R9 asking for his suitcases one day when she was at the facility. Per the interview, she stated that on the day the resident eloped from the facility, Police Officer (PO) called her when R9 was found, and she drove straight to the location provided. The resident was found at a local church, sitting at a picnic table with all his earthly belongings packed into a couple brown paper bags. She stated the Resident was confused and had told the PO he had driven himself there in his mother's car. During a telephone interview with Certified Nursing Assistant (CNA)5 on 08/12/2025 at 8:25AM, she stated R9 got frustrated sometimes because staff could not give him enough attention, adding, he was a talker. She stated sometimes she could redirect him, but his anxiety increased during the part of the evening when CNAs were typically busy putting other residents to bed. CNA5 stated she wished she had had more things to offer R9 so that he could stay independently busy. She went on to say, I offered to get him some cards, but he said he didn't play.Further, CNA5 stated on 08/12/2025 at 8:25 AM, the evening of the elopement, R9 was aggravated on and off. She stated she recalled R9 followed the nurse down the hall talking to him as he passed medications but then R9 refused to take his own medications. CNA5 stated she did not think to talk with her nurse or her supervisor about his behavior. A phone interview with LPN4 on 08/09/2025 at 6:56 PM, revealed he was the nurse caring for R9 on 07/27/2025 when R9 eloped. LPN4 said R9 was courteous but began asking for his keys on his first day and told him, it was time to go home. LPN4 stated he thought the Resident was ‘sundowning' and described R9 as more anxious in the evening than in the day. LPN4 stated ‘I asked him to go to his room, and he ignored me'. LPN4 stated the aids were checking him regularly; however, stated he never contacted Administration to ensure increased supervision for the Resident was provided, as per the Resident's care plan. He stated he would have been dayshift to have made that call. An interview with the Director of Maintenance on 08/11/2025 at 3:11 PM, he stated he was called on 07/27/2025 at 7:00 AM, the morning of the elopement, and he went to the facility. The Director of Maintenance said R9 had broken the window stop, which had been secured with a [NAME] head screw. Further, he stated this allowed R9 to move the lower sash enough to engage the tilt latch and remove the lower sash from the window frame entirely. He stated he was not sure how R9 removed the screws, stating they were not in super tight, or the tension would have split the vinyl, but they were too tight to loosen by hand. He stated R9 had later apologized for breaking the window frame but did not elaborate on how he had dismantled the hardware.An interview with the Director of Nursing (DON) on 08/12/2025 at 2:35 PM, she stated it was her expectation for nursing staff to utilize the interventions on the resident's plan of care. She further stated safety was first; and staff should increase the resident's supervision without permission or an order, according to their judgement. Further, she stated staff should also inform their supervisor and/or the provider before the end of their shift, so ongoing staffing arrangements could be made. An interview with the Administrator on 08/12/2025 at 2:35 PM revealed it was his expectation that the facility would always have increased resident supervision and one-to-ones (1:1) covered. Per interview, he stated that staffing was not an issue and a supervisor present at all times to pitch in when needed. The facility provided an acceptable plan for the removal of the Immediate Jeopardy on 08/14/2025. The State Survey Agency (SSA) survey team validated the IJ was removed on 08/04/2025 at 2:15 PM according to the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice was determined to be past non-compliance. The Removal of Immediate Jeopardy/Past Non-compliance was validated with implementation of the following measures:On 07/27/2025 the Facility initiated Emergency Preparedness Plan, and the Administrator, Emergency Contact, and Police were notified. On 07/27/2025 upon return to the facility Resident 9 received a head-to-toe physical and psychosocial assessment with no injury or emotional distress noted. Resident placed one on one supervision. His wander guard placement and functionality were validated. On 07/27/2025 R9's Wandering/Elopement Risk Observation/Assessment, Brief Mental Status Exam (BIMS), Elopement/Wandering Risk Care Plan interventions were all updated. On 07/27/2025 all windows were checked for proper functionality.On 07/28/2025 all exit door armed with the wander guard system was functioning properly.On 07/27/2025 and 07/28/2025 staff assigned to R9 at time of incident received one on one education including but not limited to increased behaviors, exit seeking, notification of supervisor and physician of change of condition, resident care plan and following care plan interventions, and potential need to increase supervision.On 07/28/2025 an audit of all facility resident Elopement and Wandering safety risk was conducted by completion of: Wandering Risk/Observation Assessments, Identification of any additional potentially at-risk residents, Care Plan updates, Verification of Interventions and Inclusion in the Elopement Binders.On 07/28/2025 an Ad Hoc Quality Assurance Performance Improvement Committee (QAPI) met and performed an incident root cause analysis. An updated procedure for all new referrals was established, to ensure Resident functional status, mobility level, goals, and desire for placement are reviewed by the Interdisciplinary Team (IDT). Additionally, the secure unit began to conduct hourly rounding for all new admissions for 72 hours, this supervision will increase to every 15 minutes if residents actively exit seek, express the desire to leave, or has a noted change of condition. The QAPI committee will meet monthly and as needed. On 07/28/2025 the IDT began a daily review of the Elopement Binders and Care Plans will be reviewed for accuracy for individuals at risk for elopement. On 07/27/2025 all windows were sealed shut with adhesive caulk. Daily door checks and weekly window checks conducted for four (4) weeks, then every other week for four (4) weeks and monthly thereafter until compliance is maintained for at least three consecutive months and the QAPI Committee reviews for potential safety concerns for accidents or hazards.From 07/27/2025 through 07/28/2025 staff on the secured unit were educated on recognizing exit seeking behaviors in residents with dementia, appropriate verbal redirection and other non-pharmacological intervention, resident change in condition, notification of supervisor, person-centered care plan, and implementation of appropriate interventions to promote resident safety, identify potential elopement risks, and the process changes for screening, referrals and supervising new admissions. From 07/28/2025 through 08/04/2025 all facility staff were educated recognizing exit seeking behaviors in residents with dementia, appropriate verbal redirection and other non-pharmacological intervention. The facility elopement/wandering policy, and emergency protocol. Facility elopement/wandering policy, and emergency protocol, change of condition, care plan updates, increase behaviors, and supervision were also reviewed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' environment remained free of accident hazards and provide adequate supervision for one (Resident (R) 9) of five sampled residents reviewed for elopement risk. Resident 9, who had major neurocognitive impairment, eloped from the facility on 07/27/2025. Facility safety processes and systems used for supervision failed when the resident left the facility by removing the bedroom window and climbing through it without staff knowledge/supervision. The resident walked approximately 1.3 miles, in the dark. The failure to prevent R9's elopement during 81-degree heat with 90-degree heat index created Immediate Jeopardy with the likelihood for serious harm or death.Immediate Jeopardy (IJ) was identified on 08/13/2025 and was determined to exist on 07/27/2025 in the areas of 42 CFR S483.25, F689 Free of Accident/Hazards/Supervision/Devices and 42 CFR S 483.21, F656 Develop/Implement Comprehensive Care Plan. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25, F689 Free of Accident/Hazards/Supervision/Devices. The facility was notified of the IJs on 08/13/2025.On 08/13/2025 at 4:00PM, the Director of Nursing, Administrator and the Regional Director of Clinical Services were notified of the Immediate Jeopardy (IJ) and provided a copy of the Center for Medicare & Medicaid Services (CMS) IJ Template and was notified that R9's elopement from the facility on 07/27/2025 constituted an IJ.The facility provided an acceptable plan for removal of the IJ on 08/15/2025, alleging removal on 08/04/2025.The State Survey Agency (SSA) survey team validated the IJ was removed on 08/04/2025, prior to the SSA entrance on 08/07/2025, according to the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice was determined to be past non-compliance. The findings include:Review of facility policy titled, Emergency Response (Emergency Preparedness Planning and Resource Manual, pages 18-21, undated), revealed the facility defined elopement as, a situation where a resident with impaired decision making ability who was oblivious to his/her own safety needs and therefore at risk for injury outside the confines of the facility had left the facility without the knowledge of staff. Further review revealed the Resident plan of care would identify interventions to reduce the risk of elopement through use of alarms, exit avoidance, visual cues, engagement, distraction, and increased supervision. Closed Record review of R9's Face Sheet, revealed the facility admitted R9 to the secure memory loss unit on 07/24/2025 with diagnoses including moderate dementia, cataracts and unilateral hearing loss. Review of R9's admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 07/28/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment. Per this MDS, R9 required supervision and/or touch prompts, throughout or intermittently, for indoor ambulation and he displayed wandering behaviors for 1-3 days during the assessment period. These factors indicated R9 was at a significant risk of potential danger, if outside the facility unsupervised. Review of R9's admission summary, dated [DATE] revealed R9 was a falls risk and would be evaluated by therapy. Additionally, an admission elopement and wandering risk observation/assessment completed the same day, triggered a risk score of 10, moderate risk of elopement., based on R9's risk factors, as follows; independent ambulation, disorientation/confusion, both his hearing and his vision were impaired, psychotropic medication which may cause irritability and/or restlessness.Review of R9's baseline care plan initiated on 07/24/2025 revealed the Resident was at risk for elopement. Multiple interventions were assigned; admission to secure memory loss unit, medications as ordered, document/notify physician if behavior interferes with daily function, monitor for environmental hazards - which may increase supervision requirements, check exit/stairwell/door alarms on a routine schedule for operability, monitor whereabouts frequently, redirect as needed, wander alarm (a device, usually placed on resident's ankle which triggers an alarm if exiting doors with companion equipment) checking placement and functionality every shift. Additionally, explain all care before providing to reduce resident tension and promote a comfortable experience, observe for behavior/cognitive status change and notify physician if they occur.Review of R9's initial skilled nursing assessment dated [DATE] entered by Advanced Practice Nurse Practitioner (APRN) revealed R9 was found wandering the streets, unable to identify where he lived on 07/14/2025. He was hospitalized on a Geriatric Psychiatric unit, where he was treated for aggression, depression and dementia. Resident 9 was admitted to the facility on [DATE] directly from the Geriatric Psychiatric unit. Review of R9's progress notes in the Electronic Medical Record (EMR) revealed a steady increase in exit seeking behavior and irritability, following his admission up to his elopement: Review of a Nursing Note dated 07/24/2025 and entered at 4:15 PM by Licensed Practical Nurse (LPN)5, revealed R9 was pleasant but confused. [R9] started looking for his keys saying it was time to go. A wander alarm was placed on the resident's left ankle at that time. Review of a Nursing Note dated 07/24/2025 entered by LPN4 at 10:12 PM, revealed R9 stated he was ready to go home and wanted his keys. Review of a Nursing Note entered by LPN4 dated 07/26/2025 entered at 5:00 AM described R9 as increasingly anxious the prior evening 07/25/2025. R9 stated he was leaving the facility, packed up his personnel belongings in paper bags and approached the exit. Further review of the Nursing Note revealed the Resident stayed near the exit door of the unit waiting to leave. Review of a Nursing Note dated 07/27/2025 at 4:50 AM revealed LPN4 entered R9 eloped, and his Power of Attorney (POA) was notified. Review of the facility's Initial Report, dated 07/27/2025 and signed by the Administrator, revealed R9 exited the facility without staff's knowledge or supervision on 07/27/2025, sometime after 2:40 AM. Staff noted R9's absence at approximately 4:00AM, when staff entered his room and discovered the window was removed, placed by the bathroom door and the screen was on the ground outside the facility. Notifications were completed appropriately. At 6:40 AM R9 was found by the police at a nearby park sitting at a picnic table and he returned to the facility with the Administrator and R9's sister, arriving at 7:15 AM. Resident 9 had no injuries; his wander alarm was intact and functional, and he was placed on one-to-one supervision. Review of the form, Division of Health Care, Long-term Care Facility - Self-Reported Incident Form, Final Reports/5 Day Follow-Up, (5-Day FU report), dated 08/01/2025 and signed by the Administrator, revealed that all staff members working on the secure memory loss unit were interviewed following the incident. The form indicated no one saw R9 exit the building. Further review of the 5-Day FU Report revealed staff discovered R9's absence during their 4:00 AM rounds. The last round was done between 2:30 AM and 2:40 AM, during which R9 was in bed with his eyes closed. Further review revealed R9 expressed he had wanted to go for a walk, clear his head and get some peace and quiet. Resident 9 also told the Administrator he was upset and frustrated with his sister. Review of the map attached to the 5-Day FU report revealed R9 had walked 1.3 miles to a nearby church. Observation on 08/11/2025, at 1:00 PM traveled by car on the path R9 followed to the church, revealed a heavily wooded primarily residential area, with scattered sidewalks. The streetlights were present, but the tree canopy would limit their effectiveness and there was no active crosswalk. According to the National Weather Service, National Oceanic and Atmospheric Administration, NOWData revealed the low temperature for July 27, 2025, occurred in the early morning when R9 was walking, was 81 degrees with a heat index of 90. An interview on 08/11/2025 at 3:11 PM with R9's family member, revealed R9 did not want to stay [at the facility] and voiced he wanted to go home. She stated the Resident slept in his room most of the time; and R9 would communicate with the staff but never with other residents, unless they came in his room. Per the interview, she stated the day the resident eloped from the facility, LPN4 called her at 4:00 AM, on 07/27/2025 and reported the resident was gone. R9's family member stated she went to the facility and noticed the resident's window, in his room, did not appear to be broken. She said she assumed it must have been easy to open, adding, the resident did not normally mess with things like that. R9's family member stated she spoke to the police and the Administrator, then she went to look for R9. Later in the morning, the police called and stated the resident was found at a local church. She went to the church immediately. Per the interview, she stated R9 refused to get in the car with her but willingly returned to the facility with the Administrator in his car, arriving at 7:15 AM.Interview with Licensed Practical Nurse (LPN)1 on 08/08/2025 at 3:40 PM revealed she had worked for the facility for over 15 years, and the secured memory care unit had been her home unit for seven years. She stated she remembered admitting R9 and stated as soon as she saw him, she was concerned how the unit would handle him. She described him as agile for his age, jumping down from the transport stretcher. She also stated he did not fit in with the other residents on the unit, they had advanced dementia. She also stated the report from the transferring hospital indicated he had recently wandered from his home and was picked up by the Crisis Intervention Team (a specialized police team trained to work with individuals with mental illness). She stated she had learned R9's sister was trying to get him somewhere safe and had motioned for emergency guardianship. LPN1 stated R9 initially presented he ‘had it all together' but when she spent some time with him his memory loss started to show. During a telephone interview with Certified Nursing Assistant (CNA)5 on 08/12/2025 at 8:25 AM, she stated she had worked 6:00PM to 6:00 AM 'nightshift' on 07/26/2025, the day of R9's elopement. She further stated R9 was 'her resident' that night. CNA5 stated she 'rounded on him' between 12:30 AM and 1:00 AM and he had struggled to get to sleep. Resident 9 wanted to know when his sister would be coming in to pick him up and ‘I told him I didn't know'. I got him a snack and a cold drink. We talked awhile and R9 settled down. She reported, upon returning to his room between 2:20 AM and 2:30 AM, her two-hour rounds, R9 appeared to be asleep. She remembered his blue jeans folded on his bedside table and his shoes next to the bed. She further explained CNAs did not document patient (resident) rounds. She stated when it was about time for her next round, she heard a code called overhead. She stated she did a headcount on the front half of her hallway and then searched all the rooms and bathrooms for R9. A phone interview with LPN4 on 08/09/2025 at 6:56 PM, revealed he was the nurse caring for R9 on 07/27/2025 when he eloped. LPN4 had cared for R9 frequently including the day of his admission, 07/24/2025. Per the interview, LPN4 stated he thought R9 was ‘sundowning' and described R9 as more anxious in the evening than in the day. LPN4 relayed on his next shift 07/25/2025 R9 packed up his stuff in paper bags and said he was ready to go. He stated R9 then went to the exit doors and waited there to leave. LPN4 stated R9 finally went to bed around 9:00 PM. He further stated, after the other Residents went to bed, R9 was still wandering around the unit. LPN4 stated ‘I asked him to go to his room, and he ignored me'. LPN4 stated nurses rounded once a shift and he thought the aids rounded more but not sure how frequently. LPN4 said he knew R9 was gone when he saw the windowpane in the frame next to the restroom and the screen outside. LPN4 stated he did not know how the resident got the window apart. Further, he stated he alerted the CNAs, called the police, R9's sister and the Administrator. An interview with the Director of Maintenance on 08/11/2025 at 3:11 PM, he stated he was called on 07/27/2025 at 7:00 AM, the morning of the elopement, and he came straight in. The Director of Maintenance stated that when he entered R9's room, he noted a staff person stationed at the window to ensure resident safety. The staff monitor remained until the window was repaired and secure. The Director of Maintenance said R9 had broken the window stop, which had been secured with a [NAME] head screw. Further, he stated this allowed the Resident to move the lower sash enough to engage the tilt latch and remove the lower sash from the window frame entirely. He stated he was not sure how R9 removed the screws, stating they were not in super tight, or the tension would have split the vinyl, but they were too tight to loosen by hand. He stated R9 had later apologized for breaking the window frame but did not elaborate on how he had dismantled the hardware.An interview with the Director of Nursing (DON) and the Administrator, on 08/12/2025 at 2:35 PM, revealed the DON stated she learned about R9's elopement while on vacation. She stated secure memory loss unit staff were trained on hire and annually on the care of residents with Dementia and the staff who cared for R9 the day he eloped were 'well-seasoned,' long term employees. During the initial interview with the Administrator, on 08/07/2025 at 1:30 PM, he stated the elopement was a 'one off', R9 was an inappropriate admission for the secured memory care unit. He stated, R9 represented 0.0001% the residents on the secure memory care unit, and no other resident could have dissembled the window or crawled through it. He further stated the facility's Director of Maintenance came in immediately following the elopement and assessed all facility windows for similar issues and found none. Per the interview, he stated that following a team discussion, the Director of Maintenance sealed all the windows shut with adhesive silicone to ensure resident safety. The Administrator relayed in continued interview, on 08/12/2025 at 2:35 PM, the facility's newly created memory care unit admission's process, staff education, coupled with the daily elopement risk review was in place to prevent any future elopement. The facility provided an acceptable plan for the removal of the Immediate Jeopardy on 08/14/2025. The State Survey Agency (SSA) survey team validated the IJ was removed on 08/04/2025 at 2:15 PM according to the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice was determined to be past non-compliance. The Removal of Immediate Jeopardy/Past Non-compliance was validated with implementation of the following measures:On 07/27/2025 the Facility initiated Emergency Preparedness Plan, and the Administrator, Emergency Contact, and Police were notified. On 07/27/2025 upon return to the facility Resident 9 received a head-to-toe physical and psychosocial assessment with no injury or emotional distress noted. Resident placed one on one supervision. His wander guard placement and functionality were validated. On 07/27/2025 R9's Wandering/Elopement Risk Observation/Assessment, Brief Mental Status Exam (BIMS), Elopement/Wandering Risk Care Plan interventions were all updated. On 07/27/2025 all windows were checked for proper functionality.On 07/28/2025 all exit door armed with the wander guard system was functioning properly.On 07/27/2025 and 07/28/2025 staff assigned to R9 at time of incident received one on one education including but not limited to increased behaviors, exit seeking, notification of supervisor and physician of change of condition, resident care plan and following care plan interventions, and potential need to increase supervision.On 07/28/2025 an audit of all facility resident Elopement and Wandering safety risk was conducted by completion of: Wandering Risk/Observation Assessments, Identification of any additional potentially at-risk residents, Care Plan updates, Verification of Interventions and Inclusion in the Elopement Binders.On 07/28/2025 an Ad Hoc Quality Assurance Performance Improvement Committee (QAPI) met and performed an incident root cause analysis. An updated procedure for all new referrals was established, to ensure Resident functional status, mobility level, goals, and desire for placement are reviewed by the Interdisciplinary Team (IDT). Additionally, the secure unit began to conduct hourly rounding for all new admissions for 72 hours, this supervision will increase to every 15 minutes if residents actively exit seek, express the desire to leave, or has a noted change of condition. The QAPI committee will meet monthly and as needed. On 07/28/2025 the IDT began a daily review of the Elopement Binders and Care Plans will be reviewed for accuracy for individuals at risk for elopement. On 07/27/2025 all windows were sealed shut with adhesive caulk. Daily door checks and weekly window checks conducted for four (4) weeks, then every other week for four (4) weeks and monthly thereafter until compliance is maintained for at least three consecutive months and the QAPI Committee reviews for potential safety concerns for accidents or hazards.From 07/27/2025 through 07/28/2025 staff on the secured unit were educated on recognizing exit seeking behaviors in residents with dementia, appropriate verbal redirection and other non-pharmacological intervention, resident change in condition, notification of supervisor, person-centered care plan, and implementation of appropriate interventions to promote resident safety, identify potential elopement risks, and the process changes for screening, referrals and supervising new admissions. From 07/28/2025 through 08/04/2025 all facility staff were educated recognizing exit seeking behaviors in residents with dementia, appropriate verbal redirection and other non-pharmacological intervention. The facility elopement/wandering policy, and emergency protocol. Facility elopement/wandering policy, and emergency protocol, change of condition, care plan updates, increase behaviors, and supervision were also reviewed.