**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to provide adequate supervision and effective assistance devices to prevent accidents for one (Resident (R) 19) of three sampled residents reviewed for elopement risk. R19, who had severe cognitive impairment, eloped from the facility on 07/30/2025. The facility's equipment (alarm system) used for supervision of location failed to sound in a manner to immediately alert staff when the resident left the facility without staff knowledge/supervision. The failure to prevent R19's elopement, at a time when the outdoor heat index was 107 degrees, created an Immediate Jeopardy situation with the likelihood for serious harm or death.Immediate Jeopardy was identified on 08/15/2025 and was determined to exist as of 07/30/2025 (the day of the elopement), in the area of 42 CFR 483.25, Quality of Care. This deficiency also constituted Substandard Quality of Care (SQC). The Administrator and the [NAME] President of Residential Health Care were notified of the Immediate Jeopardy on 08/15/2025 at 10:12 AM. On 08/15/2025 at 10:12 AM, the Administrator and the [NAME] President of Residential Health Care were provided a copy of the CMS IJ Template and were notified that R19's elopement from the facility on 07/30/2025 constituted an Immediate Jeopardy.The facility provided an acceptable plan for removal of the Immediate Jeopardy on 08/15/2025 at 2:00 PM.The survey team validated the Immediate Jeopardy was removed on 08/06/2025 at 2:00 PM following the facility's implementation of the plan of removal of the Immediate Jeopardy and the deficient practice was determined to be past non-complianceThe findings include:Review of the facility's policy, Elopement/Missing Resident Policy (‘Code Yellow'), dated 02/06/2024 and in effect at the time of R19's elopement, revealed the facility defined elopement as, When a patient or resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired; wanders away, walks away, runs away, escapes, or otherwise leaves a caregiving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge. Review of the policy revealed that although it addressed the steps to take after a resident eloped, it did not describe steps to prevent elopements from occurring. Review of R19's Resident Face Sheet revealed R19 was admitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder, and insomnia due to mental disorder. Review of R19's admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/05/2025 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5/15, indicating severe cognitive impairment. Per this MDS, R19 displayed wandering behaviors 1-3 days during the assessment period, and these behaviors placed the resident at a significant risk of getting to a potentially dangerous place, such as outside the facility. The MDS documented the resident was independent with indoor mobility (ambulation) and used a walker. Review of R19's baseline care plan, initiated on 01/15/2025 and comprehensive care plan, initiated 02/11/2025, revealed the resident was at risk for elopement. The care plans included multiple interventions, including placement on a unit for residents with advanced dementia (secured unit), and the use of a Code Alert bracelet (device which sounds an alarm if the resident comes near a door), with its placement and functionality checked every shift. Additional interventions included elopement assessments, redirection of the resident by talking about her past work as a Missionary, and allowing R19 to speak to her family, which calms her.Review of the Observations, tab in the Electronic Medical Record (EMR) revealed that, per the care plan, the facility assessed R19 as being at risk for elopement on the following dates: 01/14/2025, 01/29/2025, 04/18/2025, and 07/13/2025. Review of the 07/13/2025 ECH Elopement Risk Assessment form (most recent prior to R19 eloping on 07/30/2025) revealed that R19's risk factors included a diagnosis of dementia, attempts to leave the facility, independence with mobility in the presence of dementia, a change in medications, verbalizations of intent to leave, wandering to find family, wandering aimlessly, and actively having exit-seeking behaviors. Review of R19's EMR, under Progress Notes, revealed she attempted to exit the facility on each of the following dates: 05/04/2025, 05/07/2025, twice on 06/30/2025, 07/06/2025, and 07/11/2025. Each of these times, R19 was re-directed by staff once the door alarm was engaged. Review of the facility's Initial Report, dated 07/30/2025 and signed by the Administrator, revealed R19 exited the facility without staff's knowledge or supervision on 07/30/2025. At 1:08 PM, the Director of Life Enrichment (DLE), who was driving through the property, found R19 walking on a sidewalk. At that time, the DLE stopped, got R19 into her car, and returned R19 to the facility. Per the report, R19 was immediately assessed and found to be free of injury, and she displayed no signs or symptoms of heat-related concerns. The document estimated R19 was outside the facility no longer than five minutes, and all necessary parties were informed of the elopement at the appropriate times.Further review of the facility's Initial Report, revealed all the exterior doors and alarms in the facility were inspected, with no concerns identified, and were found to be in proper working order. The document stated education was provided to all staff regarding response to alarms, and the elopement and abuse policies. The incident report stated R19 provided no verbalizations or behaviors to indicate she had suffered any physical or psychosocial harm.Review of the form, Kentucky Cabinet for Health and Family Services, Office of Inspector General - Division of Health Care, Long-term Care Facility - Self-Reported Incident Form, Final Reports/5 Day Follow-Up, (5-Day FU report), dated 08/05/2025 and signed by the Administrator, revealed that all staff members working on R19's secure unit were interviewed following the incident. The form indicated no one saw R19 exit the building. Further review of the 5-Day FU Report revealed the door alarm sounded when R19 pushed the door bar. However, the two Versatile Workers ((VWs), 1 and VW4) on the unit were providing care in another resident's room with the door closed, and did not hear the alarm. During the time that staff could not hear the alarm, R19 had an opportunity to wait for the 15-second egress to engage and then walked out the door undetected and unsupervised.Further review of this report revealed that VW3 had escorted R19 to her neighborhood (secure unit) prior to the elopement, and stated R19 made the comment that she needed to go home. VW3 said she explained to R19 that her daughter knew where R19 was and would come to visit her soon. Per the report, R19 admitted she opened the door, then stated that she, .wasn't looking for anything, but I know I shouldn't have done that. I don't think I have meandered like that before, I won't do that again. Further review of the 5-Day FU Report, revealed the DLE stated R19 was talkative and smiling when she put R19 into her car, and the DLE stated R19 was not sweating and did not feel hot to the touch. The document indicated the DLE brought R19 back into the facility through the front doors at 1:12 PM. Review of facility video records revealed there was no video footage to verify when the resident left the facility. Video footage of the facility's front door verified R19 and the DLE walked back into the facility on [DATE] at 1:11:46 PM. Review of R19's Progress Notes, dated 07/30/2025 at 2:02 PM, entered by Registered Nurse (RN) 1, revealed R19 was assessed immediately after her return to the unit. R19 was alert to self, was in no pain, and denied feeling hot. Further review of RN1's entry in R19's Progress Notes, revealed R19 was tearful and apologized and hoped she had not gotten any staff in trouble. Review of Weather Channel website revealed the temperature on 07/30/2025 (the day of R19's elopement) was 93 degrees, with a heat index of 107 degrees. Observation of R19 on 08/08/2025 at 4:22 PM, revealed the resident was wearing a Code Alert bracelet on her left wrist. The resident was sitting on a couch, watching TV in a common area on the secured unit. The resident was noninterviewable, based on cognitive status. Further observation at this time, revealed that the door through which R19 eloped, on 07/30/2025, was down the hall, approximately 20-25 feet from the kitchenette on the secure unit, where R19 resided. The door was observed to be alarmed, with a sign on the door noting that if you hold the (panic) bar for 15 seconds, it would unlock. Further observation of the door revealed that to open it, a person had to turn the lock above the handle, as well as hold the bar in for 15 seconds, for the door to unlock and be opened. The exit door opened into a sidewalk which led to the parking lot and onto a busy road. In an interview with VW1 on 08/08/2025 at 11:35 AM, she stated she was working on 07/30/2025 when R19 eloped. VW1 stated she and VW 4 were in another resident's room, providing care with the door closed for privacy. VW1 related that all staff were to respond when a door alarm was sounding. However, because they were in the room with the door closed, they did not hear the door alarm going off. VW1 stated they were not aware the alarm went off until they came out of the resident's room, and it was still sounding. She stated she and VW4 opened the door where the alarm was sounding, and when they did not see anyone, they did not go outside to look and see if a resident had gone out the door. VW1 stated she was not aware R19 exited the building until after the resident was found. VW1 stated there were three aides working the floor on 07/30/2025 - herself, VW4 who was her orientee, and VW3, who was R19's aide. VW1 was not aware that VW3 was on a break at the time of the elopement. VW1 stated she did not believe staffing was an issue in contributing to the elopement, adding, The problem is when everyone is busy. VW1 was aware R19 was at risk for elopement and wore a Code Alert bracelet. She stated the last place she saw R19, before the elopement, was in the dining room, and she did not see R19 display exit-seeking behaviors on 07/30/2025, prior to the elopement. VW1 stated, The door she [R19] went out, it should have locked when she [R19] was close to it because she [R19] had a Code Alert bracelet on. In an interview with VW4 on 08/08/2025 at 3:00 PM, she stated VW1 was orienting her on 07/30/2025, as she had only been working in the facility for two weeks. VW4 stated she and VW1 were in a resident's room, cleaning the resident up and putting them back in bed when the incident occurred. She stated the alarm was sounding; however, neither she nor VW1 heard it until they came out of the room. She stated she and VW1 checked the door, but did not see anyone. VW4 stated VW1 thought a staff member had just taken out the trash, causing the alarm to sound. VW4 stated she learned of the elopement shortly after, when other staff members informed her. VW4 was aware R19 was at risk for elopement, stating that was why the resident wore a Code Alert bracelet. VW4 denied observing R19 with any exit-seeking behaviors earlier in the day. VW4 also stated she was not aware of VW3 being on break at the time of the elopement. In an interview with VW3 on 08/08/2025 at 2:32 PM, she stated R19 was sitting in the common area of the secured unit, watching television when she (VW3) left the unit to go to the bathroom. She confirmed that she was not on the secure unit at the time of the elopement, as she left the unit to use the restroom. She then went to the break room for her 15-minute break. VW3 stated that she did not inform VW1 or VW4, who were the other staff on the unit, that she was leaving the unit at that time and would not be available for supervision of other residents while they were providing care in individual resident rooms. She stated she did not hear the door alarm when R19 exited the facility, and did not know that R19 eloped from the facility until she heard other staff members talking about it in the breakroom. VW3 was aware of R19 being at risk for elopement and knew she had a Code Alert bracelet in place. VW3 stated all staff were to respond to a door alarm. VW3 stated R19 did have behaviors related to exit-seeking on 07/30/2025 when R19 stated, I'm going to look for my daughter. VW3 told R19 her daughter knew where she (R19) was, and the daughter was coming to visit later in the day. VW3 stated the day prior to the elopement, R19 woke up and stated, I've got to go, and VW3 reassured R19 her daughters were coming to visit later. An interview with Registered Nurse (RN) 1, on 08/08/2025 at 12:05 PM, revealed she was R19's nurse on 07/30/2025. She stated she last observed R19 walking back to the secure unit after eating lunch in the main dining room. RN1 stated she was on the other side of the unit at the time R19 eloped. RN1 stated her assumption was there were three aides on the unit with R19. She was unaware one of the three was not on the unit, and the other two were in a closed room, providing care, at the time of the elopement. RN1 stated she did not hear the door alarm and did not know about the elopement until another staff told her. RN1 was aware R19 was at risk for elopement and had a Code Alert bracelet on. RN1 stated some of the doors inside the facility locked when a resident with a Code Alert bracelet got near the door. However, she continued, the Code Alert device for the door, through which the resident exited, does not lock due to a Fire Safety Code requirement. RN1 stated she assessed R19 after she was brought back to the secure unit, inside the facility and R19 had no skin issues or injuries.In an interview with the Director of Life Enrichment (DLE) on 08/08/2025 at 2:08 PM, she stated that on 07/30/2025 at approximately 1:07 PM, she was driving around the campus to get to a meeting she was running late for, as the meeting was supposed to start at 1:00 PM. The DLE stated once she drove past the dumpsters, on the left side of the building, she saw a resident walking with her walker, alone, which raised some concern. The DLE stated she put her car into reverse, confirmed the resident was alone, then asked if the resident needed any help. The DLE stated R19 told her while she smiled, I just need to get home. The DLE stated the temperature was in the 90s on this day and she helped R19 get into her car. She noted R19 was not sweating, her skin was cool to the touch, she did not have any shortness of breath and was in no distress. The DLE proceeded to drive R19 back around to the front of the building, where she escorted R19 back into the facility, safely, at 1:12 PM. The DLE recalled the alarm sounding as they walked into the building because of R19's Code Alert bracelet. The DLE stated another VW was in the front lobby and offered to escort R19 back to her secured unit at that time, and the DLE stated she went to inform the Administrator of the elopement at that time. The DLE stated she felt blessed to have found R19 when she did.In an interview with the Director of Nursing (DON), on 08/08/2025 at 3:49 PM, she stated, It's everyone's responsibility to answer the door alarms. Per the DON, the elopement on 07/30/2025 occurred when staff could not hear the alarm, since they were working in a resident's room with the door closed. The DON added that, due to this, the facility had since replaced the alarms with ones that were louder. Further interview with the DON revealed that when a door alarm was sounding, staff should not only look outside the door, but they must also go outside to look around and possibly identify a resident who had eloped. The DON stated R19 did not have exit seeking behaviors or any behaviors out of the ordinary on the day of the elopement and was unaware that VW3 had observed behaviors related to exit seeking prior to the elopement. The DON stated R19 was assessed as being at risk for elopement. She stated once it was known the resident had exited the facility, all units or neighborhoods in the facility must conduct a head count to ensure all residents were accounted for. The DON stated there must be a search of the neighborhood completed by staff, the nurse should call the receptionist desk and notify of the missing resident, notify the DON and the Administrator, begin to search for the resident and expand the search if needed, and lastly the police would be called if the resident was still missing. After the elopement, the DON stated all the staff were interviewed and new elopement assessments were completed on each resident. In an interview with the Administrator, on 08/08/2025 at 4:27 PM, she stated the DLE notified her of R19's elopement on 07/30/2025. She stated immediately after being notified, she initiated a head count on all units of all the residents, then she had maintenance check the door alarms and locks to ensure they were all functioning, which they were. She stated RN1 assessed R19 once she was returned to the unit. The Administrator stated, I decided, ultimately, this was just a perfect storm. She stated that all staff on R19's unit were responsible for R19, but VW4 and VW1 were the only staff on the unit when R19 eloped. She continued that they were in another resident's room, providing care, with the door closed for privacy, and were unable to hear the door alarm. The Administrator stated she went into a resident's room and had another staff person engage the alarms, and she verified the alarm was not able to be heard. To address this, the Administrator stated they purchased new screamer alarms that were much louder. The facility provided an acceptable plan for removal of the Immediate Jeopardy on 08/15/2025 at 2:00 PM. The survey team validated the Immediate Jeopardy was removed on 08/06/2025 at 2:00 PM following the facility's implementation of the plan of removal of the Immediate Jeopardy and the deficient practice was determined to be past non-complianceThe Removal of Immediate Jeopardy/Past Non-compliance was validated with implementation of the following measures:1. R19 was evaluated/assessed immediately for signs and symptoms of any heat-related issues, none were noted. A head-to-toe assessment was completed by a nurse for R19 upon arrival back to the secure unit. R19 was placed on enhanced supervision/observation upon her return to the secure unit, and every 15-minute checks were performed for the 24 hours following the elopement. Notification of the elopement was made to R19's physician and her Power of Attorney (POA). R19 was interviewed for her thoughts/feelings of the elopement. R19's medication regime reviewed for any changes that could have contributed to the elopement, and none were identified. R19's orders and progress notes were reviewed to identify increasing behaviors leading up to the elopement, and none were identified. A new elopement risk assessment was completed for R19. R19's POA was contacted for more detailed information of R19's past, and memorabilia was requested, to develop an individualized activity box. The Comprehensive care plan was updated to reflect the elopement, and more elopement interventions were added.2. A head count of all residents in the facility was done, all residents were accounted for. A facility-wide audit of residents for elopement risk was completed within 24 hours. All residents' care plans were reviewed for elopement risks and any revisions needed were made. Activity programming for all residents was reviewed to validate the appropriateness for the population of residents.3. Statements were obtained from all staff working on 07/30/2025, the date of the elopement, on R19's secure unit. Inspection of all exterior doors for proper functioning and alarms completed, no issues identified, all doors and alarms functioned properly. A Root, Cause, and Analysis of the elopement event completed. In response, new, louder alarms were purchased and installed on all doors that lead outside of the facility. The door alarms were inspected by a technician, the volume was increased to the maximum level, and alarms are functioning properly.In addition, Elopement books on each unit were audited to ensure they were accurate, with updated pictures of the residents who are at risk for elopement. Treatment Administration Record (TARs) audited for proper placement and function of Code Alert device. The procedure for escorting residents back and forth to and from the primary dining room and the secure unit was revised. There will now be an extra staff member available to remain in the dining room to either escort resident(s) or coordinate a staff member to remain in the dining room and/or assist the resident(s) back to their unit.New process implemented for the Versatile Workers, they now must sign in and out for lunch and breaks, to ensure all staff are aware of who is actually available on the units.Staff were educated on elopement risk, door alarm response, supervision requirements, and new escorting residents to and from the primary dining room procedure implemented. All new education was also added to the newly hired staff education and checklists.4. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss elopement policies and procedures. An audit of the door alarms to validate staff's response began 07/31/2025, daily for two weeks, then three days a week for two weeks, then once a week for a total of four weeks.