**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, video camera footage review, and facility policy review, it was determined the facility failed to have an effective system to ensure care plans were implemented to provide proper care and supervision to residents to prevent elopement for one (1) of three (3) sampled residents (Resident 1). The facility assessed Resident 1 (R1) to be at risk for elopement after his/her admission on [DATE]. The facility developed a care plan component on 01/25/2023 to address the resident's risk for elopement. Interventions included assessing the resident's living spaces for potential hazards, as needed, and identifying any triggers that increased the resident's need for wandering and intervene as necessary. Per interview with Licensed Practical Nurse (LPN) 3, R1 had spoken in the past with LPN1 of people coming to pick him/her up and take him/her to his/her hometown. LPN 1 noted that on 09/23/2023, R1 was exit seeking. However, LPN3 and LPN1 did not report the resident's exit seeking behaviors to their supervisors. On 10/22/2023, at approximately 4:05 PM, R1 exited the facility to the outdoor fenced courtyard. R1 slid through a gap at the bottom of the gate and the ground. Visitors alerted facility staff that someone was outside on their knees by the gate. Staff responded and found R1 standing by the fence outside of the gated courtyard. Staff brought R1 back inside the facility and he/she was assessed by the nurse. Immediate Jeopardy (IJ) was identified on 11/09/2023 and was determined to exist on 08/08/2023, at 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), Develop/Implement Person-Centered Comprehensive Care Plans, at a S/S of a J; and 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision at a S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision. A partial Extended Survey was initiated on 11/18/2023 and concluded on 11/18/2023. The facility submitted an acceptable Immediate Jeopardy (IJ) Removal Plan on 11/17/2023 alleging the IJ was removed on 11/17/2023. The State Survey Agency validated the IJ was removed on 11/17/2023 as alleged, prior to exit on 11/18/2023, with remaining non-compliance at S/S of D while the facility develops and implements a Plan of Correction. The findings include: Review of the facility's policy titled, Care Plans-Comprehensive, dated 01/01/2017, revealed each resident would have an individualized comprehensive care plan that included measurable goals and corresponding interventions developed by the Interdisciplinary Team (IDT) to meet their physical and psychosocial needs. The comprehensive care plan (CCP) would serve as a reference for daily resident care, as well as a tool for relaying each resident's personal preferences and routines. Review of the facility's policy titled, Elopement/Missing Resident, revised date 10/18/2022, revealed the facility must ensure adequate supervision of residents to prevent accidents. It was the responsibility of staff to investigate and report any resident who tried to leave the premises or was suspected of elopement to Security and his/her supervisor immediately. Record review revealed on 10/22/2023, at approximately 4:05 PM, R1 exited the facility to the outdoor fenced courtyard. R1 slid through a gap at the bottom of the gate and the ground. Visitors alerted facility staff that someone was outside on their knees by the gate. Staff responded and found R1 standing by the fence outside of the gated courtyard. R1 stated, I am trying to get back home to pay for my stay and get my medicine. Observation, on 10/30/2023 at 10:44 AM, revealed on 10/20/2023, when R1 left the facility, he/she walked approximately eighty-one (81) feet away from the courtyard gate, as measured by the Maintenance Branch Manager and as reported by S/S1. Review of Resident 1's (R1) admission Record, revealed the facility admitted R1 on 12/13/2022 with diagnoses that included unspecified dementia, cognitive communication deficit, mixed conductive and sensorineural hearing loss; bilateral, and unspecified visual loss. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/05/2023, revealed R1 scored eight (8) of fifteen (15) on the Brief Interview for Mental Status (3.0 BIMS) examination. This score indicated the resident had moderate cognitive impairment. Review of R1's Comprehensive Care Plan (CCP) revealed the facility initiated a personal safety care plan with a care focus on 12/13/2022, that indicated R1 wished to exercise his/her right to be independent in the pursuit of outdoor activities on the external facility grounds. The CCP's goal was that R1 would enjoy self-directed activities while maintaining his/her personal safety on the external facility grounds. Nursing interventions included that R1 was to remain in the designated safe area while outside. During an interview, on 11/07/2023 at 4:15 PM, the MDS Coordinator stated outdoor activities were care planned for all residents, and the external facility grounds included the outdoor gated and locked courtyard adjacent to the indoor unit where R1 lived. She stated R1 was allowed to be on the courtyard by himself/herself according to R1's outdoor personal safety care plan. The MDS Coordinator stated all residents were allowed in the facility's courtyards by themselves but were rounded on or checked on frequently. She stated, We do not take things away. If [residents] want to go out, we do not stop them. Continued review of R1's CCP revealed the facility initiated a care focus on 01/25/2023, that R1 was at risk for elopement. The CCP's goal was that R1 would continue to walk safety within the unit/facility. Nursing interventions included to assess the resident's unit as needed for potential hazards, cue and redirect as needed, and identify any triggers that increased need for wandering and intervene as necessary. During an interview, on 11/07/2023 at 4:15 PM, the MDS Coordinator stated she could not say if R1's unit was assessed for potential hazards prior to R1's elopement from the facility. She stated if she had looked at the gap in the 500 C unit's courtyard gate, she would not have thought someone could get under the gate. The MDS Coordinator stated, in any case we do not know what is going to happen, that is how crazy it is to me that [R1's elopement] happened. She stated R1 was rounded on and when staff round, they are supervising, indicating staff made routine rounds when they observed the residents' whereabouts. During further interview the MDS Coordinator stated it was hard to tell if someone is exit seeking or if they are just walking. She stated triggers that increased R1's need for wandering were that R1 had said he/she had wanted to leave the facility. The MDS Coordinator stated, Here was a red flag, that maybe [the facility] should not have let [him/her] outside. She stated the facility did not keep R1 safe. In interview she stated the resident's care plan was implemented until the moment he/she slid under the gate. The MDS Coordinator stated she would not have thought the gap in the 500 C Unit's courtyard gate was a hazard. During an interview, on 11/08/2023 3:50 PM, the MDS Coordinator stated interventions for Low Risk for Wandering would be to just monitor the resident with hourly rounding. She stated she did not like the word wander because walking from unit to unit was not considered exit seeking. Wandering was subjective, and exit seeking was less subjective. If a resident verbalized he/she wanted to go away from the facility, or was going, that should be reported so the next staff person knew what had happened. The MDS Coordinator stated if she heard a resident say something like he/she wanted to leave the facility, she would enter a progress note in the clinical record for review by the IDT at a later date. She stated it would take more than one documented attempt of a resident seeking a way out of the facility, or verbalizing they wanted to leave, for the MDS Coordinator to assess the resident as known wanderer/history of wandering during an Elopement Risk Assessment. However, the facility's policy required staff to investigate and report any resident who tried to leave the premises, or who was suspected of elopement to security and his/her supervisor immediately. During further interview, on 11/08/2023 at 3:50 PM the MDS Coordinator stated if staff identified any triggers indicating R1 wanted to get out of the facility, like [he/she] came out with bags packed and shoes on, then staff would intervene, and redirect the resident. The MDS Coordinator stated, there was no staff present to redirect R1 from the trigger of a gap in the gate. During an interview, on 10/26/2023 at 1:37 PM, RN3 stated she was working as an aide (on Sunday 10/22/2023) and saw R1 outside within the unit's locked and gated courtyard between 4:00 PM and 4:05 PM. She then took another resident, R2, to the bathroom. RN3 stated she then heard a visitor say they saw someone on their hands and knees by the gate. She went out the door to the courtyard and saw R1 outside of the locked and gated courtyard. RN3 stated R1 had walked along the fence outside of the courtyard and could have had the intention of leaving the facility. During an interview, on 10/27/2023 at 2:41 PM, the Maintenance Branch Manager (MBM) stated the maintenance crew rounded and checked everything at the facility. Doors and gates were check daily by security and maintenance. The MBM stated the maintenance crew usually went through all the courtyard gates with the mowing crew, and no one ever noticed the gap in the courtyard gate. He stated he never would have thought somebody could ever slide underneath the courtyard gate like R1 had, and it floored me when he got the phone call. The MBM did not even know there was a gap in the courtyard gate, and it was not a big gap, was the odd thing, he said. During an interview, on 11/07/2023 at 3:30 PM, Nurse Aide State Registered ([NAME]) 4 stated she had cared for R1 and knew R1 tended to wander, that he/she was confused, and needed to be reoriented by staff. [NAME] 4 stated R1 would talk to her about looking for his/her car and wanting to go to his/her hometown. She stated prior to R1's elopement, his/her environment was probably not assessed to be as safe as possible for the resident because there needed to be more safeguards for going out on the courtyard, such as closer monitoring and clearer guidelines for going outside. NASR4 stated she wanted to see those guidelines on the care plan because the nurse may not always be available. When LPN1 heard R1 speak of going to Florida and was asked, during an interview on 11/08/2023 at 2:24 PM, if that was an exit seeking trigger, LPN1 stated he did not think he understood the wording of the question. When asked if LPN1 implemented R1's Elopement Risk nursing care plan Interventions/Tasks to Identify any triggers that increase need for wandering and intervene as necessary, LPN stated he did not understand that care plan intervention. During an interview, on 11/07/2023 at 4:00 PM, RN7 stated the facility did not keep R1 safe, and his/her care plan was implemented until the moment R1 slid under the gate. RN7 stated they were not expecting R1 to elope, were shocked that it happened, and the facility was now more aware of the surroundings. RN7 stated if R1 verbalized he/she wanted to go to his/her hometown or find his/her car, that was an exit seeking trigger which increased R1s need for wandering, and should have been reported to a supervisor, but in the past month she had not heard any exit seeking triggers from R1. During an interview, on 11/04/2023 at 4:30 PM, Nurse Supervisor (NS) stated if something like a fall or elopement happened, the IDT figured out what happened and what to place on the care plan. Then the care plan was updated, usually by MDS, and the IDT met with the nursing staff to ensure they knew about the changes. The NS stated care plan changes were communicated to nursing staff directly in huddles, which took place on Tuesdays and Thursdays, and as often as needed if something was going on. The NS stated if the care plan was not implemented or updated, and an intervention was missed, the very thing that caused the intervention to be put on the care plan could happen, such as R1's elopement. During an interview, on 11/07/2023 at 3:10 PM, the Director of Nursing (DON) stated the facility could have avoided R1's elopement if during environmental rounds when staff assessed the unit as needed for potential hazards per the CCP, the gap in the 500 C unit courtyard gate had been found. The DON stated she did not expect nursing staff to measure gaps in gates, but she could not point her finger at maintenance since all staff were responsible for residents' safety. During an additional interview, on 11/08/2023 at 8:45 AM, the DON stated resident care plans were important because care plans were the guides for staff to follow for giving daily resident care, based on the facility's assessments of the residents. The DON expected staff to follow the guide. During an additional interview, on 11/18/2023 at 5:00 PM, the Administrator stated she expected nursing staff to follow residents' care plans because they guided staff on how to meet residents' needs, and if the care plans were not followed, residents' needs might not be met, as in the case of R1. The facility alleged it had taken the following actions to remove the Immediate Jeopardy: 1. On 10/22/2023 at approximately 4:12 PM, R1 was cued and redirected inside by Licensed Practical Nurse (LPN)1. On 10/22/2023 at 4:15 PM, LPN1 documented R1 had crawled beneath the gate in the courtyard on the 500 C hall neighborhood. Further, LPN1 had notified the Charge Nurse and Nurse Practitioner (NP), Medical Director (MD) designee. 2. Corrective action also included on 10/22/230 at 4:30 PM, LPN1 initiated 15 minute checks for R1. 3. Further corrective action included on 10/22/2023 at approximately 5:00 PM, the courtyards in the 500 and 400 households were assessed by the Administrator for potential hazards. Work orders were placed for maintenance to address the gap between the ground and secured gate on each courtyard. The Courtyard door leading from each household on neighborhoods 400 and 500 were locked with access only by staff to swipe to enter/exit with signs posted. 4. Corrective action included on 10/22/2023 at 5:34 PM, the Charge Nurse assessed R1, with new assessment score of five (5), as a moderate risk for elopement. A wander-prevention bracelet was applied to R1's wrist. 5. Further corrective action included on 10/22/2023, R1's Comprehensive Care Plan (CCP) was revised by LPN1, to include new interventions; wander-prevention bracelet and 15 minute checks as identified on the printed copy of the Care Plan Elopement section print date of 10/23/2023. Statement by LPN1 attesting the creation of the care plan intervention and the statement by Director of Nursing (DON) of verification and validation on 10/23/2023. Staff was alerted verbally directly after R1's elopement of the changes to the care plan for fifteen (15) minute checks, EPLAS applied, and household courtyard door secured and locked. The Charge Nurse (CN1) for buildings 400 and 500 made all staff aware of the incident and changes to secure locked household door and the elopement. 6. Corrective action on 10/23/2023 between 8:00 AM and 12:00 PM, LPN1 reassessed elopement risk for all veterans in the facility, including the previous nine (9) who had already been identified as requiring safety using the wander-prevention bracelet. No necessary changes were identified. Census for 10/23/2023 was 57 residents. 7. Further corrective action included, on 10/25/2023, R1 continued with hourly rounding, completed by assigned direct care nursing staff, licensed, and certified nursing staff, documented on Daily Hourly Rounding forms. 8. Corrective action included, on 11/10/2023, R1's CCP was revised by the CSW to include asking to go to home; goal directed wandering tin the household; reminiscing about hitchhiking. 9. Corrective action included, on 11/10/2023, CCPs for the nine (9) veterans assessed to be at risk for elopement were reviewed and revised by the CSW and Minimum Data Set (MDS) Coordinator to include person-centered focuses [sic]. 10. Further corrective action included new admissions after 10/22/2023 will be assessed upon admission, quarterly and as needed for risk for elopement and care plans will be revised and developed as needed in a person-centered format. 11. Corrective action included from 10/26/2023-11/04/2023, training was provided to all staff with one hundred (100) percent of nursing staff in-serviced by the Director of Nursing, Assistant Director of Nursing, Nurse Supervisors, or Charge Nurses, on developing and implementing each veteran's care plan to ensure they included measurable objectives and timeframes to meet a veteran's medical, nursing, and mental and psychosocial well-being. The care plan must be reviewed and revised by the interdisciplinary team (IDT) after assessments and as needed to include changes in residents. Developing, implementing, and revising the care plan for each resident ensures their personal needs are met/quality of care is provided. Training will be added to new hire orientation for all licensed nursing staff and certified nursing staff before reporting to his/her shift and before direct care is provided. Any staff currently on leave was contacted via phone to complete all inservicing and post-test. Any staff that may be on leave that is identified by the HR Administrator will notify the Director of Nursing, ADON, NSs, CNs or CSW to receive training by DON, ADON, NSs, CNs or CSW prior to reporting to shift and providing direct care. Training related to the above was validated with all licensed or certified nursing staff via verbal acknowledgement of material presented on 10/26/2023-11/04/2023. 12. Further corrective action included, on 11/10/2023, training was provided to all staff with one hundred percent of licensed or certified nursing staff received education by DON, ADON, NS, CN, or CSW on wandering, goal directed wandering, and exit seeking definitions. Additionally, in-serviced on following an event of wandering or exit seeking, licensed nursing staff should complete a Progress Note to describe specifics of what occurred. Documentation should include the event, implementation of care planned interventions, or initiation of a new intervention; and effectiveness of the intervention Notification to nursing supervisor; reassessment of elopement risk with exit seeking; review/revision of a care plan to include event, and any new intervention used. Training will be added to new hire orientation for all staff before reporting to his/her shift and before direct care is provided. Any staff currently on leave was contacted via phone to complete all inservicing and the post-test. Any staff that may be on leave that is identified by the HR Administrator will notify the Director of Nursing, ADON, NSs, CNs or CSW to receive training by DON, ADON, NSs, CNs or CSW prior to reporting to shift and providing direct care. Training related to the above was validated with all licensed or certified nursing staff via verbal acknowledgement of material present on 11/10/2023. 13. Corrective action included, on 11/15/2023, training was provided to all staff with one hundred percent of non-clinical facility staff (dietary, housekeeping, laundry, maintenance, security, administration) received education by DON, ADON, NS, CN, CSW, Business Office Manager, Administration Specialist, or Health Information Management, on wandering, goal directed wandering and exit seeking definitions and reporting wandering and/or exit seeking to a licensed nurse. Any staff currently on leave was contacted via phone to complete all inservicing and posttest. Any staff that may be on leave that is identified by the HR Administrator will notify the DON, ADON, NS, CN or CSW to receive training by DON, ADON, NS, CN or CSW prior to reporting to shift and providing direct care. 14. Further corrective action included, on 11/15/2023, training was provided to all staff with 100 percent of licensed and certified nursing staff and 100 percent non-clinical facility staff (dietary, housekeeping, laundry, maintenance, security, administration) completed post testing on 11/15/2023 through 11/16/2023 related to the above training by DON, ADON, NS, CN, CSW, Business Office Manager (BOM), Administration Specialist (AS), or Health Information Management (HIM). All staff will complete a post in-service test with a 100 percent pass rate. Any staff currently on leave was contacted via phone to complete all inservicing and posttest. Any staff that may be on leave that is identified by the HR Administrator will notify the DON, ADON, NS, CN or CSW to receive training by DON, ADON, NS, CN or CSW prior to reporting to shift and providing direct care. 15. Corrective action included, on 10/25/2023, an Ad Hoc QAPI meeting was held to review Policy #33 Accidents and Incidents and Policy #44 Safety and Supervision. Staff in attendance were the Administrator leading the meeting with the DON, CSW, NS, ADON, APRN (Medical Director [MD] designee), Chaplain, Infection Preventionist (IP), Administrative Branch Manager (ABM), Maintenance Branch Manager (MBM), Administrative Specialist (AS) III, HIM, Admissions Coordinator (AC), Activities Director (AD), Rehab Program Director, and the Registered Dietician (RD). 16. Further corrective action included, on 11/10/2023 an Ad Hoc QAPI meeting was held to review Immediate Jeopardy removal plans to include training on auditing the CCP, the Progress Notes, and the Behavior Report by DON, ADON, NS, CN and/or the CSW. Attendance consisted of: Chaplain, AD, SDC, DON, FM, Administrator, QA Nurse led the meeting. AD, ASIII, SCW, ADON, Housekeeping/Laundry Director (H/LD), IP, ABM, NS, MDS, and MD joined by telephone. 17. Corrective action included, from 10/22/2023 daily and ongoing, the DON, ADON, NS, CH, or SCW will review Progress Notes and Behavior Reports to ensure wandering and exit seeking behaviors are assessed and care planned appropriately. If issues are identified based on monitoring, immediate corrective action (revision to CCP, assessment/reassessment, notification to licensed nursing supervisor, documentation and/or education to staff) will be provided by the DON, ADON, NS, SDC, IP, MDS Coordinator, CN, or CSW. Upon completion of in-servicing for wander/goal directed wandering and exit seeking and expectation following documentation of wandering/exit seeking, beginning 11/10/2023, audits will be completed daily of the Behavior Report, Progress Notes and Care Plans by the DON, ADON, NS or CSW. The audits completed daily of the Behavior Report, Progress Notes and Care Plans by the DON, ADON, NS or CSW will be reported by the DON to the QA committee for review on 11/17/2023. The State Survey Agency validated the facility had removed the IJ as alleged: 1. During an interview, on 11/18/2023 at 9:30 AM, LPN1 stated on the day R1 eloped from the facility, afterwards he walked with R1 back to the facility, wrote the Progress Note, and notified his supervisor and the NP. Record review of Nursing Note, dated 10/22/2023 at 4:15 PM, revealed on 10/22/2023 at 4:15 PM, LPN1 documented R1 had crawled beneath the gate in the courtyard on the 500 C hall neighborhood. Further, LPN1 had notified the Charge Nurse and Nurse Practitioner (NP), Medical Director (MD) designee. 2. During an interview, on 11/18/2023 at 9:30 AM, LPN1 stated on 10/22/2023 he initiated 15 minute checks for R1. Review of the document titled 24-Hour Q-15 Minute Check, dated 10/22/2023 revealed 15 minute checks were initiated for R1 at 4:30 PM that day and continued until 10/24/2024 at 4:30 PM. Review of the facility's Maintenance Work Order #22437 revealed the Administrator requested all courtyard gates be checked and a correction be implemented as so this did not occur again. Staff work order was created on 10/22/2023 at 6:20 PM. 3. Review of Statement of the Administrator, undated, revealed she assessed the 500 C Unit outside courtyard gate and determined that there was enough room for R1 to elope. During an interview, on 11/18/2023 at 5:00 PM, the Administrator stated she had assessed the facility soon after R1 had eloped and asked that a work order be entered to fix the courtyard gates. 4. Review of Elopement Risk Assessment dated 10/22/2023 revealed R1 was assessed by the CN as moderate risk for wandering. Observation, on 11/18/2023 at 4:30 PM, revealed R1 was ambulating with his/her cane nearby within the unit. During an interview, on 11/18/2023 at 4:30 PM, NASR4 asked R1 if she could see his wrist. R1 agreed. Observation, on 11/18/2023 at 4:31 PM, revealed a black band, which looked similar to a watch, around R1's right wrist. 5. Review of an untitled, undated document revealed the DON documented On 10/23/2023, when reviewing R1's care plan, she saw that LPN1 had revised R1's care plan to include interventions; wander-prevention bracelet and 15 minute checks. Further, the care plan was printed to include in the follow up investigation. During an interview, on 11/18/2023 at 9:30 AM, LPN1 stated he revised R1's care plan on 10/22/2023 to include the wander-prevention bracelet and 15 minute checks. During an interview, on 11/18/2023 at 9:55 AM, CN1 stated she let all the staff in the building on 10/22/2023 know about the changes to R1's care plan for 15 minute checks, a wander-prevention band applied to his/her wrist, and about the courtyard doors being secured and locked. 6. Review of the report Assessment History Multi, dated 11/16/2023, revealed the date range of the report was 10/23/2023 to 10/23/2023. Fifty-nine (59) elopement risk assessments were completed on fifty-four (54) residents. 7. Observation, on 11/18/2023 at 11:00 AM, revealed Daily Hourly Rounding forms were filed in the Nurse Supervisor's office. Observation, on 11/18/2023 at 4:25 PM revealed a Daily Hourly Rounding form lay on the dining table of one of the facility's units. [NAME] were noted by Residents' names indicating they had been checked on by NASR7. During an interview, on 11/18/2023 at 4:30 PM, NASR7 stated, as she picked up her Daily Hourly Rounding Form from the unit's dining table, that she checked on her residents on every odd hour during her shift and was going to do so at 5:00 PM. During an interview, on 11/18/2023 at 11:00 AM, the Nurse Supervisor (NS) stated nurses and NASRs rounded hourly on residents, and that hourly rounding and the Daily Hourly Rounding forms were not a new process and that hourly rounding by certified and licensed nursing staff had been implemented before R1 eloped. 8. Review of R1's CCP revealed, on 11/10/2023, the MDS Coordinator revised R1's care plan to include talking about the resident going to his/her previous home and him/her reminiscing about hitchhiking. During an interview, on 11/18/2023 at 1:48 PM, the CSW stated she and the MDS Coordinator worked on the care plans together. The CSW reviewed the Behavior Notes, and the MDS Coordinator did the updates. 9. Review of the nine (9) veterans assessed to be at risk for elopement were reviewed and revised by the CSW and Minimum Data Set (MDS) Coordinator to include person-centered focuses [sic]. 10. Review of Elopement Risk Assessment, Effective Date 10/30/2023, revealed R15, had an admission Wandering Risk Score of Low Risk for Wandering. Review of Elopement Risk Assessment, Effective Date 11/02/2023, revealed R16, had an admission Wandering Risk Score of Low Risk for Wandering. 11. Review of Employee Sign-In Record; Title: Care Plans; Target Audience: Nursing Staff, revealed in-services were held between 10/26/2023 and 11/04/2023 regarding development and implementation for each resident care plan which included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in assessments for licensed and certified nursing staff. During an interview, on 11/18/2023 at 11:35 AM, RN4 stated she had training recently on care plans. She stated she would update a resident's care plan if she assessed a resident to be at risk for elopement, and enter a progress note in the resident's clinical record, which described the resident's exit-seeking behavior, and she would report it immediately to her supervisor. RN4 stated a supervisor was always available to help her if she had any questions about updating the care plan. In an interview, on 11/18/2023 at 1:30 PM, SDC Nurse Consultant #2 stated she had provided care plan education to facility staff that all licensed nursing staff could enter for residents' care plan interventions, and the IDT team met to review them for quality of care. 12. Review of Employee Sign-In Record; Title: Wandering and Exit Seeking; Target Audience: Nursing Staff revealed in-services were held on 11/10/2023 between 10/26/2023 and 11/04/2023 regarding wandering and exit seeking definitions, and the requirement of licensed nursing staff to complete a Progress Note to describe the specifics of what occurred following an event of wandering or exit seeking. Documentation should include the event, implementation of care planned interventions or initiation of a new intervention, and effectiveness of the intervention. Licensed nursing staff were to also notify their supervisor and re-assess the resident for elopement risk. During an interview, on 11/18/2023 at 11:15 AM, [NAME] 10 stated she had training recently about on wandering and exit seeking. She stated residents walking around, or wandering, was different than exit seeking. NASR10 stated if she saw signs that made her think the resident wanted to leave the facility, she would ensure the resident's safety and immediately tell the nurse. 13. During an interview, on 11/18/2023 at 11:40 AM, the Cosmetologist stated she knew the residents and talked with them often when she cut their hair. She stated she had training recently and if she heard a resident talking about wanting to home she would immediately tell the nurse. 14. Record review of Wandering/Goal Directed Wandering and Exit Seeking Post Test revealed a post test was administered to therapy, nursing, and non-clinical staff on 11/15/2023, some via telephone. During an interview on 11/18/2023 at 2:30 PM the HR Administrator stated the pink marks on the employee roster indicated staff members who took the posttest while in the facility. Those who were not working that day were contacted by telephone. 15. During an interview, on 11/18/2023 at 5:15 PM, the DON stated they had QAPI meetings on 10/25/2023, 11/10/2023 and on 11/17/2023. 16. During an interview, on 11/18/2023 at 1:30 PM, the Chaplain stated she attended the QAPI meeting on 11/10/2023. She stated she was not clinical and could not update care plans but knew if a resident talked about wanting to get out of the facility, she would immediately tell the nurse. The Chaplain stated she would also try to engage the resident and try to figure out what was going on with him/her so that he/she could be redirected from exit seeking. (Did you review sign-in sheets for those meetings? If so, add here.) Completed below Review of QAPI QAA Committee Meeting Attendance Record/Sign In Sheet, dated 11/10/2023, revealed a QAPI meeting was held at 11:30 AM on[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's policies, and review of video camera footage, it was determined the facility failed to have an effective system in place to ensure residents at risk for elopement received the necessary supervision to maintain their safety and prevent elopement for one (1) of three (3) sampled residents, (Resident 1). The facility assessed Resident (R) 1 to be at low risk for elopement on 09/05/2023. Registered Nurse (RN) 8 noted that R1 was exit seeking on 08/08/2023. Continued record review revealed on 09/23/2023, Licensed Practical Nurse (LPN) 1 noted R1 was exit seeking. However, LPN1 did not report the resident's behavior. On 10/22/2023, at approximately 4:05 PM, R1 exited the facility to the outdoor fenced courtyard. R1 slid beneath the courtyard gate through a gap between the bottom of the gate and the ground. Visitors alerted facility staff that someone was outside on their knees by the gate. Staff responded and found R1 standing by the fence outside of the gated courtyard. R1 stated, I am trying to get back home to pay for my stay and get my medicine. R1 was brought back inside the facility and assessed by the nurse. Immediate Jeopardy (IJ) was identified on 11/09/2023 and was determined to exist on 08/08/2023, at 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), Develop/Implement Person-Centered Comprehensive Care Plans, at a S/S of a J; and 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision at a S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision. A Partial Extended Survey was initiated on 11/18/2023 and concluded on 11/18/2023. The facility submitted an acceptable Immediate Jeopardy (IJ) Removal Plan on 11/17/2023 alleging the IJ was removed on 11/17/2023. The State Survey Agency validated the IJ was removed on 11/17/2023 as alleged, prior to exit on 11/18/2023, with remaining non-compliance at S/S of D while the facility develops and implements a Plan of Correction. An additional deficiency was cited at 42 CFR 483.90(g) Resident Call System: F919. The findings include: Review of the facility's policy, Safety and Supervision of Residents, approved date 01/01/2017, revealed the facility strove to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents were facility-wide priorities. According to the policy, the facility's resident-oriented approach to safety addressed groups of residents. Safety risks and environmental hazards were identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; Quality Assurance (QA) reviews of safety and incident/accident reports; and a facility wide commitment to safety at all levels of the organization. Employees shall be trained and in-serviced on potential accident hazards and how to identify and report accident hazards and try to prevent avoidable accidents. Further review of the Safety and Supervision of Residents policy, approved 01/01/2017, revealed the Interdisciplinary Care Team (IDT) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. Review of the facility's policy, Elopement/Missing Resident, revised date 10/18/2022, revealed the facility must ensure adequate supervision of residents to prevent accidents. It was the responsibility of staff to investigate and report any resident who tried to leave the premises or was suspected of elopement to Security and his/her supervisor immediately. Review of the facility's policy, Wandering Unsafe Resident, revised 07/16/2018, revealed the facility would strive to maintain a safe environment while maintaining the least restrictive environment for residents who were at risk for elopement or unsafe wandering. The resident's care plan would indicate identified risk for elopement or wandering into areas that exposed (the) resident to other safety issues. The Interdisciplinary Team would utilize interventions to maintain safety such as a personalized monitoring plan, application of wander-prevention band and/or consideration for resident to move to a more secure location. A Medical Provider order would be written should the need for a wander-prevention band be identified. Review of the admission Record, in Resident 1's (R1) clinical record revealed the facility admitted R1 on 12/13/2022 with diagnoses that included unspecified dementia, mixed conductive and sensorineural hearing loss; bilateral, unspecified visual loss, and cognitive communication deficit. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/05/2023, revealed R1 scored eight (8) of fifteen (15) on the Brief Interview for Mental Status (BIMS). This score indicated the resident was assesses as moderately cognitively impaired. Review of the Quarterly Elopement Risk Assessment, dated 09/05/2023, revealed the facility assessed R1 to be at Low Risk for Wandering. Additionally, item G, History of Wandering indicated the facility assessed R1 not to be a known wanderer/history of wandering. During an interview, on 11/09/2023 at 5:22 PM, the MDS Coordinator stated interventions for Low Risk for Wandering would be to just monitor the resident with hourly rounding, meaning staff would check on residents every hour and provide any needed care to those residents. She stated if she heard a resident say something like he/she wanted to leave the facility, a progress note would be entered into the clinical record for the IDT to review. During an interview, on 11/08/2023 at 3:50 PM, the MDS Coordinator stated a resident would have a history of wandering if there were several documented attempts of that resident seeking a way out of the facility, or the resident verbalized he/she wanted to get out of the facility, or wanted to go away. She stated more than one documented assessment of exit seeking behavior would be needed for the MDS Coordinator to check Known wanderer/history of wandering on the resident's Elopement Risk Assessment. Additionally, the MDS Coordinator stated the designated safe area while outside and the external facility grounds included the outdoor gated and locked courtyard adjacent to the indoor unit where R1 lived. Review of R1's elopement risk care plan revealed on 12/13/2022 the facility initiated a care Focus that R1 wished to exercise his/her right to be independent in the pursuit of outdoor activities on the external facility grounds. The Goal was that R1 would enjoy self-directed activities while maintaining his/her personal safety on the external facility grounds. The Intervention was that R1 was to remain in the designated safe area while outside. Review of an untitled care plan document revealed on 01/25/2023 the facility initiated a care Focus, that R1 was at risk for elopement, with a Goal that R1 would continue to walk safely within the unit/facility. Nursing Interventions/Tasks included assessing unit as needed for potential hazards, cueing, and redirecting as needed, and identifying any triggers that increased need for wandering and intervene as necessary. During an interview, on 11/02/2023 at 11:35 AM, Nurse Aide State Registered ([NAME]) 9 stated she knew R1, and he/she often spoke of wanting to go back to his/her hometown. During an interview, on 11/15/2023 at 9:02 AM, LPN3 stated she was familiar with R1 and had cared for him/her. LPN1 recalled that she and R1 had quite a few conversations about people coming to pick him/her up and R1 had asked LPN3 how far it was to his/her hometown. LPN3 stated R1 was confused. Although it was the facility's policy to immediately report any suspicion of elopement to her supervisor, LPN3 stated she did not report to her supervisor R1's questions about the distance to his/her hometown, and R1's statements about people coming to pick him/her up, but was sure she gave it in report. Further interview revealed LPN3 did not think R1 was going to leave the facility, and she felt R1 was confused about where [he/she] was staying. During an interview, on 10/28/2023 at 3:07 PM, LPN2 stated she was familiar with R1, but it had been a while since she took care of him/her, and that was probably during this past summer. LPN2 stated R1 was usually walking around looking for his/her car, and he/she liked to go out to the facility's 500 C Unit outdoor courtyard. LPN2 stated at night R1 would walk around looking for his/her car and would say I gotta find my car and get home. Review of Progress Notes, dated 09/29/2023 at 1:36 PM, revealed LPN1 documented R1 noted to be exit seeking at this time. During an interview, on 11/08/2023 at 2:24 PM, LPN1 stated he had written R1 noted to be exit seeking at this time. LPN1 stated exit seeking most likely meant R1 had been pushing on doors, or was probably talking about going home. LPN1 stated his note did not say R1 was attempting to leave the facility, and that was why he did not report it to his supervisor, although the facility's Elopement/Missing Resident policy stated staff were to report any suspicion of elopement to their supervisor immediately. LPN1 stated if a resident said they wanted to go to Florida, it was one thing. Actually going there was another. Further interview revealed when asked if LPN1 implemented R1's Elopement Risk nursing care plan Interventions/Tasks to Identify any triggers that increase need for wandering and intervene as necessary, LPN stated he did not understand that care plan intervention. During an interview, on 11/03/2023 at 11:30 AM, Charge Nurse (CN) 1 stated R1 had a wander-prevention band when he/she was first admitted to the facility, but it aggravated him/her, and R1 took off the wander-prevention band. CN1 stated the facility assessed R1 to be better than when he/she first came into the facility, and after he/she had been in the facility awhile R1 did not seem to need the wander-prevention band. CN1 stated the day R1 eloped he/she had a moment of dementia. Review of the facility's video footage of the event, which was recorded by a camera located on the facility's 500 C unit outdoor courtyard where Resident #1 had eloped, revealed on 10/22/2023 at 4:04:49, R1 could be seen exiting the unlocked door of the 500 C Unit where he/she resided. R1 was then seen walking toward the gated section of the iron fence which surrounded the 500 C unit's courtyard. At 4:05:04 PM, R1 was no longer in the view of the courtyard camera. Review of the facility's Initial Report of their investigation, dated 10/22/2023 at 6:15 PM, revealed the facility described the incident as R1 was identified going outside to the residence's secured courtyard at 4:05 PM. At approximately 4:10 PM R1 was observed by Visitors (V1 and V2) who had parked to come in to visit. R1 was observed to be on his/her knees having crawled under the outside courtyard gate on the unit. R1 stood and held onto the fence. V1 and V2 came immediately to the door to inform staff. Staff went immediately to R1 and escorted him/her into the unit at approximately 4:15 PM. CN1 and LPN1 asked R1 to follow them to his/her room so that they could check for any injuries. Further review of the Initial Report, dated 10/22/2023 at 6:15 PM, revealed the steps taken after R1's elopement to protect him/her were described as R1 was placed on 15 minute checks for forty-eight (48) hours and would reassess. All household courtyard doors have been locked with signage to ask for assistance to be in the outside courtyard. Maintenance was contacted. Wander-prevention band was applied to R1's right wrist with his/her consent. During an interview, on 11/18/2023 at 9:55 AM, CN1 stated she assessed R1's skin after he/she eloped on 10/22/2023 and observed superficial scratches on R1's back. Review of a statement by LPN1, dated 10/22/2023, revealed that on 10/22/2023 at approximately 4:15 PM, LPN1 was made aware that R1 had crawled beneath the gate in the courtyard on the unit. LPN1 then exited the facility and noted R1 standing on the other side of the gated courtyard. When LPN1 approached R1, he/she stated I was headed to [his/her hometown] to get money to pay for my stay [at the facility] last night. Review of the facility's investigation Interview of R1 at 3:28 PM on 10/22/2023, revealed R1 stated he/she was out in the courtyard walking around, was going to hitchhike home [be]cause he/she was out of money. [I] just looked at the distance and skid [sic] right under the gate to outside of the courtyard. I walked over there around the courtyard and the main road is on out from here to where you would need to hitchhike. During an interview, on 10/25/2023 at 3:10 PM, Safety/Security (S/S) Staff 1 stated he was going to the unit (where R1 resided) to deliver food to another resident when he looked out the window of the corridor and saw two (2) staff members and R1. S/S1 stated R1 was on the outside of the gate with other staff. S/S1 delivered the food and then went back outside and saw staff walking R1 back to the gate of the courtyard. S/S1 stated staff told him/her R1 got out of the secured courtyard by crawling under the gate. Observation, on 10/30/2023 at 10:44 AM, revealed R1 had walked approximately eighty-one (81) feet away from the facility's courtyard gate, as measured by the Maintenance Branch Manager and as reported by S/S1. During an interview, on 10/29/2023 at 4:26 PM, V1 stated he and his brother (V2) visited their relative on the weekends. V1 stated, on 10/22/2023, he and V2 signed in at the facility's front desk and drove around to the 500 C Unit's entrance. V1 stated he noticed a person (R1) on his/her knees facing the gate. V1 stated he and V2 pulled in and saw R1 stand up and R1 had a cane. V1 stated he said to V2, I think that is a resident. V1 saw R1 turn around and V1 stated he recognized him/her, and R1 waved when he/she saw V1 and V2 in the facility's parking lot. V1 stated he went to the door of the 500 C Unit, rang the doorbell, and told a man who was working there (LPN1) that he thought a resident was outside. During the interview, on 10/29/2023 at 4:26 PM, V1 stated R1 had to have just walked around the edge of the fence. V1 stated he thought he heard someone saying something about a space under the gate, but he could not believe it. V1 stated he would have never thought that would have happened. He stated he had never noticed the gap until after it happened and could not believe R1 crawled under there. Review of the Progress Notes, dated 10/22/2023, revealed LPN1 documented at 4:15 PM that he had been made aware R1 had crawled beneath the gate in the courtyard of the facility. LPN1 exited the facility and noted R1 standing on the other side of the gated courtyard; when approaching R1 he/she stated that he/she was headed home to get money to pay for his/her stay last night; LPN1 explained to R1 that he/she did not need to pay for his/her stay at the facility as insurance took care of it. Continued review revealed R1 was redirected inside of facility and his/her skin was assessed where he/she had crawled under the fire exit gate in courtyard - scattered abrasions to upper back noted; R1 denied complaints of (c/o) pain or discomfort at that time; courtyard doors were to remain locked for the remainder of the shift; Supervisor made aware; Nurse Practitioner (NP) made aware; responsible party made aware. LPN1 would continue to update R1's chart as necessary that shift. During an interview, on 10/26/2023 at 1:37 PM, RN3 stated she was working as an aide on Sunday 10/22/2023 and saw R1 outside within the unit's locked and gated courtyard between 4:00 PM and 4:05 PM. She stated she took another resident, R2, to the bathroom. RN3 stated she then heard a visitor say they saw someone on their hands and knees by the gate. She went out the door to the courtyard and saw R1 outside of the locked and gated courtyard. RN3 stated R1 had walked along the fence outside of the courtyard and could have had the intention of leaving the facility. During an interview, on 11/07/2023 at 3:10 PM, the Director of Nursing (DON) stated R1's elopement was avoidable and could have been prevented if the gap in the courtyard gate, where R1 exited the courtyard, had been identified during environmental rounds of the facility. The DON stated maintenance walked through and around the building to check the environment for problems and hazards. She stated she could not point her finger at maintenance because all facility staff were responsible for residents' safety. During further interview, on 11/07/2023 at 3:10 PM, the DON said R1's elopement could have been a bad situation and she was thankful visitors pulled in and saw R1 getting up from his/her knees. The DON stated she expected staff to keep the facility's environment as safe as possible and provide supervision to prevent any unforeseeable accidents from occurring. During an interview, on 11/07/2023 at 5:30 PM, the Administrator stated she would never have thought R1's elopement could have ever happened. The facility was responsible for the safety of the residents. The Administrator stated R1 got out and to her that went along with why so many children died in pools in the summertime. It took that one moment that you never expected, and this was that one moment. She stated she now thought differently about assessing the facility's environment since R1's elopement, she had created a subcommittee for environmental safety. The subcommittee would look at R1's incident and determine if we have enough eyes to adequately supervise residents. The Administrator said she was not aware of any preventative maintenance plan prior to R1's elopement, but there was now a plan. The facility alleged it had taken the following actions to remove the Immediate Jeopardy: 1. Corrective action included on 10/22/2023 at approximately 4:12 PM, R1 was cued and redirected inside by Licensed Practical Nurse (LPN)1. Corrective action also included on 10/22/2023 at 4:15 PM, LPN1 documented R1 had crawled beneath the gate in the courtyard on the 500 C hall neighborhood. Further, LPN1 had notified the Charge Nurse and Nurse Practitioner (NP), Medical Director (MD) designee. 2. Corrective action included on 10/22/2023 at 4:30 PM, LPN1 initiated 15 minute checks for R1, and continued until 10/25/2023, by licensed staff assigned to R1. DON, ADON, NS or CN ensured 15 minute checks were documented/completed on a 24-hour Q15-minute checks form. 3. Further corrective action included on 10/22/203 and 10/23/2023, licensed or certified nursing staff documented hourly rounds on Daily Hourly Rounding forms for all residents when in the courtyard. 4. Corrective action included on 10/22/2023 at approximately 4:45 PM, all courtyard doors on 400 and 500 households were secured by locking the door and only able to open by staff with a badging system card, and signs were posted. 5. Further corrective action included on 10/22/2023, after the event, 10/23/2023 and 10/24/2023, residents assessed to be at risk for elopement were provided 1:1 supervision by licensed or certified nursing staff, when in the courtyards, until the gates were modified to include metal plates on the bottom. 6. Corrective action included, on 10/22/2023 at approximately 5:00 PM, the courtyards in the 500 and 400 households were assessed by the Administrator for potential hazards. Work orders were placed for maintenance to address the gap between the ground and secured gate on each courtyard. Additional corrective action was on 10/23/2023 at approximately 4:30 PM, 500 household courtyard gates were modified to include metal plates on the bottom by the Maintenance Branch Manager (MBM), Maintenance Supervisor (MS), Maintenance Technician (MT) I, or Maintenance Worker (MW) I. Also, on 10/24/2023 at approximately 4:30 PM, 400 household courtyard gates were modified to include metal plates on the bottom by MBM, Maintenance Supervisor (MS), Maintenance Technician I, or Maintenance Worker I. 7. Further corrective action included on 10/22/2023, R1's Comprehensive Care Plan (CCP) was revised by LPN1, to include new interventions; wander-prevention band and 15 minute checks as identified on the printed copy of the Care Plan Elopement section print date of 10/23/2023. Statement by LPN1 attesting the creation of the care plan intervention and the statement by Director of Nursing of verification and validation on 10/23/2023. 8. Corrective action included on 10/22/2023, R1's Comprehensive Care Plan (CCP) was revised by LPN1, to include new interventions; wander-prevention band and 15 minute checks as identified on the printed copy of the Care Plan Elopement section print date of 10/23/2023. Statement by LPN1 attesting the creation of the care plan intervention and the statement by Director of Nursing of verification and validation on 10/23/2023. Staff was alerted verbally directly after R1's elopement of the changes to the care plan for fifteen (15) minute checks, EPLAS applied, and household courtyard door secured and locked. The Charge Nurse for buildings 400 and 500 made all staff aware of the incident and changes to secure locked household door and the elopement. 9. Further corrective action included on 10/23/2023 DON added an order for licensed nursing staff to check placement and function every shift for R1's wander-prevention band. 10. Corrective action included on 10/23/2023 between 8:00 AM and 12:00 PM, LPN1 reassessed elopement risk for all veterans in the facility, including the previous nine (9) who had already been identified as requiring safety using the wander-prevention band. No necessary changes were identified. Census for 10/23/2023 was 57 residents. 11. Corrective action included on 10/23/2023, all residents in the facility's CCP, based on elopement risk, were reviewed by the Certified Social Worker (CSW) 12. Further corrective action included, on 10/24/2023, licensed and certified nursing staff continued with hourly rounding for R1, documented on Daily Hourly Rounding forms. 13. Corrective action included on 11/05/2023, MDS Coordinator revised CCP to include certified nursing staff to complete documentation on checking placement and ensuring function of wander-prevention bands. 14. Further corrective action was Training: 10/24/2023-11/04/2023, one hundred (100) percent of licensed or certified nursing staff were in-serviced by the DON, ADON, NS, or CN, on ensuring the residents' environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Identifying and addressing risks, including the potential for accidents, included consideration of the environment. All staff can identify, report, and implement interventions for resident risk and environmental hazards. Communicate potential hazards to supervisors. Attestation of acknowledgement and understanding of the in-service provided was contained on the In-service Training Sheet. New staff would be in-serviced by the DON, ADON, NS, or CN, before accepting and reporting to direct care assignment. Any staff currently on leave was contacted via phone to complete all in-servicing and post-test. Any staff that may be on leave that was identified by the HR Administrator will notify the DON, DON, NSs, CNs or CSW to receive training by DON, ADON, NSs, CNs or CSW prior to reporting to shift and providing direct care. Training related to the above was validated with all licensed or certified nursing staff via verbal acknowledgement of material present on 10/24/2023-11/04/2023. 15. Corrective action included, on 11/10/2023, training was provided to all staff with one hundred percent of licensed or certified nursing staff received education by DON, ADON, NS, CN, or CSW on wandering, goal directed wandering and exit seeking definitions. Additionally, in-serviced on following an event of wandering or exit seeking, licensed nursing staff should complete a Progress Note to describe specifics of what occurred. Documentation should include the event, implementation of care planned interventions or initiation of a new intervention and effectiveness of the intervention. Notification to nursing supervisor; reassessment of elopement risk with exit seeking; review/revision of care plan to include event and any new intervention used. Attestation of acknowledgement and understanding of the in-service provided was contained on the In-service Training Sheet. All staff would be trained upon hire and before reporting to his/her shift and before providing direct care. Any staff member currently on leave was contacted via phone to complete all in-servicing and post-test. Any staff that may be on leave that was identified by the HR Administrator would notify the DON, ADON, NSs, CNs or CSW to receive training by DON, ADON, NSs, CNs or CSW prior to reporting to shift and providing direct care. Training related to the above was validated with all licensed or certified nursing staff via verbal acknowledgement of material present on 11/10/2023. 16. Further corrective action included on 11/15/2023, training was provided to all staff with 100 percent of non-clinical facility staff (dietary, housekeeping, laundry, maintenance, security, administration) received education by DON, ADON, NS, CN, CSW, Business Office Manager, Administration Specialist, or Health Information Management, on wandering, goal directed wandering and exit seeking definitions and reporting wandering and/or exit seeking to a licensed nurse. Attestation of acknowledgement and understanding of the in-service provided was contained on the in-service training sheet. All staff will be trained upon hire and before reporting to his/her shift and before providing direct care. Any staff currently on leave was contacted via phone to complete all in-servicing and post-test. Any staff that may be on leave that was identified by the HR Administrator will notify the DON, ADON, NS, CN or CSW to receive training by DON, ADON, NS, CN or CSW prior to reporting to shift and providing direct care. On 11/15/2023, training was provided to all staff with 100 percent of licensed certified nursing staff and 100 percent of non-clinical facility staff completed post-testing on 11/15/2023 and 11/16/2023 related to the above training by DON, ADON, NS, CN, CSW, Business Office Manager, Administration Specialist, or Health Information Management. All staff will complete a post in-service test with 100 percent pass rate. All staff will be trained upon hire and before reporting to his/her shift and before providing direct care and take the post test with a 100 percent pass rate. Any staff currently on leave was contacted via phone to complete all in-servicing and post-test. Any staff that may be on leave that was identified by the HR Administrator will notify the DON, ADON, NS, CN or CSW to receive training by DON, ADON, NS, CN or CSW prior to reporting to shift and providing direct care. 17. Corrective action included on 10/25/2023, an Ad Hoc QAPI meeting was held to review Policy #33 Accidents and Incidents and Policy #44 Safety and Supervision. Staff in attendance were the Administrator leading the meeting the DON, CSW, NS ADON, APRN (Medical Director designee), Chaplain, Infection Preventionist, Associate Business Manager (ABM) MBM, Administrative Specialist III, HIM, Admissions Coordinator, Activities Director, Rehab Program Director, and the Registered Dietician. 18. Further corrective action included on 11/10/2023 an Ad Hoc QAPI meeting was held to review Immediate Jeopardy removal plans to include training on auditing the CCP, the Progress Notes, and the Behavior Report by DON, ADON, NS, CN and/or the CSW. Attendance consisted of: Chaplain, AD, SDC, DON, FM, Administrator, QA Nurse led the meeting. Admissions Coordinator, Administrative Specialist III, CSW, ADON, Housekeeping/Laundry Director, IP, ABM, NS, MDS Coordinator, and MD joined by telephone. 19. Corrective action included: 10/22/2023 daily ongoing, the DON, ADON, NS, CN, or CSW will review Progress Notes and Behavior Reports to ensure wandering and exit seeking behaviors were assessed and care planned appropriately. If issues were identified based on monitoring, immediate corrective action (revision to CCP, assessment/reassessment, notification to licensed nursing supervisor, documentation and/or education to staff) will be provided by the DON, ADON, NS, SDC, IP, MDS Coordinator, CN, or CSW. Upon completion of in-servicing for wander/goal directed wandering and exit seeking and expectation following documentation of wandering/exit seeking, beginning 11/10/2023, audits will be completed daily of the Behavior Report, Progress Notes and Care Plans by the DON, ADON, NS or CSW. 20. Further corrective action included the audits completed daily of the Behavior Report, Progress Notes and Care Plans by the DON, ADON, NS or CSW will be reported by the DON to the QA committee for review on 11/17/2023. The State Survey Agency validated the facility had taken the alleged actions. 1. During an interview, on 11/18/2023 at 9:30 AM, LPN1 stated on the day R1 eloped from the facility, afterwards he walked with R1 back to the facility, wrote the Progress Note, and notified his supervisor and the NP. 2. During an interview, on 11/18/2023 at 9:30 AM, LPN1 stated on 10/22/2023 he initiated 15 minute checks for R1. 3. Record review of the document titled 24-Hour Q-15 Minute Check, dated 10/22/2023 revealed 15 minute checks were initiated for R1 at 4:30 PM that day and continued until 10/24/2024 at 4:30 PM. Observation, on 11/18/2023 at 11:00 AM, revealed Daily Hourly Rounding forms were filed in the Nurse Supervisor's office. 4. Observation, on 11/18/2023 at 4:30 PM, revealed a sign was posted on the inside of the courtyard door notifying residents to Please let staff know if [they] wanted to go outside. 5. During an interview, on 11/18/2023 at 9:30 AM, LPN1 stated he and other staff provided 1:1 supervision to residents at risk for elopement when they were outside in the courtyard until the courtyard gates were fixed. 6. Review of theMaintenance Work Order #22437 revealed, on 10/22/2023 at 6:20 PM, a work order request was added that stated, Administrator requests all courtyard gates be checked and a correction be implemented so [R1's elopement] does not happen again. Observation, on 11/18/2023 at 9:00 AM, revealed a metal plate was installed to the bottom of the 500 C Unit's outdoor courtyard gate. The metal plate extended to within three (3) inches of the ground which eliminated the gap which R1 slid under on 10/22/2023. Observation, on 11/18/2023 from 9:10 AM until 9:25 AM revealed any gaps in the facility's courtyard gates had been modified with metal plates to eliminate any gap between the bottom of the gate and the ground. 7. During an interview, on 11/18/2023 at 9:30 AM, LPN1 stated he revised R1's care plan after he/she eloped from the facility. Review of a document titled std_intervention_id revealed on 10/22/2023 the nursing intervention of I [R1] wear a [Wander-prevention band]. Check placement and function each shift. had been initiated on R1's care plan. 8. Review of an untitled, undated document [TRUNCATED]