**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure 1 (#1) of 2 (#1, #2) residents whom was assessed at high risk for elopement, was adequately supervised to prevent him from eloping from the facility. This deficient practice resulted in an Immediate Jeopardy situation on 12/18/2023 at approximately 5:30 p.m. when Resident #1 (a severely cognitively impaired resident identified as an elopement risk), was unsupervised and eloped from the facility. Resident #1 was found lying on the ground of a creek bank approximately ¼ of a mile from the facility on 12/18/2023 at 8:06 p.m. by the Sherriff's Department. Resident #1 was taken to the local emergency department for evaluation. Review of the local emergency department notes dated 12/18/2023 at 9:35 p.m. revealed Resident #1's skin temperature was cool, abrasions sustained to head, neck, right and left arm, right and left hand, buttocks, back of left and right leg, back, and right hip. Resident #1 was covered in debris including leaves, pine straw, and twigs. Resident #1 was returned to the nursing facility via ambulance from the local emergency department on 12/19/2023 at 12:49 a.m. S1Adminsitrator was notified of the Immediate Jeopardy situation on 12/27/2023 at 1:46 p.m. The deficient practice continued at a potential for more than minimal harm for Resident #1 and Resident #2. The Immediate Jeopardy was removed on 12/27/2023 at 7:43 p.m. as confirmed by onsite verification through observations, interview and record reviews that the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Review of the facility's Elopement Policy revision dated 12/19/2023 revealed there was no guidance in the policy on placing a resident that had eloped on any type of supervision or monitoring. Review of the facility's Verbal/Written Consent for placement of Resident to the secured dementia unit revealed in part. I further understand the following limitations with placement on a secured unit: 1) The resident will be unable to leave the secured unit without supervision 2) The resident will remain on the unit for meals, activities, etc. unless accompanied by family or a staff member to access other parts of the facility. Review of the medical record for sampled Resident #1 revealed an admission date of 05/08/2023 with diagnoses including unspecified dementia (severe, with other behavioral disturbances), restlessness and agitation, diabetes mellitus, cerebrovascular disease, anxiety, depression, hyperglycemia, hypertension and schizophrenia. Review of the Minimum Data Set assessment (MDS) dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score was a 6 out of 15, which indicated Resident #1 had severe cognitive impairment for daily decision making. Further review of the MDS revealed under the section E0900. Wandering - Presence and Frequency - Behavior of this type occurred daily. Resident #1 required limited assistance with one person physical assistance with bed mobility and transfers. Review of the care plan revealed Resident #1 was at risk for elopement, and had a history of wandering. Further review of the care plan revealed the interventions were to assess quarterly and as needed for wandering/elopement risk, encourage family support, and ensure staff awareness of resident's risk, Resident #1 resides on the secured unit, monitor meds for the need for adjustment and notify the physician as needed, and monitor resident with visual checks every hour (initiated on 12/18/2023), photo on the wander list at the front desk and staff are aware of resident's wandering risk (initiated on 12/18/2023), staff to monitor identification bracelet placement every shift (initiated on 12/18/2023). Review of the physician's orders dated 06/11/2023 revealed an order for Resident #1 to be moved to the dementia unit. Review of Resident #1's Social Services assessment dated [DATE] revealed in part: Resident requires more close supervision during group activities related to wandering status. Staff reports resident wandering into other resident's room, also wanders up and down halls, and required daily redirection. Observations during all days of the survey on 12/21/2023 to 12/28/2023 revealed Resident #1 resided in the secured unit, was able to ambulate independently, and was observed walking in the TV room and the hallways on the locked unit. Review of the Wander Data Collection Tool dated 11/09/2023 revealed Resident #1 was cognitively impaired and ambulated independently. Further review of the Wander Data Collection Tool revealed Resident #1 was identified at high risk for elopement. Review of the Incident/Accident report dated 12/18/2023 revealed the Certified Nursing Assistant (CNA) came to the nurses station looking for Resident #1, and stated she couldn't find him. This nurse and other staff immediately began looking for him searching all rooms outdoors, corridors and in the facility. Resident #1 wasn't able to be located. Called Nursing Facility Administrator (NFA) and Director of Nursing (DON), here at facility searching. NFA stated to do another sweep of the facility. This nurse and CNAs searched outdoors. I went to the highway looking for the resident without success. NFA was notified and called the police. NFA and DON continued to search with the police. On 12/21/2023 at 8:30 a.m. interview with S10Maintenance Director revealed the working cameras inside and outside of the building did not capture Resident #1 on video. S10Maintenance Director revealed he checks the door locks to ensure they are in working condition but he did not keep a log to indicate he was monitoring the doors. On 12/21/2023 at 8:45 a.m. interview with S7CNA revealed Resident #1 can walk without help in the hallways and he was at risk for elopement. Further interview with S7CNA revealed Resident #1 was to never to be left alone, and the staff were to keep Resident #1 in eye contact at all times. On 12/21/2023 at 9:15 a.m. interview with S4Certified Nursing Assistant (CNA) revealed she worked with Resident #1 in the locked unit on 12/18/2023. S4CNA revealed Resident #1 was at high risk for elopement and the staff would keep him in sight at all times because he wandered. S4CNA revealed on 12/18/2023 during dinner, between 4:30 p.m. and 5:00 p.m. she brought Resident #1, which resided on the locked unit, out to the regular dining room to eat. She revealed when the resident finished eating, she was asked if she could help feed a resident down the hall. S4CNA said she went to the nurse's station by the locked unit where S5Assistant Director of Nursing (ADON) was sitting and she told S5ADON she needed her to watch the resident because she needed to go feed a resident down the hall. S4CNA said S5ADON said okay, so she left Resident #1 at the nurse's station sitting in a chair in sight of S5ADON. She said on 12/18/2023 at about 5:30 p.m. S6MDS Coordinator asked S4CNA if she came and got Resident #1 from the nurses station and she said no. On 12/21/2023 at 10:00 a.m. interview with S5ADON revealed she was working the floor and unit the night that Resident #1 eloped from the facility, and she knew Resident #1 was outside of the secured unit and he was on the main floor. S5ADON revealed the resident walked independently, was at high risk for elopement, and staff would always have him in sight. Further interview with S5ADON revealed no one came to her the evening of 12/18/2023 and told her she needed to watch Resident #1. On 12/21/2023 at 1:35 p.m. interview with S2DON revealed she was working 12/18/2023 when Resident #1 eloped from the facility. S2DON revealed Resident #1 walked independently, was at high risk for elopement, and staff were to keep him in eye sight at all times when not on the secured unit. Further interview with S2DON revealed she knew that staff would bring Resident #1 out of the secured unit to eat in the main dining room. S2DON revealed she assumed Resident #1 left out of the door with a visitor. On 12/21/2023 at 1:45 p.m. interview with S8CNA revealed Resident #1 does not need help walking and he was at risk for elopement. On 12/21/2023 at 1:55 p.m. interview with S6MDS Coordinator revealed she was at the facility when Resident #1 eloped on 12/18/2023. S6MDS Coordinator revealed Resident #1 ambulated independently and was at high risk for elopement. At approximately 5:15 p.m. he was sitting outside the secured unit across from the nurse's station close to the nurse's station, and about 15 minutes later she heard someone say they couldn't find Resident #1. On 12/27/2023 at 8:00 a.m. interview with S9LPN revealed Resident #1 lived on the locked unit due to at high risk for elopement. Resident #1 was able to walk independently. During the survey, there was no documented evidence of monitoring the resident for elopement, monitoring doors or any of the other items that were put into place until after the survey team entered on 12/21/2023 at 8:00 a.m. On 12/27/2023 at 1:05 p.m. S1Administrator was unable to provide the surveyors with any type of documentation for monitoring the system they put in place after the elopement incident on 12/18/2023. S1Administrator acknowledged no monitoring was put in place prior to the survey team entering the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure 1 (#1) of 2 (#1, #2) residents (whom were at high risk for elopement and resided in the secured unit), was adequately supervised to prevent Resident #1 from eloping. This deficient practice resulted in an Immediate Jeopardy situation on 12/18/2023 at approximately 5:30 p.m. when Resident #1 (a severely cognitively impaired resident identified as an elopement risk), was unsupervised and eloped from the facility. Resident #1 was found lying on the ground of a creek bank approximately ¼ of a mile from the facility on 12/18/2023 at 8:06 p.m. by the Sherriff's Department. Resident #1 was taken to the local emergency department for evaluation. Review of the local emergency department notes dated 12/18/2023 at 9:35 p.m. revealed Resident #1's skin temperature was cool, abrasions sustained to head, neck, right and left arm, right and left hand, buttocks, back of left and right leg, back, and right hip. Resident #1 was covered in debris including leaves, pine straw, and twigs. Resident #1 was returned to the nursing facility via ambulance from the local emergency department on 12/19/2023 at 12:49 a.m. S1Adminsitrator was notified of the Immediate Jeopardy situation on 12/27/2023 at 1:46 p.m. The deficient practice continued at a potential for more than minimal harm for Resident #1 and Resident #2. The Immediate Jeopardy was removed on 12/27/2023 at 7:43 p.m. as confirmed by onsite verification through observations, interview and record reviews that the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Cross Reference F689 Review of the facility's Elopement Policy revision dated 12/19/2023 revealed there was no guidance in the policy on placing a resident that had eloped on any type of supervision or monitoring. Review of the facility's Verbal/Written Consent for placement of Resident to the secured dementia unit revealed in part: I further understand the following limitations with placement on a secured unit: 1) The resident will be unable to leave the secured unit without supervision 2) The resident will remain on the unit for meals, activities, etc. unless accompanied by family or a staff member to access other parts of the facility. Review of the Incident/Accident report dated 12/18/2023 revealed the Certified Nursing Assistant (CNA) came to the nurses station looking for Resident #1, and stated she couldn't find him. This nurse and other staff immediately began looking for him searching all rooms outdoors, corridors and in the facility. Resident #1 wasn't able to be located. Called Nursing Facility Administrator (NFA) and Director of Nursing (DON), here at facility searching. On 12/21/2023 at 1:35 p.m. interview with S2Director of Nursing (DON) revealed when resident #1 returned from the hospital on [DATE] he was placed in the secured locked unit, in which he resided prior to the elopement. Observations during all days of the survey on 12/21/2023 to 12/28/2023 revealed the resident resided in the secured unit, was able to ambulate independently, and was observed walking in the TV room and the hallways on the locked unit. On 12/21/2023 at 8:30 a.m. interview with S10Maintenance Director revealed they have two cameras in the building and one camera outside of the building that were in working condition, but these cameras did not capture resident #1 on video. S10Maintenance Director revealed he checks the door locks to ensure they are in working condition but he did not keep a log to indicate he was monitoring the doors. On 12/21/2023 at 1:35 p.m. interview with S2DON revealed she knew that the staff would bring resident #1 out of the unit to eat in the main dining room. The staff were to keep him in eye sight at all times when not on the secured unit. Further interview with S2DON revealed they didn't have a system in place to monitor the resident when he was out of the secured unit. During the survey, there was no documented evidence of monitoring the resident for elopement, monitoring proper locking of exit doors, or any of the other items that were put into place until after the survey team entered on 12/21/2023 at 8:00 a.m. On 12/27/2023 at 1:05 p.m. S1Administrator was unable to provide the surveyors with any type of documentation for monitoring the system they put in place after the elopement incident on 12/18/2023. The Administrator failed to ensure resident #1 had adequate supervision to prevent elopement from the facility on 12/18/2023.