**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to provide supervision to keep a resident free from elopement for 1 (Resident #96) of 10 residents (Resident #29, Resident #49, Resident #71, Resident #75, Resident #96, Resident #98 Resident #133, Resident #147, Resident #158, and Resident #159) identified at risk for elopement in the facility. This deficient practice resulted in an Immediate Jeopardy situation for Resident #96 with a BIMS (Brief Interview Mental Status) score of 3, which indicated Resident #96 had severely impaired cognition on 02/09/2023 when Resident #96 eloped from the facility at approximately 5:00 p.m. Staff were notified by phone at approximately 5:00 p.m. by S18Licensed Practical Nurse (LPN), that Resident #96 was in the front parking lot of the facility approximately 25 feet from the main highway. Resident #96 was assisted back into the facility immediately after receiving the phone call and no injuries identified upon assessment. S1Administrator was notified of the Immediate Jeopardy on 06/13/2023 at 12:27 p.m. The Immediate Jeopardy was removed on 06/13/2023 at 6:22 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1. Resident #96 was assessed on 02/09/2023 at 5:00 p.m. with no injuries noted from wandering. No additional wandering behaviors were noted at that time. Resident #96 was reassessed on 06/13/2023 at 4:44 p.m., with no additional existing behaviors noted. Resident has had a room assignment change, to be located in a high traffic area directly across from the nurse's station, for increased direct supervision from staff. Staff were in-serviced to redirect Resident #96 to an area of high traffic to be monitored by direct supervision from staff when he exhibited wandering behaviors. 2. Safe Survey Elopement Checks were conducted and completed on 06/13/2023 approximately between 9:00 a.m. and 10:30 a.m. on residents identified at risk for elopement. There were 10 total residents presently at risk for elopement that were all present and accounted for by 10:00 a.m. on 06/13/2023. 3. Staff were in-service, including contracted staff, on identifying residents at risk for elopement, the elopement prevention protocol, the elopement reporting policy and procedures, and on the wanderguard system, this was initiated on 06/13/2023 at 11:30 a.m., and would be completed by 06/16/2023 by 6:00 p.m. Staff that were not in-serviced would not be permitted to work until in-serviced. On 06/13/2023, the social worker composed a letter to residents and their responsible parties regarding the use of facility doors that required codes as of 06/14/2023. It addressed not letting other residents exit with them and to notify staff of any incidents of the alarm sounding or other residents trying to exit with them. On 06/13/2023 as of 5:30 p.m., facility door codes were changed and only designated staff would have access to facility door codes. The facility's main entrance would be designated as an entrance/exit for residents and family member. As of 06/13/2023, a staff member would be designated to supervise this entrance with shifts of 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., and 10:00 p.m. to 6:00 a.m. In-serviced staff were not to share code. Designated staff would allow entrance and exit to the facility. Monitored use of code by observation 15 minutes a day, 3 days a week for 4 weeks ending on 07/11/2023. Every two hours monitoring of resident's that were at risk for elopement. Assessed residents at risk for elopement would determine if increased supervision was needed, on a resident by resident basis, completed on 06/13/2023 by 5:00 p.m. After assessments completed, if determined the need of increased supervision for resident, it would be initiated on the residents that demonstrated increased wandering behaviors at the time. At the time the resident displayed the behaviors, the resident would be moved to an area of high traffic for monitoring by direct supervision from staff. When residents started to wander, education would be initiated on redirecting resident and would provide direct supervision of resident. High Risk residents would be reassessed weekly for 4 weeks. 4. NFA or designee would perform safe survey elopement checks of residents identified at risk for elopement three times a week times for four weeks, and then weekly thereafter indefinitely. 5. The Facility Administrator would put in place an Elopement Prevention Program initiated by Administration. The Administrator would provide opportunities for staff to express concerns related to elopement risk by open door practice starting on 06/13/2023. a. The S2Director of Nursing and Administrator in-serviced all scheduled staff starting on 06/13/2023 on elopement prevention program, including contracted staff. b. All remaining employees would be in-serviced on elopement prevention program prior to the shift start, by Administrator or designee by 06/13/2023. c. Elopement Prevention Program open door practice included in orientation process for new hire and contract staff. d. Regional [NAME] President or Quality Assurance Nurse would ensure the Administrator/Designee was conducting random observation of elopement risk assessment and monitoring tool completion weekly times 30 days. e. Any negative findings from the Safe Survey Checks would be acted on by the Administrator and immediately report findings to the Q.A.P.I. weekly for 30 days, then monthly thereafter. This deficient practice had the likelihood to cause serious harm to the remaining 9 residents identified as elopement risks by the facility. Findings: Review of the facility's Wandering and Elopement Policy revealed, in part, the elopement risk tool will determine if the resident is at risk for wandering/elopement and will be completed on admission/readmission, quarterly during observation period of MDS, annual, significant changes and as needed. Review revealed, staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. Review revealed, if an employee observes a resident leaving the premises he/she should: attempt to prevent the departure, get help from other staff members, instruct a staff member to inform the charge nurse or Director of Nursing that a resident has left the premises. When the resident returns to the facility, the director of nursing or charge nurse shall: notify regulatory agencies per state guidelines as indicated. Review of Resident #96's medical record revealed, in part, Resident #96 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbances and major depressive disorder. Review of Resident #96's MDS (Minimum Data Sheet) with an ARD(Assessment Reference Date) of 05/17/2023 revealed, in part, Resident #96 had a BIMS (Brief Interview Mental Status) score of 3, which indicated Resident #96 had severely impaired cognition. Further review revealed, Resident #96 used a wander/elopement alarm daily. Review of Resident #96's Comprehensive Care Plan revealed, in part, Resident #96 was at risk for elopement. Further review revealed Resident #96's interventions included: should have a wanderguard applied as ordered. Resident #96's wanderguard should be monitored for proper functioning, staff should be aware of their surroundings daily, staff should redirect Resident #96 as needed, and Resident #96 should be on the wander list located at the nurse's station. Further review of Resident #96's care plan revealed no additional interventions implemented after elopement on 02/09/2023. Review of Resident #96's nurses' notes revealed, in part, a nurse's note with a date of 02/09/2023 written by S5LPN which stated Resident #96 was found outside by staff. Further review revealed, in part, Resident #96 left out of the door behind a resident who goes outside regularly and alarm was not censored at the time. Review of Resident #96's medical record revealed, in part, Resident #96 did not have an elopement risk assessment completed prior to the incident of elopement on 02/09/2023. Review of Resident #96's elopement risk assessment dated [DATE] revealed, in part, Resident #96 had a history of leaving the facility without needed supervision. Further review revealed, Resident #96 is at risk for elopement. Review of the facility's Incident Report for Resident #96 dated 02/09/2023 revealed, in part, Resident #96 was found outside of the facility by staff. Observation on 06/11/2023 at 10:00 a.m., revealed Resident #96 in his wheelchair rolling near Door A with no direct staff supervision. Observation on 06/11/2023 at 11:28 a.m., revealed Resident #96 in his wheelchair rolling on Hall 3 asking a staff member about getting out of the facility to go home. In an interview on 06/12/2023 at 9:06 a.m., S8CNA (Certified Nursing Assistant) stated Resident #96 wanders frequently. S8CNA further stated Resident #96 frequently tries to get out of the facility so he can go home to his mother. In an interview on 06/12/2023 at 9:10 a.m., S9MDS LPN (Licensed Practical Nurse) stated Resident #96 was found in the parking lot a few months ago while wearing a wanderguard. In an interview on 06/12/2023 at 10:25 a.m., S9MDS LPN stated elopement risk assessments are completed quarterly. S9MDS LPN confirmed Resident #96's elopement risk assessment was not completed quarterly and should have been completed quarterly. In an interview on 06/12/2023 at 10:34 a.m., S11Maintenance Supervisor stated wander guards were checked weekly. Observation on 06/12/2023 at 10:27 a.m., revealed Resident #96 sitting in wheelchair in dining area with staff present at the nurses station. Resident #96 talking with administrator stating, I am hoping to get out of here. In an interview on 06/12/2023 at 11:00 a.m., S10MDS RN (Registered Nurse) stated Resident #96 did not have any elopement risk assessments completed in 2021 or 2022. In an interview on 06/12/2023 at 12:15 p.m., S5LPN stated she was alerted by another staff member that Resident #96 was found outside of the facility. S5LPN further stated she was not aware Resident #96 had exited the facility and would not have known if she had not been notified by another staff member. In an interview on 06/12/2023 at 12:25 p.m., S12TreatmentNurse (TN) stated she answered the phone when someone called to report Resident #96 was outside in the grass area near the road. S12TN stated she and other staff assisted Resident #96 back inside and notified the nurse. S12TN stated she was not aware Resident #96 had exited the building and does not recall whether the alarm sounded when Resident #96 exited the building. In an interview on 06/12/12023 at 12:35 p.m., S5LPN stated she was on the hall and did not recall hearing the alarm on 02/09/2023 when she was notified Resident #96 was found outside of the building. In an interview on 06/12/2023 at 12:53 p.m., S14CNA stated she is only aware of residents who wander by their wanderguard. In an interview on 06/12/2023 at 2:36 p.m., S16CNA stated Resident #96 wanders around the building and thinks Resident #96 has a wanderguard on. In an interview on 06/12/2023 at 3:15 p.m., S2DON stated elopement risk assessments are completed on admission, readmission, status changes, and quarterly. S2DON stated she was told Resident #96 was found outside. S2DON further stated Resident #96 got outside when another resident had the door open, and unsure how long Resident #96 was outside. S2DON stated when Resident #96 was assisted back inside the facility, the nurse ensured Resident #96's wanderguard was on. S2DON stated some cognitive residents have the door code. S2DON stated all staff are expected to provide increased supervision and be aware of residents who are identified as an elopement risk, location in the facility at all times. In an interview on 06/12/2023 at 3:25 p.m., S1Administrator stated he was present in the facility when Resident #96 went out of Door A when the door was propped open by Resident #13 who was smoking in the front of the building. S1Administrator stated he did not complete a SIMS (Statewide Incident Management System) report since he did not consider Resident #96 exiting the facility a reportable event because Resident #96 was still on facility grounds. S1Administrator stated cognitive residents who are capable of going in and out of the facility are allowed to have the door code to access any of the entrances in the facility. S1Administrator stated he does not have a documented investigation related to the incident. In an interview on 06/12/2023 at 4:25 p.m., S26Administrator stated Hall 4 does not have an elopement risk binder because that is the vent unit and the majority of those residents are bedbound. S26Administrator stated all of the facility doors lock at 7:00 p.m., and an alarm will go off if the door is held open. S26Administrator further stated the box located at Station 1 and Station 2 will indicate which door is alarming. At this time, S26Administrator held the door open and it took approximately 1 minute for the alarm to sound. In an interview on 06/12/2023 at 5:55 p.m., S17Assistant Administrator stated S18LPN witnessed Resident #96 going out of Door A down the driveway near the ambulance entrance when she was getting in her car after her shift. In an interview on 06/12/2023 at 6:18 p.m., S18LPN stated on 02/09/2023 she left the facility when her shift ended at 3:00 p.m., to run an errand and did not see Resident #96 in the parking lot when she left the facility. S18LPN further stated when she passed back in front of the facility after her errand she noticed Resident #96 outside in the front parking lot heading toward the ambulance entrance. S18LPN stated she called the facility to let staff know Resident #96 was outside because she knew Resident #96 was confused. S18LPN stated she turned into the parking lot and prior to exiting her car the other staff were coming out the door to assist Resident #96 back in the facility. In an interview on 06/13/2023 at 8:45 a.m., S17Assistant Administrator stated the facility did not have any documented evidence that the incident on 02/09/2023 for Resident #96 was reviewed in the Quarterly Quality Assurance (QA) meeting held on 04/25/2023. Observation on 06/13/2023 at 9:40 a.m. S18LPN escorted surveyor from Resident #96's previous room, which was located across the building, to the front of the facility and displayed the area where Resident #96 was found on 02/09/2023. Observation further revealed the area Resident #96 was found in was the front parking lot of the facility approximately 25 feet from the main highway, which was unable to be supervised by staff assigned to Resident #96. In an interview on 06/13/2023 at 9:40 a.m., S24CNA stated she had been working at the facility for approximately 4 months. S24CNA further stated residents who wander are identified by their wander guard bracelets. In an interview on 06/13/2023 at 9:46 a.m., S25CNA stated she has been working at the facility for approximately 1 year. S25CNA further stated residents who wander are identified by their wander guard bracelets. S25CNA stated if the alarm goes off the staff know a wander resident is at the door. S25CNA further stated without a wander guard in place, the staff do not have any way of knowing if a resident is an elopement risk. In an interview on 06/13/2023 at 11:35 a.m., S20CNA stated Resident #96 is allowed to move throughout the facility in his wheelchair without direct staff supervision. In an interview on 06/13/2023 at 11:36 a.m., S21CNA stated monitoring a resident that is at risk for wandering, every 2 hours is not sufficient. In an interview on 06/13/2023 at 11:37 a.m., S22CNA stated monitoring a resident that is at risk for wandering, every 2 hours is not sufficient. S22CNA further stated Resident #96 moves around freely in the wheelchair and likes to sit by the door. In an interview on 06/13/2023 at 11:39 a.m., S23CNA stated monitoring a resident that is at risk for wandering, every 2 hours is not sufficient. In an interview on 06/13/2023 at 4:40 p.m., S13QI Nurse stated if Resident #96 did not have direct supervision while in the parking lot then the facility should have notified herself or the regional vice president to review the situation and determine whether a SIMS (state incident reporting system) report should have been completed. S13QINurse also stated she was not notified by the facility of the elopement incident on 02/09/2023. S13QI Nurse stated residents who are elopement risk should have increased supervision. S13QI Nurse stated the regional vice president or herself will oversee the administrator with weekly site visits for 4 weeks, at the end of the 4 weeks they will evaluate whether weekly site visits should be extended. In an interview on 06/13/2023 at 5:30 p.m., S13QI Nurse stated an investigation should be completed when residents are outside of the facility unsupervised. In an interview on 06/13/2023 at 5:35 p.m., S1Administrator stated the family members are allowed to have the code to enter the facility at any of the entrances because his facility is too big for him to control who comes in and out of it through one entrance. S1Adminstrator stated any resident in the facility who is cognitive or a safe smoker can have the code to the facility doors. S1Adminstrator stated his facility was not a 1 on 1 facility and they could not provide 24 hour continuous supervision for Resident #96. S1Administrator stated an incident of an elopement could occur at any point in his facility and there would be nothing he could do about it.

The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to provide supervision to keep a resident free from elopement for 1 (Resident #96) of 10 residents (Resident #29, Resident #49, Resident #71, Resident #75, Resident #96, Resident #98 Resident #133, Resident #147, Resident #158, and Resident #159) identified at risk for elopement in the facility. This deficient practice resulted in an Immediate Jeopardy situation for Resident #96 with a BIMS (Brief Interview Mental Status) score of 3, which indicated Resident #96 had severely impaired cognition on 02/09/2023 when Resident #96 eloped from the facility at approximately 5:00 p.m. Staff were notified by phone at approximately 5:00 p.m. by S18Licensed Practical Nurse (LPN), that Resident #96 was in the front parking lot of the facility approximately 25 feet from the main highway. Resident #96 was assisted back into the facility immediately after receiving the phone call and no injuries identified upon assessment. S1Administrator was notified of the Immediate Jeopardy on 06/13/2023 at 12:27 p.m. The Immediate Jeopardy was removed on 06/13/2023 at 6:22 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1. Administrator was in-serviced by S13QI Nurse on Elopement on 06/13/2023 at 12:00 p.m. Resident #96 was assessed on 02/09/23 at 5:00 p.m. with no injuries noted from wandering. No additional wandering behaviors were noted at that time. Resident #96 was reassessed on 06/13/2023 at 4:44 p.m., with no additional existing behaviors noted. Resident has had a room assignment change, to be located in a high traffic area directly across from the nurse's station, for increased direct supervision from staff. Staff were in-serviced to redirect Resident #96 to an area of high traffic to be monitored by direct supervision from staff when he exhibited wandering behaviors. 2. Administrator was in-serviced by S13QI Nurse on reporting of elopement on 06/13/2023. a. Regional [NAME] President or Quality Assurance Nurse would ensure Administrator/Designee is conducting random observation of elopement audit with residents' weekly times 30 days with completion date of 07/11/2023. 3. The S11Maintenance Supervisor conducted and completed a safe survey elopement checks on 06/13/2023 to ensure that any further potential elopement was prevented. Safe Survey Elopement Checks would be conducted by Administrative designees on random residents weekly for 30 days, then monthly thereafter indefinitely. Any negative finding will be reported to the Administrator and acted on immediately. Staff in-serviced, including contracted staff, on identifying residents at risk for elopement, the elopement prevention protocol, the elopement reporting policy and procedures, and on the wanderguard system was initiated on 06/13/2023 at 11:30 a.m. and to be completed by 06/16/2023 by 6:00 p.m. Staff not in-serviced would not be permitted to work until in-serviced. On 06/13/2023 Social Worker, composed a letter to residents and their responsible parties regarding the use of facility doors that required codes as of 06/14/2023. It would address not letting other residents exit with them and to notify staff of any incidents of the alarm sounding or other residents trying to exit with them. On 06/13/2023 as of 5:30 p.m., facility door codes would have been changed, and only designated staff would have access to the facility's door codes. The facility's main entrance would be designated as an entrance/exit for residents and family members. As of 06/13/2023, a staff member would be designated to supervise this entrance with shifts of 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., and 10:00 p.m. to 6:00 a.m. In-serviced staff not to share code. Designate staff would allow entrance and exit to the facility. Monitored use of code by observation 15 minutes a day 3 days a week x 4 weeks ending on 07/11/2023. Every two hours monitoring of resident's at risk for elopement. Assessed resident's at risk for elopement would determine if increased supervision is needed, on a resident by resident basis, completed on 06/13/2023 by 5:00 p.m. After assessments completed, if determined the need of increase supervision for resident, it would be initiated on the residents that demonstrated increased wandering behaviors at the time. At the time the resident displayed the behaviors, the resident would be moved to an area of high traffic for monitoring by direct supervision from staff. When residents started to wander, education would be initiated on redirecting resident and to provide direct supervision of resident. High Risk residents will be reassessed weekly for 4 weeks. 4. The Administrator reviewed the completed the safe survey checks on 06/13/2023 to determine if any abuse, neglect or mistreatment had occurred. a. Safe Survey Elopement Checks would be reviewed by Administrator weekly for 30 days, then monthly thereafter. Any negative finding would be acted upon immediately. 5. After elopement investigation is completed by facility, it would be reviewed by Regional [NAME] President or Quality Improvement Nurse prior to closing the SIMS report. 6. Any negative findings from the Safe Survey Elopement Checks would be acted on by the Administrator immediately, then reported findings to the Q.A.P.I. weekly for 30 days, then monthly thereafter. This deficient practice had the likelihood to cause serious harm to the remaining 9 residents identified as elopement risks by the facility. Findings: Cross Reference F689 In an interview on 06/12/2023 at 3:15 p.m., S2DON stated elopement risk assessments are completed on admission, readmission, status changes, and quarterly. S2DON stated she was told Resident #96 was found outside. S2DON further stated Resident #96 got outside when another resident had the door open, and unsure how long Resident #96 was outside. S2DON stated when Resident #96 was assisted back inside the facility, the nurse ensured Resident #96's wanderguard was on. S2DON stated some cognitive residents have the door code. S2DON stated all staff are expected to provide increased supervision and be aware of residents who are identified as an elopement risk, location in the facility at all times. In an interview on 06/13/2023 at 8:45 a.m., S17Assistant Administrator stated the facility did not have any documented evidence that the incident on 02/09/2023 for Resident #96 was reviewed in the Quarterly Quality Assurance (QA) meeting held on 04/25/2023. In an interview on 06/13/2023 at 4:40 p.m., S13QI Nurse stated if Resident #96 did not have direct supervision while in the parking lot then the facility should have notified herself or the regional vice president to review the situation and determine whether a SIMS (state incident reporting system) report should have been completed. S13QINurse also stated she was not notified by the facility of the elopement incident on 02/09/2023. S13QI Nurse stated residents who are elopement risk should have increased supervision. S13QI Nurse stated the regional vice president or herself will oversee the administrator with weekly site visits for 4 weeks, at the end of the 4 weeks they will evaluate whether weekly site visits should be extended. In an interview on 06/13/2023 at 5:30 p.m., S13QI Nurse confirmed she in-serviced S1Adminstrator, S17Assistant Administrator, and S26Administrator on reporting reportable events. In an interview on 06/13/2023 at 5:35 p.m., S1Administrator stated the family members are allowed to have the code to enter the facility at any of the entrances because his facility is too big for him to control who comes in and out of it through one entrance. S1Adminstrator stated any resident in the facility who is cognitive or a safe smoker can have the code to the facility doors. S1Adminstrator stated his facility was not a 1 on 1 facility and they could not provide 24 hour continuous supervision for Resident #96. S1Administrator stated an incident of an elopement could occur at any point in his facility and there would be nothing he could do about it.