**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to have a system in place to ensure staff increased supervision to prevent elopement for severely cognitively impaired residents who displayed exit seeking behaviors for 2 (#1 and #3) of 7 (#1-#7) sampled residents to prevent elopement. The Immediate Jeopardy situation began on 08/01/2023 at approximately 1:00 a.m. when Resident #1, a severely cognitively impaired resident, eloped from the facility without the facility staff's knowledge. On 08/01/2023 at approximately 1:00 a.m., Resident #1 climbed through his bedroom window and exited the facility grounds through the unlocked fence located at the end of Hall W. Resident #1 walked approximately 1 mile, crossed a set of railroad tracks and a busy four lane highway, and stopped at a friend's house. According to the facility's incident report, the facility did not discover Resident #1 was missing from the facility until 08/01/2023 at approximately 8:00 a.m. Resident #1 was later found on 08/01/2023 at approximately 2:51 p.m. when S24Driver arrived at a local hospital and recognized Resident #1 in the lobby of the hospital. S24Driver then notified local authorities and S2Director of Nursing (DON). Resident #1 returned to the facility assisted by local police at approximately 4:00 p.m. on 08/01/2023. An order was received on 08/02/2023 to transport Resident #1 to the hospital for an inpatient psychiatric visit. The immediate jeopardy ended when Resident #1 was placed on 1 on 1 supervision until Resident #1 was transported to the hospital on [DATE] at 3:09 p.m. The Immediate Jeopardy continued for Resident #3, a severely cognitively impaired resident, who began displaying exit seeking behaviors on 02/24/2023 and staff supervision was not increased. S5Regional [NAME] President of Operations (RVPO) was notified of the Immediate Jeopardy on 08/03/2023 at 4:23 p.m. The Immediate Jeopardy was removed on 08/04/2023 at 4:33 p.m. as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice had the likelihood to cause more than minimum harm to the remaining 4 residents identified (#1, #3, #4, and #8) identified as elopement risks. Findings: Review of the facility's policy for Wanderer Management, Monitoring System and Resident Elopement Protocol revealed, in part, an elopement risk was determined by the use of the Wander Data collection tool. Review revealed the assessment should also include review of the resident's medical records, if available, interview with resident/family, or conference with the interdisciplinary team member. Review revealed the Wander Data collection tool was to be completed on admission, quarterly, upon change of condition, or after an elopement incident. Review revealed, an elopement risk binder would be maintained in a central area and would contain a current picture of the resident and a current face sheet. Further review revealed, after an elopement incident the interdisciplinary team must review the resident's plan of care to determine changes that may be warranted. The family must be included to assure that all areas are addressed. The facility would provide proper psychosocial support to the resident and/or family. The facility may assess the resident to determine if alternate placement was necessary to assure the resident's safety. The facility's Quality Assurance Performance Improvement Team shall review facility system to evaluate if all systems are working appropriately. On 08/02/2023, review of the facility's elopement risk binder revealed Resident #1 and Resident #4 were identified as an elopement risk. Review of the facility's Staffing, Sufficient and Competent Nursing policy revealed, in part, licensed nurses and nursing assistants are trained and must demonstrate competency in identifying, documenting, and reporting resident changes of conditions consistent with their scope of practice and responsibilities. Resident #1 Review of the facility's incident report entered on 08/01/2023, revealed an incident description which read at approximately 8:00 a.m. staff discovered Resident #1 was missing from the facility. The facility completed the following: search of the facility to include all rooms, restrooms, closets, the facility grounds, and staff was deployed to search the surrounding community and local hospitals were notified. A silver alert was issued with the local police to assist with the search. Review of Resident #1's medical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, Unspecified Psychosis, Major Depressive Disorder, Dementia with other behavioral disturbances, and Anxiety Disorder. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/06/2023 revealed, in part, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3, which indicated Resident #1 had severe cognitive impairment. Further review revealed, Resident #1 was independent with walking and did not use a wander/elopement alarm daily. Review of Resident #1's Comprehensive Care Plan revealed, in part, a focus that included Resident #1 was at risk for elopement related to his impaired safety awareness with an initiation date of 01/06/2023. Further review revealed no documented evidence and the facility did not present any documented evidence of having interventions implemented to prevent elopement before 08/02/2023. Resident #1's Care Plan also revealed he had impaired cognitive function with an initiation date of 11/07/2022. Further review revealed Resident #1's interventions with an initiated date of 11/07/2022 that staff should cue, reorient, and supervise Resident #1 as needed. Review of Resident #1's Physician's Orders from January 2023- August 2023 revealed, in part, an order with a start date of 01/02/2023 and a status of discontinued that read wander bracelet r/t wandering/exit seeking behaviors 2nd to psychosis. Review of Resident #1's Wander Data Collection form with a completion date of 01/05/2023, revealed, in part, Resident #1 was cognitively impaired, displayed wandering behaviors that put Resident #1 at a significant risk of getting to a potentially dangerous place, was able to ambulate independently, verbally expressed the desire to go home, had a visual, auditory, and/or communication deficits, and was searching and/or seeking to find a spouse and/or family member. Further review Resident #1 was assessed as being at high risk for wandering. Review of Resident #1's Wander Data Collection form with a completion date of 02/06/2023, revealed, in part, Resident #1 was cognitively impaired and did not display wandering behaviors that put Resident #1 at a significant risk of getting to a potentially dangerous place. Further review revealed Resident #1 was able to ambulate independently, did not verbally express the desire to go home, did not have any visual, auditory, or communication deficits, and was not searching and/or seeking to find a spouse and/or family member. Further review Resident #1 was assessed for being at low risk for wandering. Review of Resident #1's Wander Data Collection form with a completion date of 05/05/2023, revealed, in part, Resident #1 was not cognitively impaired and did not display wandering behaviors that put Resident #1 at a significant risk of getting to a potentially dangerous place. Further review revealed Resident #1 was not able to ambulate independently, did not verbally express the desire to go home, did not have any visual, auditory, or communication deficits, and was not searching and/or seeking to find a spouse and/or family member. Further review Resident #1 was assessed for being at low risk for wandering. Review of Resident #1's nurse's notes dated 05/30/2023 at 7:07 a.m. written by S28LPN revealed, in part, that Resident #1 was at the facility's lobby door and wanted to leave to go to a job in Texas. Further review, revealed Resident #1 became upset after the nurse attempted to redirect him and went to his room to pack his belongings. Review revealed an additional nurse's note with a date of 07/13/2023 at 3:45 p.m. written by S31LPN which stated Resident #1 was at the facility's nurse's station and stated he wished he could go run off on the highway and get hit by a car. Review also revealed an additional nurse's note with a date of 08/01/2023 at 9:24 a.m. written by S2DON which stated at approximately 8:30 a.m. S2DON was notified by staff Resident #1 was not able to be located. In an interview on 08/02/2023 at 9:15 a.m. S5RVPO stated he was currently serving as the administrator of the facility. S5RVPO stated in the last 6 months the facility had two incidents of elopement. S5RVPO stated the first incident occurred on 05/27/2023 when, a cognitive resident, Resident #2 climbed out of his window and was found shortly after, still on facility grounds, by a staff member and was brought back into the facility. The second incident occurred on 08/01/2023 when Resident #1 climbed out of his window and left the facility grounds. In an interview on 08/02/2023 at 10:04 a.m. Resident #1 stated he eloped from the facility on 08/01/2023 shortly after midnight. Resident #1 stated throughout the day on 08/01/2023 and into the evening he had been telling staff he was going to leave the facility. Resident #1 stated he opened his window, placed his right leg out of the window, placed his left leg out of the window, climbed out of the window, walked around the building to the fence located at the end of Hall W, and walked out of the unlocked gate. Resident #1 stated he then walked up the road that led to the facility towards the highway, crossed the railroad tracks, crossed the four lane highway, and kept walking until he got to his friend's house that he was going to do a job with. Resident #1 stated it took him about 45 minutes to get to his destination, but he does not remember the address of where he went. Resident #1 stated his friend and he later arrived at a local hospital for his girlfriend's medical care and during that time a staff member from the facility recognized him. Resident #1 stated he then was brought back to the facility by the police. Observation on 08/02/2023 at 10:06 a.m. revealed Resident #1 in his room lying in his bed. Observation further revealed Resident #1's window was able to be unlocked and opened. In an interview on 08/02/2023 at 10:09 a.m. S29CNA stated she works for the facility full time on the night shift. S29CNA further stated she worked on the night of 07/31/2023, which led into the morning of 08/01/2023. S29CNA stated residents who wander are identified by their wander guard bracelets. S29CNA stated she was not notified that Resident #1 was an elopement risk prior to this incident. S29CNA stated she is not aware of any residents in the facility that are elopement risks at this time. In an interview on 08/02/2023 at 10:30 a.m. S9MDS Nurse stated she was assigned to Resident #1. S9MDS Nurse stated Wander Data Collection forms were completed on admission, readmission, when status changes occur, and quarterly. S9MDS Nurse stated in order to complete a Wander Data Collection forms, she gathers information from the floor nurse that was taking care of the resident. S9MDS Nurse stated Resident #1 was an elopement risk as of 01/06/2023 when he began displaying exit seeking behaviors. S9MDS Nurse stated Resident #1 used to wear a wander guard bracelet, but it was discontinued and she did not remember why. S9MDS Nurse further stated prior to the incident on 08/01/2023 she had not been notified Resident #1 was displaying exit seeking behaviors. In an interview on 08/02/2023 at 10:45 a.m. S2DON stated Resident #1 has had exit seeking behaviors since he was admitted to the facility. S2DON stated Resident #1 had a wander guard bracelet in place, but he kept removing the wander guard bracelet so the facility discontinued it. S2DON further stated she was not notified on 05/30/2023 or 07/31/2023 Resident #1 displayed exit seeking behaviors. S2DON further stated the facility identified on 07/26/2023, they could not meet Resident #1's needs due to his suicidal ideations and exit seeking behaviors. S2DON further stated Resident #1 was not placed on 1 on 1 monitoring until after the elopement incident on 08/01/2023. Observation on 08/02/2023 at 10:50 a.m. revealed the windows in Room a, Room b, Room c, Room d, Room e, Room f, Room g, Room h, Room I, Room j, and Room k on Hall Z was able to be unlocked and slide open to access the front of the facility that was not gated and faced the road. In an interview on 08/02/2023 at 11:00 a.m. S6Regional Maintenance Director stated all of the windows in the facility were not secured. S6Regional Maintenance Director stated the windows were able to be locked from the inside, but can be easily opened at any time from the inside. S6Regional Maintenance Director stated half of the facility's windows opened to the back of the facility that was fenced in, but the other half opened to the road. S6Regional Maintenance Director stated Resident #1's window had been sealed, but nothing was keeping him or any other resident from entering another resident's room and crawling out of their window. In an interview on 08/02/2023 at 11:20 a.m. S7Unit Manager stated she completed Resident #1's a Wander Data Collection form on 01/05/2023. S7Unit Manager stated Resident #1 was labeled as an elopement risk because he was cognitively impaired, frequently displayed exit seeking behaviors, and was always looking for his daughter. In an interview on 08/02/2023 at 12:45 p.m. S28Licensed Practical Nurse (LPN) stated she was the nurse on 05/30/2023 when Resident #1 said he wanted to leave to go to a job in Texas. S28LPN further stated she did consider this behavior exit seeking behavior. S28LPN further stated she notified S2DON, but she did not increase supervision for Resident #1. In an interview on 08/02/2023 at 2:45 p.m. S3Assistant Director of Nursing (ADON) stated she was never notified by staff on the evening of 07/31/2023 that Resident #1 was displaying exit seeking behaviors. In an interview on 08/02/2023 at 2:50 p.m. S10Quality Assurance (QA) Nurse stated Resident #1 had been to the psychiatric hospital from [DATE]- 07/26/2023 for suicidal ideations. S10QA Nurse stated upon returning to the facility, the IDT team had discussed the facility could not meet Resident #1's needs and he needed alternate placement. S10QA Nurse stated she was not notified Resident #1 was displaying exit seeking behavior, only that he desired to go to another facility. In an interview on 08/02/2023 at 3:00 p.m. S24Driver stated she was the staff member that found Resident #1 at a local hospital. S24Driver stated she arrived at the hospital to deliver labs and Resident #1 was sitting in the lobby. S24Driver stated she notified authorities and Resident #1 was brought back to the facility around 4:00 p.m. S24Driver stated Resident #1 had left the facility and went to an address which was approximately 1-2 miles from the facility. S24Driver stated she knew the address of the location in which Resident #1 went to because he spoke about going to this address since he was admitted to the facility. S24Driver stated Resident #1 displayed exit seeking behaviors often. Review of the global positioning system revealed when walking from the facility to the address Resident #1 walked to after eloping from the facility was approximately 1 mile. Further review revealed, in order to reach the destination a set of train tracks and a four lane highway had to be crossed. Observation on 08/03/2023 at 12:50 p.m. revealed the windows in Room l, Room m, Room n, Room o, Room p, Room q, Room r, Room s, Room t, Room u, Room v, and Room w were able to be unlocked and slide open to access the front of the facility that was not gated and faced the road. In an interview on 08/03/2023 at 2:33 p.m. Resident #1's Responsible Party (RP) stated S10QA Nurse called and notified her on 08/01/2023 around 9:48 a.m. that Resident #1 was missing and the facility was unaware of his location. Resident #1's RP stated she was currently on vacation out of state and she had no idea where Resident #1 could have went at the time. Resident #1's RP stated she was very concerned because prior to Resident #1 being admitted to the facility, he would wander into random people's homes due to his diagnosis of dementia. Resident #1's RP stated she informed the facility prior to his admission of the above and that was the reason she was admitting him to the facility. Resident #1's RP stated Resident #1 had a wander guard bracelet around his ankle, but he removed it multiple times so the facility chose to leave it off. Resident #1's RP further stated she received a second call from the facility stating they had located Resident #1, he was in no distress, and he would be transferred to a psychiatric facility for evaluation between 08/01/2023 and 08/02/2023. In an interview on 08/04/2023 at 9:30 a.m. S1Administrator stated it was determined Resident #1 got out of the backyard fencing because the gate was left unlocked by the contracted lawn company. S1Adminsitrator stated normal practice of the facility was for himself or S30Maintenance Director to ensure the fence was locked when yard work was completed. S1Administrator stated at the time of the incident himself and S30Maintenance Director were both on leave and was unable to ensure the gate was locked after the lawn company left the facility. In an interview on 08/04/2023 at 10:04 a.m. S2DON stated staff should have immediately recognized Resident #1's behavior as exit seeking and implemented increased supervision. S2DON further stated if staff had notified her of Resident #1's behavior earlier in the shift, she would have been able to implement 1 on 1 monitoring and Resident #1 would've never been able to elope from the facility. In an interview on 08/04/2023 at 10:07 a.m. S1Administrator stated two residents had used the same tactic to elope from the facility through a window. S1Adminstrator further stated if the facility had implemented the above stated interventions after the first time a resident left the facility through a window on 05/27/2023, all residents would have been assessed properly for elopement, appropriate interventions would have been implemented for each resident, and Resident #1's elopement would have been prevented. In a phone interview on 08/04/2023 at 1:02 p.m. S25Certified Nursing Assistant (CNA) stated she was the CNA assigned to Resident #1 the night he eloped from the facility. S25CNA stated the last time she had seen Resident #1 was around 10:00 p.m. at the beginning of her shift on 07/31/2023 when Resident #1 requested he be left alone to go to sleep. S25CNA stated she was not notified by the facility that Resident #1 was an elopement risk. S25CNA stated the facility had not ever educated her or communicated to her who the wandering residents in the facility were. S25CNA further stated if the facility had notified her Resident #1 was displaying exit seeking behaviors she would have provided 1 on 1 monitoring and Resident #1 would not have eloped from the facility. In an interview on 08/04/2023 at 1:15 p.m. S9MDS Nurse stated Resident #1's Wander Assessments completed on 02/06/2023 and 05/05/2023 were completed incorrectly, which was the reason Resident #1 was assessed as being at low risk for wandering. S9MDS Nurse further stated Resident #1 should have had a wander assessment completed after each change in condition when he began displaying exit seeking behaviors. S9MDS Nurse further stated Resident #1 should have had interventions put into place prior to 08/02/2023 address his exit seeking behaviors. Resident #3 Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date(ARD) of 05/23/2023 revealed, in part, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated that he was severely cognitively impaired. Further review revealed, Resident #3 required supervision with one-person physical assistance for locomotion on the unit, locomotion and required supervision with set up help only for transfer, walking in the room, and walking in the corridor. Review of Resident #3's physician progress note dated 01/19/2023 revealed, in part, Resident #3 was adamant about going home. Review of Resident #3's progress note dated 02/23/2023 revealed, in part, Resident #3 wanted to go home and did not have any transportation, but insisted on going home. Review of Resident #3's progress note dated 03/23/2023 revealed, in part, Resident #3 wanted to go home. Review of Progress Note dated 04/26/2023 revealed, in part, Resident #3 complained of wanting to go home and wanting his truck. Review of Resident #3's progress note dated 05/18/2023 revealed, in part, Resident #3 still wanted to go home. Review of Resident #3's psychiatric progress note dated 06/01/2023 revealed, in part, staff was reporting Resident #3's was exit seeking and was increasingly confused as dementia was progressing. Review of Resident #3's progress note dated 07/27/2023 revealed, in part, Resident #3 wanted to go home. Review of Resident #3's nurse's note dated 02/24/2023 at 9:53 a.m., revealed, in part, Resident #3 was in the front lobby screaming and attempting to leave the facility. Further review revealed, Resident #3 stated my truck is outside, and I am leaving out this god damn place Review of Resident #3's nurse's note dated 02/24/2023 at 12:24 p.m., revealed, in part, Resident #3 refused to stay in his room where he was on isolation for COVID-19. Further review revealed, resident swore at staff, attempted to push his walker over staff, and demanded to be let out of the front door to get his car to go home. Further review revealed, Resident #3 had also packed all of his belongings in a large suitcase in his room. Review of Resident #3's nurse's note dated 03/26/2023 revealed, in part, Resident #3 noted with agitation related to attempting to leave facility to get back to his car. Further review revealed, resident pulled on the door and demanded to, and resident paced up and down the hall while yelling at staff very aggressively. Review of Resident #3's nurse's note dated 03/27/2023 revealed, in part, Resident #3 continued to request to leave the facility. Further review revealed, staff attempted to redirect, but Resident #3 returned minutes later with identical behavior. Review of Resident #3's nurse's note dated 03/29/2023 revealed, in part, Resident #3 was noted with increased agitation, attempted to leave the facility, slammed doors, and cussed at the staff. Review of Resident #3's nurse's note dated 04/05/2023, revealed, in part, Resident #3 had been increasingly agitated and seeking to go home. Review of Resident #3's nurse's note dated 04/07/2023 revealed, in part, Resident #3 was noted with increased agitation in the front lobby and stated, I need to go to [NAME] City, and somebody stole my truck. Further review revealed staff reoriented frequently, but Resident #3 later continued with the same behavior. Review of Resident #3's nurse's note dated 06/18/2023 revealed, in part, Resident #3 ambulated around the hall with the use of a walker and was hard of hearing. Further review revealed, Resident #3 had a large suitcase packed and talked constantly of going home to see about his house and truck. Review of Resident #3's Wander Data Collection report dated 02/22/2023 revealed, in part, Resident #3 was assessed as being at low risk for wandering. Review of Resident #3's Wander Data Collection report dated 05/23/2023 revealed, in part, Resident #3 was assessed as being at low risk for wandering. Further review revealed, the answer no was indicated for questions related to if Resident #3 was cognitively impaired, if Resident #3 wandered, did the resident have any auditory deficits, and did the resident verbally express the desire to go home or pack up their belonging to leave. Further review of Resident #3's Wander Data Collection report revealed assessments related to Resident #3's wandering or exit seeking was performed on 02/24/2023, 03/26/2023, 03/27/2023, 03/29/2023, 04/05/2023, 04/07/2023, and 06/18/2023. Observation on 08/02/2023 at 1:57 p.m., revealed Resident #3 was lying in the bed without staff present in his room or within the line of sight of staff. Observation revealed, Resident #3's window was able to be opened at this time. Further observation revealed, Resident #3 without a wander guard bracelet in place. In an interview on 08/02/2023 at 1:28 p.m. Resident #3 stated he wanted to get out of this place and go home. Resident #3 further stated he was going to figure out a way to leave this facility. In an interview on 08/03/2023 at 11:20 a.m., S1Administrator stated if a resident was having wandering or exit seeking behaviors, the facility's procedure was that a wandering assessment should be completed on the resident exhibiting those behaviors. Observation on 08/03/2023 at 8:42 a.m., revealed Resident #3's door to his room was closed and no staff was present to supervise Resident #3. Further observation upon entering room revealed, Resident #3 sitting on the side of his bed. Further observation revealed, Resident #3's window was able to be opened, and a large suitcase was in the middle of Resident #3's room. Observation on 08/03/2023 at 10:57 a.m., revealed Resident #3's door to his room was closed and no staff was present to supervise Resident #3. Further observation upon entering room revealed, Resident #3 lying in bed. Further observation revealed, Resident #3's window was able to be opened, and a large suitcase was in the middle of Resident #3's room . In an interview on 08/03/2023 at 10:57 a.m., Resident #3 stated that he had his suitcase out because it was packed for him to take home. Resident #3 stated that he needed to get out of the facility to go and check on his truck. In an interview on 08/03/2023 at 11:02 a.m., S7Unit Manager stated all resident's wandering evaluations should be completed on admission, quarterly, and as needed when residents displayed wandering or exit seeking behaviors such as trying to leave the facility and having a plan to go home. In an interview on 08/03/2023 at 11:05 a.m., S21Certified Nursing Assistant (CNA) stated she saw Resident #3 try to go out into the facility's parking lot and try to get out of the facility on multiple occasions. S21CNA further stated Resident #3 packed his luggage constantly to try to leave with his stuff. In an interview on 08/03/2023 at 11:05 a.m., S23CNA confirmed that Resident #3 has wandered and tried to get out of the building, but stated she was unsure if Resident #3 was a wandering or elopement risk. S23CNA further stated she had witnessed Resident #3's had packed luggage to leave with, and Resident #3 was constantly worried about getting to his truck. In an interview on 08/03/2023 at 11:13 a.m., S24Driver stated Resident #3 constantly asked to go outside or to leave the facility, including this morning, 08/03/2023, at 10:00 a.m. In an interview on 08/03/2023 at 12:00 p.m., S9MDS Nurse stated she had not realized that Resident #3 was displaying wandering or exit seeking behaviors on 02/24/2023, 03/26/2023, 03/27/2023, 03/29/2023, 04/05/2023, 04/07/2023, and 06/18/2023. S9MDS Nurse further stated a wandering assessment should have been conducted for each new behavior noted on the above dates, and Resident #3's care plan should have been updated to reflect his exit seeking and wandering behaviors. In an interview on 08/03/2023 at 2:30 p.m., S8MDS Nurse stated when completing a quarterly wandering assessment, staff assess for wandering or exit seeking behaviors noted in a seven-day lookback period. S8MDS Nurse further stated that this practice was not adequate, because Resident #3's assessments were only being done every quarter. S8MDS nurse also stated that staff should have reported any new wandering or exit seeking behavior done by Resident #3 and a new wandering assessment should have been performed. In an interview on 08/03/2023 at 2:40 p.m. S7Unit Manager stated that she was unaware that Resident #3 had exit seeking behaviors since 02/24/2023. S7Unit Manager further stated each time Resident #3 started exhibiting wandering or exit seeking behaviors, a new wandering evaluation should have been performed, and Resident #3 should have possibly had increased supervision. S7Unit Manager further stated that Resident #3 now has a wander guard bracelet on, but that this device would not alert if resident attempted to exit the building via window. In a phone interview on 08/04/2023 at 9:54 a.m., S20Licensed Practical Nurse (LPN) stated her nurse's note on 04/07/2023 was related to Resident #3's dementia behaviors. S20LPN further stated that Resident #3 was able to ambulate around the facility with his walker, and that on 02/24/2023 Resident #3 attempted to leave the facility with his Guitar packed. S20LPN also stated that Resident #3 always has his luggage packed to go home. In an interview on 08/04/2023 at 10:01 a.m., S3Assistant Director of Nursing (ADON) stated it was important for staff to complete new wandering assessments when residents start exhibiting new wandering or exit seeking behaviors because these assessments give facility information to help keep the residents safe. A phone interview on 08/04/2023 at 10:19 a.m., S22LPN stated she had noted Resident #3 talking about wanting to get out of the facility and packing and unpacking his bag, but was unaware if he had ever attempted to get out of the facility. S22LPN further stated she did not specifically report the behaviors noted above to S2DON or Resident #3's physician because Resident #3 had been having these behaviors and everyone in the facility was aware. In an interview on 08/04/2023 at 10:50 a.m., S2Director of Nursing stated that when she noted Resident #3 was having exit seeking behaviors and packing a bag on 02/24/2023, a wandering assessment should have been completed. S2DON further stated that when Resident #3's was displaying wandering or exit seeking behaviors on 03/26/2023, 03/27/2023, 03/29/2023, 04/05/2023, 04/07/2023, and 06/18/2023, a wandering assessment should have been completed and Resident #3's care plan should have been updated. In an interview on 08/04/2023 at 2:31 p.m., S7Unit Manager stated she was not thorough when completing Resident #3's wandering assessment on 08/03/2023, and should have assessed him fully for wandering behaviors, exit seeking behaviors, verbalizing wanting to go home, or packing a bag. S7Unit Manager further stated that she was in-serviced on correctly completing a wandering evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 2 (#1 and #3) of 7 (#1 - #7) sampled residents. The facility failed to: 1. Ensure Resident #1, a severely cognitively impaired resident, who was care planned for wandering, was accurately assessed and/or adequately supervised when exit seeking behaviors were displayed; and 2. Ensure Resident #3, a severely cognitively impaired resident, was accurately assessed and adequately supervised when exit seeking behaviors were displayed. The Immediate Jeopardy situation began on 08/01/2023 at approximately 1:00 a.m. when Resident #1, a severely cognitively impaired resident, eloped from the facility without the facility staff's knowledge. On 08/01/2023 at approximately 1:00 a.m., Resident #1 climbed through his bedroom window and exited the facility grounds through the unlocked fence located at the end of Hall W. Resident #1 walked approximately 1 mile, crossed a set of railroad tracks and a busy four lane highway, and stopped at a friend's house. According to the facility's incident report, the facility did not discover Resident #1 was missing from the facility until 08/01/2023 at approximately 8:00 a.m. Resident #1 was later found on 08/01/2023 at approximately 2:51 p.m. when S24Driver arrived at a local hospital and recognized Resident #1 in the lobby of the hospital. S24Driver then notified local authorities and S2Director of Nursing (DON). Resident #1 returned to the facility assisted by local police at approximately 4:00 p.m. on 08/01/2023. An order was received on 08/02/2023 to transport Resident #1 to the hospital for an inpatient psychiatric visit. The immediate jeopardy ended when Resident #1 was placed on 1 on 1 supervision until Resident #1 was transported to the hospital on [DATE] at 3:09 p.m. The Immediate Jeopardy continued for Resident #3, a severely cognitively impaired resident, who began displaying exit seeking behaviors on 02/24/2023 and staff supervision was not increased. S5Regional [NAME] President of Operations (RVPO) was notified of the Immediate Jeopardy on 08/03/2023 at 4:23 p.m. The Immediate Jeopardy was removed on 08/04/2023 at 4:33 p.m. as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice had the likelihood to cause more than minimum harm to the remaining 4 residents identified (#1, #3, #4, and #8) identified as elopement risks. Findings: Cross Reference F-689. In an interview on 08/04/2023 at 10:04 a.m. S2DON stated staff should have immediately recognized Resident #1's behavior as exit seeking and implemented increased supervision. S2DON further stated if staff had notified her of Resident #1's behavior earlier in the shift, she would have been able to implement 1 on 1 monitoring and Resident #1 would've never been able to elope from the facility. In an interview on 08/04/2023 at 10:07 a.m. S1Administrator stated two residents had used the same tactic to elope from the facility through a window. S1Adminstrator further stated if the facility had implemented the above stated interventions after the first time a resident left the facility through a window on 05/27/2023, all residents would have been assessed properly for elopement, appropriate interventions would have been implemented for each resident, and Resident #1's elopement would have been prevented. In an interview on 08/04/2023 at 2:00 p.m., S5RVPO stated he completed an in-service with S1Administrator, S2DON, S3ADON, S10QA Nurse, S8MDS Nurse, S9MDS Nurse, S16Maintenance Assistant, S7Unit Manager, S15Housekeeping and Laundry Supervisor, S17Business Office Manager, S18Human Resources, S14Therapy Director, and S11Social Services Director that covered all elements listed in the plan for the above stated deficiencies and discussed listed interventions to ensure continued compliance. S5RVPO further stated he will be coming monthly to ensure all the above stated audits and education is completed by the administrative staff.