**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to increase supervision of residents at risk for elopement and respond to alarms appropriately, for 2 (Resident #1 and Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents for elopement. The facility failed to: 1. Ensure door exit alarms could be heard by all staff in residents' rooms when the doors are closed; 2. Ensure a system of staff response was in place when the door alarm sounded, and staff were knowledgeable of the response system; and 3. Ensure Administration was notified when staff became aware that the alarm system and doors were not functioning properly. This deficient practice resulted in an Immediate Jeopardy situation on 05/17/2023 at 6:15 p.m., when Resident #1 who had a diagnosis of Dementia, exhibited exit seeking behaviors and wore a Wanderguard bracelet, exited the facility after the door exit alarm. Resident #1 was found by local police at 6:30 p.m. near a busy four lane highway that ran parallel to the facility. The facility's continued failure to identify potential system failures and respond appropriately, resulted in the immediate jeopardy continuing on 06/04/2023 at 8:00 a.m., when Resident #2 who had a diagnosis of Dementia, exhibited exit seeking behaviors and wore a Wanderguard bracelet, exited the facility, although staff were aware of a previous door malfunction, walked alongside a busy four lane highway, crossed a two lane highway that intersected the four lane highway, and was found at a convenience store by store staff 0.2 miles away. This deficient practice continues at a potential for more than minimal harm for all 5 residents (#1, #2, #3, #4 and #5) assessed as being at risk for elopement, have exit seeking behaviors, and wore Wanderguard alert bracelets. S1Administrator was notified of the Immediate Jeopardy situation on 07/18/2023 at 3:21 p.m. The Immediate Jeopardy situation was removed on 07/19/2023 at 5:00 p.m. when an acceptable plan of removal was presented. The facility's plan to remove the immediate jeopardy situation included the following: On May 17, 2023 Resident #1619 eloped from the facility. On June 4, 2023 Resident #1586 eloped from the facility. These incidents have the potential to affect all 5 residents who are at risk for elopement, and have been identified with exit seeking behaviors and require supervision. Staff being unable to hear the Wanderguard alarm sound when in a resident's room with the door closed, and thus failed to adequately supervise these residents, has been identified as the root cause of the elopement. The facility put the following corrective actions in place for the residents affected by the alleged deficient practice: On 07/18/2023 at 4:00 p.m., an operational check was completed on all exit doors by the Medical Equipment vendor to evaluate the current operational status of the magnetic door locking system. The volume was increased on the Hall W exit door. All exit Door codes were changed on 07/18/2023 by the Medical Equipment vendor. On 07/18/2023 at 4:30 p.m., an assigned employee was placed at the nurse's station as a Door Watch across all shifts to monitor the facility's Wanderguard annunciator panel to ensure the residents' safety and well-being. Door Watch staff will be in-serviced by the Administrator/Designee on required duties prior to assuming the Door Watch assignment. Door Watch staff will have no additional duties. Door alarm monitoring will be documented every 30 minutes by assigned staff. The Administrator/Designee will supervise the door watch documents 5 times weekly for 4 weeks to ensure no further issues have occurred. The Elopement and Wandering Resident Policy was reviewed and updated on 06/05/2023. The Elopement Risk Binder was reviewed on 07/18/2023 by the Director of Nursing to ensure the binder information is current. The Elopement Risk Binder will be updated by the MDS staff when a resident is identified with changes in cognition and if there are new admissions to the facility that meet the criteria for elopement risk and require a Wanderguard bracelet. The binder will be reviewed by the Director of Nursing/Designee weekly to ensure continued accuracy. Wanderguard bracelet for Resident #1586, #1596, #1604, #1607, and #1619 were checked on 07/18/2023 to ensure proper working order, and were functioning properly. Education of all staff by the Administrator/Designee on residents at risk for elopement and proper monitoring of those residents and current residents at risk for elopement began immediately on 07/18/2023, and will be completed on 07/19/2023. Upon hire, employees will be educated on the Elopement and Wandering Residents Policy, and annually thereafter unless such actions occur again. The QA Committee will supervise staff education to ensure all staff are properly educated. Resident that have been identified as elopement risk will be supervised by Administration/Designee or nursing staff/designee every 15 minutes for 7 days, then every 30 minutes for 7 days, then every hour continuously. The Administrator/Designee will monitor elopement risk documentation 5 times a week for 4 weeks. The QA Committee will discuss during daily or weekly meetings the interventions put in place as a result of the elopements that occurred on 05/17/2023 and 06/04/2023, and evaluations of interventions and if there is a need for an altered plan of interventions. The QA Committee will designate each department head to monitor/supervise weekly for a minimum of 3 months. The magnetic locking door system will be checked every 30 minutes by Administrative/Designee or nursing staff for 2 weeks then every hour for 2 weeks. The Administrator/Designee will monitor the door locking system checks 5 times a week for 4 weeks. Elopement Risk Assessments are completed by the MDS staff for all new admissions. A QAPI Performance Improvement Project will be implemented to review all corrective actions. All findings will be discussed at the monthly QAA meeting for a minimum of 3 months and quarterly thereafter for continued compliance and further interventions if needed Estimated completion date of 07/19/2023. For the remainder of this document Resident #1 is #1619, Resident #2 is #1586, Resident #3 is #1607, Resident #4 is #1596, and Resident #5 is #1604. Findings: Resident #1 Review of the facility Elopement policy revealed the following in part . Policy Statement: Please contact 911. Review of the Elopement policy revealed no information regarding prevention of elopement, or the procedure to follow in the event a door alarm sounds. Review of Resident #1's Face Sheet revealed an admit date of 03/30/2023 with diagnoses that included: Unspecified Dementia; Schizoaffective Disorder; Major Depressive Disorder, recurrent; Anxiety Disorder; and Insomnia, unspecified. Review of Resident #1's Wanderguard consent form dated 04/12/2023 revealed Wanderguard to wheelchair secondary elopement risk. Recommended restraint: Wanderguard with census checks q 2 hours. Medical symptoms warranting use: wanders in hallways in wheelchair and verbalizes she wants to go home. Reassess in 90 days. Review of Resident #1's Quarterly MDS with an ARD of 07/07/2023 revealed Resident #1 had a BIMS of 14 (cognitively intact). Resident #1 had behavior symptoms (pacing) not directed toward others, and was dependent with chair to bed transfers and walking 10 feet. Resident #1 used a wheelchair for mobility. Review of Resident #1 Comprehensive Care Plan revealed the following in part . Elopement: Potential for elopement r/t current diagnosis dementia 06/05/2023. Plan: 1. Redirect and reorient as needed. 2. Elopement/Wandering risk assessment for potential for elopement completed on admit, quarterly, and prn. 4. Apply Wanderguard bracelet if indicated with transmitter test q day. 5. Monitor and document visual census check as indicated. 6. Utilize a discrete personal identifier so staff is aware resident is at risk for elopement (running man placed on resident's door). 9. Notify MD and RR of any actual elopements. Has Wanderguards with census checks q 30 minutes. 07/07/2023 - Continue with Wanderguard to right lower leg with census checks of 1 hour. Continue with Wanderguard on front of w/c when/if resident gets up in w/c for short periods. Review of Resident #1's 04/03/2023 Risk of Elopement/Wandering Review revealed in part . Resident #1 verbalized that she wanted to go home, but did not seek exits. 04/12/2023 - Resident #1 verbalized that she wanted to go home, did not seek exits, but told S6 LPN that she wanted to leave, Wanderguard placed on front of w/c. 05/17/2023 - Resident #1 eloped from building with Wanderguard already attached to w/c. Wanderguard with census checks q 30 minutes for 24 hours, and Wanderguard to left lower leg and continue with Wanderguard on front of w/c. 05/18/2023 - Census checks to every hour. 06/04/2023 - Resident #1 has history of elopement. Continue with Wanderguard and census checks. 06/06/2023 - Wanderguard moved to right lower leg secondary to edema/wound to left lower extremity. 07/07/2023 - Continue with Wanderguard to right lower leg and front of w/c when Resident #1 gets up for short periods. Continue with census checks every hour. Review of Resident #1's Physician's Orders revealed the following: 04/12/2023 at 9:00 a.m. - Wanderguard with census checks q 2 hours. Wanderguard placed on front of w/c. Wander Guard transmitter test q day 6/2 shift. 05/17/2023 at 6:45 p.m. - Wanderguard with census checks q 30 minutes x 24 hours. Wander Guard to left lower leg and continue with Wanderguard on front of w/c. 05/18/2023 at 3:30 p.m. - Continue Wanderguard on front of w/c and left lower leg, and change census checks to q hour. 06/04/2023 (no time noted) - Change Wanderguard with census checks to q 30 minutes. 06/06/2023 (no time noted) - Wander Guard changed to right lower leg with census checks q 15 minutes x 72 hours as of 06/05/2023, then q 30 minutes x 72 hours then q 1 hours (expiration 01/2024) secondary to edema/wound to LLE. Continue with Wander Guard on front of w/c. Review of the facility's 05/19/2023 Investigation Report revealed an incident was reported to S1 Administrator on 05/17/2023 at 6:36 p.m., that local police brought Resident #1 back to the facility after recovering her from the side of the highway. Observation on 07/17/2023 at 10:04 a.m. revealed Resident #1 lying in bed, and a Wanderguard bracelet was noted to Resident #1's right lower leg. Resident #1 was alert and oriented to person and place. Interview with Resident #1 at that time however, revealed she was unable to remember leaving the facility unsupervised on 05/17/2023. Telephone interview conducted on 07/17/2023 at 10:49 a.m. with S5 CNA revealed she worked the night Resident #1 left the building. S5 CNA stated she did not work on Resident #1's hall, but she heard the alarm go off. S5 CNA stated she went to the nurse's station to see which door was alarming, and went to the door at the end of Hall W. S5 CNA stated she opened the door, looked around, and did not see anyone. S5 CNA stated she could not remember if there were any cars in the parking lot. S5 CNA stated she did not see anyone outside so she thought the door was messed up. S5 CNA stated she went back to the nurse's station and as she arrived, the door alarm went off again. S5 CNA stated she went back to Hall W door and looked outside again and did not see anyone. S5 CNA stated she then went back to her hall to work. S5 CNA stated she told the nurse on duty, but was not instructed to do anything further. S5 CNA stated she did not perform a resident check at that time, and was not instructed to do so. S5 CNA stated the CNA assigned to Hall W, came and told her the police brought Resident #1 back to the facility. Interview on 07/17/2023 at 11:12 a.m. with S6 LPN revealed she was not working at the facility when the incident with Resident #1 occurred, but she received a telephone call from S1 Administrator and went to the facility. S6 LPN stated she received report that Resident #1 had been picked up down the highway by the local police and returned to the facility. S6 LPN stated Resident #1 was assessed when she returned and was found without any injuries. S6 LPN stated she sat with Resident #1 upon return and ask her how she left the building. S6 LPN stated Resident #1 said she put in the code and left. S6 LPN stated she asked what the code was, and Resident #1 did not give the correct code. S6 LPN stated staff were instructed to check doors when they heard an alarm. Telephone interview on 07/17/2023 at 11:52 a.m. with S4 LPN revealed she was assigned to Hall W the night of the incident with Resident #1. S4 LPN stated she came out of a resident's room on Hall W at approximately 6:30 p.m., to find a police officer and Resident #1 standing outside of the door at the end of Hall W. S4 LPN stated the police officer stated she was bringing me (S4 LPN) a patient. S4 LPN stated she had not been notified an alarm had gone off, and she had not heard an alarm. S4 LPN stated she last observed Resident #1 at 4:30 p.m. S4 LPN stated before Resident #2's elopement, a resident was able to leave the building if the door was opened for them with a Wanderguard on, but since then, the Administrator had fixed things up, the alarm now sounded if a resident was near the door with a Wanderguard. Telephone interview on 07/17/2023 at 1:42 p.m. with S8 CNA revealed she worked on Hall W the night Resident #1 left the facility. S8 CNA stated she was in another resident's room on Hall W at the time the event occurred. S8 CNA stated she did not hear an alarm go off. S8 CNA stated she heard the police officer beating on the door at the end of Hall W, and the officer had Resident #1 with her. S8 CNA stated she saw Resident #1 in the living room of the facility about 10 minutes before the police arrived with Resident #1. S8 CNA stated that when Resident #1 returned, she kept yelling out an address that she wanted to go to. Interview on 07/17/2023 at 2:17 p.m. with S10 Maintenance revealed he did no actual monitoring of the alarms on the facility doors, but was contacted if there was a problem. S10 Maintenance stated he was not aware of how the Wanderguard alarm functioned if the code was put in and the door was opened. Interview on 07/18/2023 at 8:30 a.m. with S1 Administrator revealed the alarm system had alarm tones which were different if a resident was loitering (near the door), or if the exit doors were opened. S1 Administrator stated the special tones were initiated after the incident with Resident #2 on 06/04/2023. Observation beginning on 07/18/2023 at 8:30 a.m. revealed S2 LPN placed a Wanderguard on her ankle, went to the front door of the facility, and demonstrated the alarm for a loitering resident. The alarm sounded. At this time, the surveyor went into a resident's room on Hall W which was 4 doors down from the exit door, and shut the door. The loitering alarm could not be heard. S2 LPN was then asked by the surveyor to open the exit door of the facility on Hall W, and the alarm sounded. At 8:34 a.m., the surveyor and S9 CNA went into a resident's room on Hall W and closed the door. The surveyor and S9 CNA were unable to hear the exit alarm when the door to a room on Hall W was closed. S9 CNA confirmed she was unable to hear the alarm. Interview on 07/18/2023 at 8:36 a.m. with S1 Administrator confirmed she was unable to hear the exit alarm from a resident's room on Hall W when the door was closed. S1 Administrator stated she did not investigate this issue after the incident on 05/17/2023, because a CNA reported that she heard the alarm. S1 Administrator stated she did not know how this issue could be resolved without having alarms in each room. S1 Administrator confirmed that residents are still at risk for elopement due to inability of staff to hear alarms. Interview on 07/18/2023 at 12:25 p.m. with S1 Administrator revealed there was no documented education given to employees concerning response to the facility alarm system before or after the 05/17/2023 incident. Resident #2 Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included: Unspecified Dementia, Hyperlipidemia, Major Depressive Disorder and Essential Hypertension. Review of Resident #2's Quarterly MDS with an ARD of 05/17/2023 revealed BIMS of 6, which indicated severe cognitive impairment. Resident #2 required one-person physical assist with personal hygiene, toilet use and dressing; and supervision with locomotion on and off the unit. Resident #2 was coded for behaviors of wandering. Review of Resident #2's Care plan with a review date of 08/17/2023 revealed in part . Elopement: potential for elopement r/t current diagnosis Dementia - Plan 1. Redirect and reorient as needed. 4. Monitor and document visual census. Review of Resident #2's 07/2023 Physician Orders read in part . 06/04/2023 - Wanderguard with census checks Q1 hour. 03/06/2023 - Wanderguard Transmitter test every day. Review of Resident #2's Risk of Elopement/Wandering assessment read in part . 05/17/2023 - Resident is at risk for elopement/wandering, as evidence by: wanders hallways and verbalizes I need to get out of here on occasion. Continue with Wanderguard with census checks Q2 hours. 06/04/2023- Resident is at risk for elopement /wandering, as evidence by: Resident eloped from facility x 1. Continue with Wanderguard with census checks Q1hour after Q 30 minute checks x 24 hours. Appropriate interventions have been reviewed and modified: personal safety alarm devices, exit and stairwell alarms, frequent monitoring, staff aware or residents wander risk. Plan of care updated. Review of the facility's Investigation Report revealed on 06/04/2023 at 8:10 a.m., S3 RN received a telephone call from a local convenience store that a female resident was at their store under the protection of a local deputy. Resident #2 was then picked up from the convenience store by facility staff, and brought back to the facility at 8:20 a.m. where she was immediately assessed with no injuries noted. An interview on 07/18/2023 at 9:10 a.m. with S3 RN revealed that she worked as the weekend Registered Nurse and Treatment Nurse on 06/04/2023. S3 RN stated when she arrived to work on 06/04/2023 at 5:30 a.m., she noticed Resident #2 sitting in a chair in the lobby near the front door. S3 RN stated she put the code in the front door and was able to open the door. S3 RN stated she felt the door may have been malfunctioning because of how close Resident #2 was sitting to the door without alarming when she entered the building. S3 RN stated she told S11 LPN that she felt there was an issue with the door, and S11 LPN reset the door. Afterwards, S3 RN assisted Resident #2 to the door and the door alarm lights blinked indicating proper function. S3 RN stated that around 8:00 a.m. she went back to the nurses' station after passing medications, and noticed the front door was not closed properly and the alarm was not sounding. S3 RN stated she opened the front door and looked around outside to if there was anyone outside, but she didn't see anyone. S3 RN stated she then notified staff to do a census check to make sure all residents were accounted for. S3 RN revealed at 8:10 a.m., a clerk/employee from a local convenience store called and notified them that they believed they had one of their residents there. S3 RN stated she went to the store and picked up Resident #2, and once they got her back into the building, the door alarm went off. S3 RN stated that Resident #2 was assessed after she was brought back into the facility, and family and facility MD was notified. S3 RN revealed S1 Administrator was notified of the incident and Resident #2 was then placed on 1:1 observation. S3 RN revealed that if there were any issues with the door alarm system, staff were told they were to notify S1 Administrator. S3 RN stated that S1 administrator was not notified of a door malfunction until after Resident #2 eloped from the building. An interview on 07/18/2023 at 10:00 a.m. with S1 Administrator revealed that she was notified on 06/04/2023 at 8:15 am that Resident #2 had eloped. S1 Administrator stated that S11 LPN informed her of a potential issue with the door when she called to notify her that Resident #2 had eloped. S1 Administrator stated that once she got to the facility, she investigated and noted that there were no issues with the door lock or alarm at that time. S1 Administrator stated there was no routine maintenance for the alarm system, and that the door alarm system company only came out when they were called. An interview on 07/19/2023 10:45 a.m. with S11 LPN revealed that she worked the day Resident #2 eloped. S11 LPN stated a few minutes before 8:00 a.m., she saw Resident #2 in the hallways and Resident #2 was upset because she saw a little boy in the facility that she thought he was her son, and wanted him to go with her. S11 LPN stated Resident#2 was redirected and then went to the dining room. S11 LPN stated she continued with her medication pass. S11 LPN revealed that at 8:10 a.m., she was notified by a staff member that a resident had eloped, and was at a local convenience store. S11 LPN denied hearing an alarm sound the morning prior to the elopement. S11 LPN stated on the morning of 06/04/2023, there was a resident (unsure which one) was able to get close to the front door without it alarming, so she used a key to reset the door alarm system to ensure that it functioned properly. S11 LPN stated that on 06/04/2023 at 2:00 p.m., she notified S1 Administrator that she did not feel the front door was functioning as it should, and S1 Administrator initiated a door watch at that time. S11 LPN revealed that she did not notify S1 Administrator of a door malfunction prior to the elopement that took place on 06/04/2023. Interview on 07/18/2023 at 12:25 p.m. with S1 Administrator revealed the Elopement policy was used as education for the in-service given after Resident #1 eloped from the facility. S1 Administrator confirmed there was no information concerning responding to facility alarms. An Interview on 07/19/2023 at 2:25 p.m. with S1 Administrator revealed that she should be notified immediately if there are any issues with the function of the doors. S1 Administrator stated she was unaware a key had been used to reset the door alarm on the morning of 06/04/2023. S1 Administrator confirmed that staff should have notified her prior to Resident #2's elopement on the morning of 06/04/2023, when they felt there was an issue with the front door, and they did not.

Based on interview and record review the failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 residents (#1 and #2) in a sample of 5 residents (#1, #2, #3, #4 and #5) reviewed for elopement. The facility's Administration failed to: 1. Ensure supervision was increased for residents at risk for elopement when staff became aware of improper functioning of door alarms and doors; 2. Ensure an effective system of staff response was in place when the door alarm sounded; and 3. Ensure staff were effectively trained and knowledgeable of their system of response, and adhered to training. This deficient practice resulted in an Immediate Jeopardy situation on 05/17/2023 at 6:15 p.m., when Resident #1 who had a diagnosis of Dementia, exhibited exit seeking behaviors and wore a Wanderguard bracelet, exited the facility after the door exit alarm. Resident #1 was found by local police at 6:30 p.m. near a busy four lane highway that runs parallel to the facility. The facility's continued failure to identify potential system failures and respond appropriately, resulted in the immediate jeopardy continuing on 06/04/2023 at 8:00 a.m., when Resident #2 who had a diagnosis of Dementia, exhibited exit seeking behaviors and wore a Wanderguard bracelet, exited the facility, although staff were aware of a previous door malfunction, walked alongside a busy four lane highway, crossed a two lane highway that intersected the four lane highway, and was found at a convenience store by store staff 0.2 miles away. S1Administrator was notified of the Immediate Jeopardy situation on 07/18/2023 at 3:21 p.m. The Immediate Jeopardy situation was removed on 07/19/2023 at 5:00 p.m. when an acceptable plan of removal was presented. The facility's plan to remove the immediate jeopardy situation included the following: Summary of Events: On July 1, 2023 at 3:21 p.m. the Administrator was notified of an Immediate Jeopardy situation for the facility's administration failure to implement a system to provide supervision to prevent elopement. An Immediate Jeopardy Template was provided at this time. The following actions were implemented immediately: On 07/18/2023 at 4:00 p.m., an operational check was completed on all exit doors by Medical Equipment Company staff to evaluate the current operation status of the magnetic door locking system. The volume was increased on Hall W exit door. Door codes were also changed on 07/18/2023 by Medical Equipment Company staff. On 07/18/2023 at 4:30 p.m., an assigned employee was placed at the nurse's station as a Door Watch across all shifts to monitor the facility Wanderguard annunciator panel to ensure the resident's safety and well-being. Door Watch staff will be in-serviced by the Administrator/Designee on required duties prior to assuming the Door Watch assignment. Door alarm monitoring will be documented every 30 minutes by assigned staff. The Administrator/Designee will monitor the door watch documentation 5 times weekly for 4 weeks to ensure no further issues have occurred. The Elopement Risk Binder was reviewed on 07/18/2023 by the Director of Nursing to ensure the binder information is current. The Elopement Risk Binder will be updated by the MDS staff when a resident is identified with changes in cognition. On 07/19/2023 at 4:10 p.m. Administration was in-serviced by VP of Operations on Policies and Procedures for Elopement to include prevention of elopement and interventions if an elopement occurs. On 07/19/2023 at 4:15 p.m. Administration was in-serviced by VP of Operations on Supervision of Residents at Risk for Elopement. VP of Operations will ensure Administration/Designee monitors resident elopement risks by auditing risk documentation weekly x 4 weeks. Resident Specific Actions: Wanderguard bracelet for Residents #1586, #1596. #1604, #1607 and #1619 were checked on 07/18/2023 to ensure proper working order. Residents that have been identified as elopement risk will be monitored by Administrative/Designee or nursing staff every 15 minutes for 7 days, then every 30 minutes for 7 days, then every hour continuously. The Administrator/Designee will monitor elopement risk documentation 5 times a week for 4 weeks. The Elopement Risk Binder was reviewed on 07/18/2023 by the Director of Nursing to ensure the binder information is current. The Elopement Risk Binder will be updated by the MDS staff when a resident is identified with changes in cognition and if there are new admissions to the facility that meet the criteria for elopement risk and require a Wanderguard bracelet. The binder will be reviewed by the Director of Nursing/Designee weekly to ensure continued accuracy. QAPI: On 07/19/2023 at 9:00 a.m. the QAPI Committee met to review and conduct a Root Cause Analysis and review policies and procedures for possible changes. A QAPI Performance Improvement Project will be implemented to review all corrective actions. All findings will be discussed at the monthly QAA meeting for a minimum of 3 months and quarterly thereafter for continued compliance and further interventions if needed. Education of all staff by the Administrator/Designee on residents at risk for elopement and proper monitoring of those residents and current residents at risk for elopement began immediately on 07/18/2023 and will be completed on 07/19/2023. Education will be continued monthly for 1 month. Upon hire employees will be educated on the Elopement and Wandering Residents Policy and annually thereafter unless such actions occur again. The QA Committee will supervise staff education to ensure all staff is properly educated and compliant. On 07/19/2023 the Administrator completed a reconciliation of the required Elopement and Wandering Residents education. No current employee or new will be allowed to work until staff education of Elopement and Residents Policy has been completed. Estimated completion date of 07/19/2023. For the remainder of this document Resident #1 is #1619, Resident #2 is #1586, Resident #3 is #1607, Resident #4 is #1596, and Resident #5 is #1604. This deficient practice continues at a potential for more than minimal harm for all 5 residents (#1, #2, #3, #4 and #5) assessed as being at risk for elopement, have exit seeking behaviors, and wore Wanderguard alert bracelets. Findings: Cross refer to F689. Review of the facility Elopement policy revealed the following in part . Policy Statement: Please contact 911. Review of the Elopement policy revealed no information regarding prevention of elopement, or what to do if a door alarm goes off. Interview on 07/18/2023 at 8:30 a.m. with S1 Administrator revealed the alarm system had alarm tones which were different if a resident was loitering near the door, or if the exit doors were open. S1 Administrator stated the special tones were initiated after the incident with Resident #2 on 06/04/2023. Interview on 07/18/2023 at 8:36 a.m. with S1 Administrator confirmed she was unable to hear the exit alarm from a resident's room on Hall W when the door was closed. S1 Administrator stated she did not investigate this issue after the incident on 05/17/2023, because a CNA reported that she heard the alarm. S1 Administrator stated she did not know how this issue could be resolved without having alarms in each room. S1 Administrator confirmed that residents were still at risk for elopement due to inability of staff to hear alarms. An interview on 07/18/2023 at 9:10 a.m. with S3 RN revealed that she worked as the weekend Registered Nurse and Treatment Nurse on 06/04/2023. S3 RN stated when she arrived to work on 06/04/2023 at 5:30 a.m., she noticed Resident #2 sitting in a chair in the lobby near the front door. S3 RN stated she put the code in the front door and was able to open the door. S3 RN stated she felt the door may have been malfunctioning because of how close Resident #2 was sitting to the door without alarming when she entered the building. S3 RN stated she told S11 LPN that she felt there was an issue with the door and S11 LPN reset the door. S3 RN stated that around 8:00 a.m. she went back to the nurses' station after passing medications, and noticed the front door was not closed properly and the alarm was not sounding. S3 RN stated she opened the front door and looked around outside to if there was anyone outside, but she didn't see anyone. S3 RN stated she then notified staff to do a census check to make sure all residents were accounted for. S3 RN revealed at 8:10 a.m., a clerk/employee from a local convenience store called and notified them that they believed they had one of their residents there. S3 RN stated she went to the store and picked up Resident #2, and once they got her back into the building the door alarm went off. S3 RN stated that Resident #2 was assessed after she was brought back into the facility and family and facility MD was notified. S3 RN revealed S1 Administrator was notified of the incident and Resident #2 was then placed on 1:1 observation. S3 RN revealed that if there were any issues with the door alarm system, staff were told to notify S1 Administrator. S3 RN stated that S1 administrator was not notified of a door malfunction until after Resident #2 eloped from the building. An interview on 07/18/2023 at 10:00 a.m. with S1 Administrator revealed that she was notified on 06/04/2023 at 8:15 am that Resident #2 had eloped. S1 Administrator stated that S11 LPN informed her of a potential issue with the door when she called to notify her that Resident #2 had eloped. S1 Administrator stated that once she got to the facility, she investigated and noted that there were no issues with the door lock or alarm at that time. S1 Administrator stated there was no routine maintenance for the alarm system, and that the door alarm system company only came out when they were called. Interview on 07/18/2023 at 12:25 p.m. with S1 Administrator revealed the Elopement policy was used as education for the in-service given after Resident #1 eloped from the facility. S1 Administrator confirmed there was no information concerning responding to facility alarms. S1 Administrator confirmed there was no documented education given to employees concerning response to the facility alarm system before or after the 05/17/2023 incident. An interview on 07/19/2023 at 2:25 p.m. with S1 Administrator revealed that she should be notified immediately if there are any issues with the function of the doors. S1 Administrator stated she was unaware a key had been used to reset the door alarm on the morning of 06/04/2023. S1 Administrator confirmed that staff should have notified her prior to Resident #2's elopement on the morning of 06/04/2023, when they felt there was an issue with the front door, and they did not.