**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure 1 (Resident #3) of 20 (#3, #5, #37, #41, #11, #9, #152, #39, #10, #14, #102, #44, #19, #42, #29, #34, #21, #1, #46, #12) residents reviewed for impaired cognition and/or a diagnosis that may increase their risk of elopement was adequately supervised to prevent elopement from the facility. This deficient practice resulted in an Immediate Jeopardy for Resident #3 on 08/21/2022 at 2:48 a.m. when Resident #3 exited from the facility unsupervised and was found across the street from the facility in front of the police station. Resident #3 had a diagnosis of Schizophrenia, Alzheimer's disease and has severe cognitive impairment with a history of confusion and escalating psychotic behaviors. The facility failed to assess Resident #3 as an elopement risk and did not adequately supervise Resident #3 to prevent elopement from the facility. Resident #3 was placed on every 15 minute checks after he eloped on 08/21/2022. Resident #3 eloped again on 08/25/2022, 08/26/2022 and 09/02/2022. The facility received a phone call from a concerned citizen on 09/02/2022 notifying them a resident in a wheelchair was in the middle of the highway a couple of blocks from the facility. The facility failed to provide adequate supervision and assess Resident #3 as an elopement risk after he eloped on 08/21/2022, 08/25/2022, 08/26/2022 and 09/02/2022. The facility's lack of adequate supervision put Resident #3 at risk for the likelihood of serious injury, harm or death. S1 Administrator, S3 Corporate Risk Management, and S4 DON (Director of Nurses) were notified of the Immediate Jeopardy on 12/07/2022 at 7:51 p.m. The Immediate Jeopardy was removed on 12/08/2022 at 3:52 p.m. when the facility Plan of Removal was approved. Through record reviews, interviews and observations, the surveyor confirmed the following components of the Plan of Removal have been initiated and/or implemented prior to exit: 1. On 9/02/22 Resident #3 was placed on the secured unit, where he remains. Facility placed employees in visual proximity to the available exits 24/7 on 12/08/2022 at 1:30 p.m. to monitor residents leaving the facility until door alarms are installed. All employees will monitor residents that are not on the locked unit for any new signs of elopement risk factors or increased confusion and will notify the administrator or DON immediately if any new risks are identified until completion of plan of correction. Employees were educated on appropriate screening for elopement risk. 2. All residents not residing on the secure unit were assessed for elopement risk and evaluated for their BIMS (Brief Interview for Mental Status) score by licensed staff 12/05/2022. Results of audit were completed to ensure that all residents at risk for elopement had adequate supervision and were free from accident hazards by placing them on the secured unit. 3. Risk manager/designee will audit preadmission screening forms daily to ensure appropriate placement prior to anyone admitting to the facility. Risk Manager/designee will audit all new admissions daily to ensure they are interviewed using the BIMS and assessed for elopement risk on day 1 and are placed on secure unit if they are identified as an elopement risk. Elopement Risk Assessment and BIMS score will continue to be completed quarterly, annually, and with any status change to identify any residents who are at risk for elopement. 4. All staff will be educated by regional Risk manager/designee on: Wandering and Elopement Policy and how to identify residents at risk for elopement, BIMS Score Interview tool and Elopement risk assessment, communication to administrator and DON if a resident displays new signs of elopement risk factors. 5. Regional risk manager/designee will document that employees, including new hires, receive above education prior to working with residents. Regional risk manager/designee will conduct staff competency interviews on above topics and document completion. Chief Nursing Officer will audit elopement risk assessments, BIMS and preadmission screening daily for two weeks and weekly thereafter. Auditing results will be brought to QAPI (Quality Assurance Performance Improvement) Committee daily for 2 weeks, weekly for 4 weeks and monthly thereafter. Implementation date 12/08/2022 This deficient practice continued at a potential for harm for 18 current residents who did not reside on the locked Dementia Care Unit, had impaired cognition and/or a diagnosis that may increase their risk of elopement as identified in the facility's Elopement Risk Tools, and were able to either ambulate or propel themselves in their wheelchairs throughout the facility with the potential to elope (#5, #37, #41, #11, #9, #39, #10, #14, #102, #44, #19, #42, #29, #34, #21, #1, #46, #12). Findings: Review of the facility's Wandering and Elopements Policy Revised December 2019 revealed in part: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Residents who have been determined to be at risk for wandering/elopement will have immediate interventions put into place according to the resident assessment .If an employee observes a resident leaving the premises, he/she should attempt to prevent the resident from leaving in a courteous manner, get help from other staff members in the immediate vicinity if necessary, and instruct another staff member to inform the Charge Nurse or DON that a resident is attempting to leave or has left the premises. If a resident is missing, initiate the elopement/missing resident emergency procedure .determine if the resident is out on an authorized leave or pass, if the resident was not authorized to leave, initiate a search of the buildings and premises, and if the resident is not located, notify the Administrator and the DON, the resident's legal representative, the attending physician .When the resident returns to the facility, the DON or charge nurse shall examine the resident for injuries, contact the attending physician and report findings and conditions of the resident, notify the resident's legal representative, notify search teams that the resident has been located, complete and file an incident report, and document relevant information in the resident's medical record. Review of Resident #3's record revealed an admit date of 06/16/2022 and diagnoses including but not limited to: Schizophrenia, Major depressive disorder, Insomnia, Anxiety disorder, and Alzheimer's disease. Review of Resident #3's December 2022 Physician orders revealed orders including: 11/07/2022-monitor anti-psychotic medication use-observe resident closely for significant side effects 09/05/2022-admit to secure care unit 09/03/2022-monitor for behaviors while resident on psychotropic medications every shift 06/18/2022- Geodon 60 mg (milligrams) twice daily for schizophrenia 06/18/2022-Depakote 750 mg every day for behavior-document number of target behavior episodes 06/16/2022-Escitalopram (for depression) 20 mg every day 06/16/2022-Clonazepam 1mg twice daily for anxiety disorder Review of Resident #3's admission MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS score of 5 out of 15 indicating severe cognitive impairment. Further review revealed the resident was independent for bed mobility, transfers, and locomotion on unit with the use of a wheelchair. Further review of Resident #3's MDS assessments revealed no reassessment was done after the resident's elopements from the facility on 08/21/2022, 08/25/2022, 08/26/2022 and 09/02/2022. Review of the Resident #3's Elopement Risk Tools revealed an elopement risk assessment dated [DATE]. The summary of the assessment indicated the resident was not been found to be at risk for elopement at that time. Further review revealed no other Elopement Risk Tools were completed after the resident's elopements on 08/21/2022, 08/25/2022, 08/26/2022 and 09/02/2022. No reassessment of elopement risk was performed until 09/27/2022 after the resident was placed on the locked dementia care unit. Review of Resident #3's Comprehensive Care Plan revealed the resident was care planned for elopement risk starting with a previous admission beginning 04/15/22 with interventions including Evaluate elopement risk on admission, quarterly and or with improvement in cognition, monitor resident for tailgating following visitors thru exits, place resident information in elopement book, encourage activities of resident interest. Further review revealed no updates to the care plan after the resident's elopements from the facility on 08/21/2022, 08/25/2022, 08/26/2022 and 09/2/2022 when he was placed on the locked dementia unit. Further review revealed the care plan was not updated until 11/07/2022 for placement on the memory care unit. Review of Resident #3's nursing notes revealed in part the following notes: 08/21/22 at 3:52 a.m. by S12 LPN (Licensed Practical Nurse)-Resident seen in lobby at 2:40 a.m. when writer headed down hall for routine rounds. At 2:48 a.m. co-worker came rushing by stating that her daughter called and stated one of the residents was across the street from the facility in front of the police station. We immediately headed that way and observed resident in wheelchair propelling self on the road still in front of police station. Resident appeared stable and denied any pain or injury and agreed to let me bring him back to facility. I then performed assessment and skin/body audit that showed no new issues .While continuously observing resident I then notified S4 DON, and then the medical doctor and was given new order to admit to secure unit .Resident was then taken to secure unit. Attempted to notify resident's responsible party with no answer. Resident does not want to go to bed at this time and is currently in dining room of secure unit with CNA (Certified Nursing Assistant) stating he is going to leave again tomorrow. 08/22/2022 at 10:58 a.m. by S13 LPN- MD (Medical Doctor) updated on resident's behavior today . He was placed in secure unit for immediate safety. He is currently at hospital to have Magnetic Resonance Imaging of his foot and toes. After returning from his appointment, we have new order for him to be back in general population. We will do 15 minute checks on him and document his whereabouts. Staff will notify MD with any changes in behavior. 08/24/2022 at 8:04 p.m. by S14 LPN -Resident yelling and cussing at other residents. Talking about kicking someone's ass, and shooting them. Thinks the police are coming after him. Really acting up tonight. Demanding cigarettes and money . 08/25/2022 at 1:22 p.m. by S15 LPN- at 9:16 a.m. resident heading down sidewalk. Resident said he was going to haul logs. Resident redirected by staff, resident entered the building cussing at unseen people . 08/26/2022 at 7:14 a.m. by S15 LPN-Resident observed outside on the sidewalk by the civic center (which is across the street). Staff redirected him inside facility. Resident told staff he was looking for a smoke. 08/27/2022 at 10:27 a.m. by S15 LPN-Resident ambulating from hallway to front lobby cussing at unseen people, staff attempted to redirect resident without success. Resident continued to cuss and threatening unseen people. 08/28/2022 at 8:47 p.m. by S 14-Resident returned to facility via ambulance from behavioral hospital .Behavioral Hospital will not accept resident. Says he does not meet criteria . 09/02/2022 at 6:50 p.m. by S13 LPN Received phone call from concerned citizen. Resident had left out front door and propelled self up to main highway (Highway 157) and was going down the road. Writer immediately went to get him. When I got to him he was smiling and laughing. I ask him what in the world are you doing: He said he was going after a pulp wood truck. Used my cell phone and called DON. Staff from facility met me down the road and brought him back to facility and I drove my vehicle back. After I returned I called MD. She said to discontinue the 15 minutes checks and put him in the secure unit permanently. There was no documentation the resident's RP was notified of the elopement or the placement on the secure unit. Review of the facility's incident reports revealed no incident reports with investigations for Resident #3's elopement episodes. Observations during the survey from 12/05/2022 to 12/07/2022 revealed all exit doors were unlocked with no sound alerting when they were opened with the exception of the doors leading out the north and west sides of the Hall B, the door out the south side of the dining room, and the doors on the locked dementia care unit. There were chairs on the front porch. The building was located in a commercial area surrounded by sidewalks. With the exception of a fence around the patio of the locked dementia unit, there was no was no fence, gate, or barrier of any kind around the building between the sidewalk and the roads. The police station was directly across the street on the [NAME] side, there was a park and the civic center across the street on the North side, and commercial buildings across the street on the South and East sides of the building. During an observation and interview on 12/07/2022 at 10:58 a.m. on the locked dementia unit, Resident #3 was seated with other residents in the day area with staff supervision. The resident was clean and well groomed, and was dressed seasonally appropriate. Resident #3 self-propelled his wheelchair across the room and said he likes it back here and was doing better than when he was out there. During an interview on 12/07/2022 at 2:07 p.m. S4 DON confirmed no incident reports were done related to Resident #3's multiple elopements from the facility and should have been. S4 DON indicated management did do an investigation after Resident #3 left on 09/02/2022, but was unable to produce investigation notes or witness statements. S4 DON indicated she had contacted the Corporate Director of Nursing and was told the resident had a purpose, an intent and knew where he was going when he left the faciity on [DATE]. The surveyor asked S4 DON if that was the case with a resident who had a BIMS score of 5 out of 15 at that time. S4 DON responded that was what corporate told her. S4 DON indicated the facility did have a process for cognitive residents and family members to sign residents out when they left on outings and confirmed Resident #3 had never signed himself out. S4 DON confirmed the facility did not have cameras or video footage of the hallways and facility exit doors. S4 DON confirmed staff doing every 15 minute checks on Resident #3 should have noticed him leaving or noticed that he was gone before receiving a phone call from a concerned citizen and did not. During an interview on 12/07/2022 at 3:33 p.m. S4 DON indicated Resident #3 was found on 09/02/2022 on Highway 157 a few blocks east of the facility. S4 DON confirmed nurses did not do incident reports each time Resident #3 had been found outside of the facility and should have. S4 DON further confirmed the staff was not retrained on monitoring residents for elopement risk or on completing incident reports and should have been. S4 DON further indicated the front door of the facility was always unlocked except late at night. S4 DON further confirmed Resident #3 was not reassessed for elopement risk and his care plan was not updated after each of his 4 elopement episodes. During an interview on 12/07/2022 at 3:36 p.m. S16 LPN on the locked dementia care unit indicated Resident #3 says he is going to get out of here all of the time. During an interview on 12/07/2022 at 3:45 p.m. S17 CNA confirmed she had worked with Resident #3 and was familiar with him. S17 CNA indicated she had never witnessed Resident #3 trying to leave the facility, but he had made comments that he was going to get out of here. S17 CNA indicated Resident #3 was placed on every 15 minute checks before he was placed on the locked unit. Indicated she checks all of her assigned residents at least once an hour, but she and the nurses assigned to Resident #3 were supposed to check on him every 15 minutes. During an interview on 12/07/2022 at 3:52 p.m. S14 LPN indicated she was familiar with Resident #3, and did remember him saying he needed to get out of here. S14 LPN confirmed Resident #3 was on every 15 minute checks after his elopement on 08/21/2022 and still managed to leave the building 3 more times. During an interview on 12/07/2022 at 3:56 p.m., Resident #3 indicated he wants to get out of here because he is tired of being on lock down. When asked if he used his wheelchair to go down the highway, Resident #3 indicated he did go down the highway to get the pulp wood truck, but it wasn't going to be enough money. Review of Resident #3's log of every 15 minute checks for 08/22/2022 through 09/02/2022 revealed checks of the resident's location and activity every 15 minutes documented by facility LPNs. Further review revealed the last entry on 09/02/2022 was for 5:30 a.m. was asleep in his bed. During an interview on 12/07/2022 at 4:17 p.m. S4 DON indicated she could not find the logs for the rest of the day on 09/02/2022, and could not confirm the resident was observed every 15 minutes prior to being notified by a concerned citizen on 09/02/2022 at 6:50 p.m. that he was in his wheelchair on the highway. During a telephone interview on 12/07/2022 at 4:52 p.m. S13 LPN confirmed she was taking care of Resident #3 the day of 09/02/2022. S13 LPN confirmed nurses were performing every 15 minute checks on Resident #3 because he had gone to the police department across the street looking for a cigarette the week before he eloped on 09/02/2022. S13 LPN indicated she last saw Resident #3 on 09/02/2022 at roughly 5:30 p.m. when she personally took him out to the smoking area to smoke, and remained outside with him while he smoked. S13 LPN indicated she did not know the resident had left the facility until she got a phone call from a citizen at around 6:30 p.m. that he was on the highway in his wheelchair. S13 LPN indicated she drove up to the gas station where he was in the road. S13 LPN further indicated an agency CNA walked the few blocks to the gas station and brought Resident #3 back to the facility in his wheelchair. During an interview on 12/07/2022 at 7:00 p.m. S3 Corporate Risk Management indicated in the presence of S1 Administrator and S4 DON that all residents were not reassessed until 12/05/2022 when she performed an audit on the 39 residents not residing on the locked unit to re-evaluate their BIMS scores and elopement risk. S3 Corporate Risk Management indicated the facility identified one resident at that time who was found to be at risk for elopement that was not already residing on the locked unit. The resident, #152, was moved to the locked unit on 12/05/2022. S3 Corporate Risk Management indicated no other residents were identified by the facility to be at risk of elopement at that time. S3 Corporate Risk Management, S1 Administrator, and S4 DON agreed supervision of Resident #3 every 15 minutes was insufficient to prevent his repeated elopements. S3 Corporate Risk Management, S1 Administrator, and S4 DON further agreed the resident should have been reassessed for elopement risk, and additional interventions should have been put in place and were not. Review of the Elopement Risk Tools performed by the facility on 12/05/2022 revealed the following 19 residents who had cognitive impairments that contribute to poor decision-making skills and/or a diagnosis that may increase the risk of elopement: #5, #37, #41, #11, #9, #152, #39, #10, #14, #102, #44, #19, #42, #29, #34, #21, #1, #46, #12. Review of Resident #5's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #37's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #41's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills. Review of Resident #11's Elopement Risk Tool performed 12/05/2022 revealed the resident had a diagnosis that may increase the risk of elopement. Review of Resident #9's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #152's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills. Review of Resident #39's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #10's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #14's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills. Review of Resident #102's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills. Review of Resident #44's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #19's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #42's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #29's Elopement Risk Tool performed 12/05/2022 revealed the resident had a diagnosis that may increase the risk of elopement. Review of Resident #34's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills. Review of Resident #21's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills. Review of Resident #1's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills. Review of Resident #46's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #12's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, the facility failed to administer its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to: 1. Ensure Resident #3 was adequately supervised to prevent repeated elopements from the facility 2. Complete incident reports, investigations, and train staff on supervision of residents to prevent elopements 3. Ensure Resident #3 was reassessed for elopement risk and update his plan of care with additional interventions to prevent repeat elopements. This deficient practice resulted in an Immediate Jeopardy for Resident #3 on 08/21/2022 at 2:48 a.m. when the facility's administration failed to ensure resources were effectively utilized to prevent Resident #3 from exiting the facility unsupervised and ensure steps were taken to identify other residents at risk for elopement. S1 Administrator, S3 Corporate Risk Management, and S4 DON (Director of Nurses) were notified of the Immediate Jeopardy on 12/07/2022 at 7:51 p.m. The Immediate Jeopardy was removed on 12/08/2022 at 3:52 p.m. when the facility's Plan of Removal was approved. Through record reviews, interviews and observations the surveyor confirmed the following components of the Plan of Removal have been initiated and/or implemented prior to exit. 1. On 09/02/2022 Resident #3 was placed on the secured unit, where he remains. Facility placed employees in visual proximity to the available exits 24/7 on 12/09/2022 at 1:30 p.m. to monitor residents leaving the facility until door alarms are installed. Employees were educated on appropriate screening for elopement risk. DON and Licensed Administrator have acknowledged re-education from Regional Risk Management Director on Wandering and Elopement Policy, how to identify residents at risk for elopement, ensuring education to all staff on communication to Administrator and DON if a resident displays new signs of elopement risk factors. 2. All residents not residing on the secure unit were assessed for elopement risk and evaluated for their BIMS (Brief Interview for Mental Status) score by licensed staff 12/05/2022. Results of audit were completed to ensure that all residents at risk for elopement had adequate supervision and were free from accidents hazards by placing them on the secured unit. 1 resident was identified at that time to be an elopement risk and moved to the locked unit immediately. 3. Regional Risk manager/designee will audit preadmission screening forms daily to ensure appropriate placement prior to anyone admitting to the facility. Risk Manager/designee will audit all new admissions daily to ensure they are interviewed using the BIMS and assessed for elopement risk on day 1 and are placed on secure unit if they are identified as an elopement risk. Elopement Risk Assessment and BIMS score will continue to be completed quarterly, annually, and with any status change to identify any residents who are at risk for elopement. 4. All staff, including administrator and DON, will be educated by regional Risk manager/designee on Wandering and Elopement Policy and how to identify residents at risk for elopement, BIMS Score Interview too, and Elopement risk assessment, Communication to administrator and DON if a resident displays new signs of elopement risk factors. 5. Regional risk manager/designee will document that employees, including new hires, receive above education prior to working with residents. Regional risk manager/designee will conduct staff competency interviews on above topics and document completion. Chief Nursing Officer will audit elopement risk assessments, BIMs and preadmission screening daily for two weeks and weekly thereafter. Auditing results will be brought to QAPI (Quality Assurance Performance Improvement) Committee daily for 2 weeks, weekly for 4 weeks and monthly thereafter. 6. Regional risk manager/designee will provide oversight over administration to ensure staff are taking the appropriate measures. Implementation Date: 12/08/2022 This deficient practice continued at a potential for harm for 18 current residents who did not reside on the locked Dementia Care Unit, had impaired cognition and/or a diagnosis that may increase their risk of elopement as identified in the facility's Elopement Risk Tools, and were able to either ambulate or propel themselves in their wheelchairs throughout the facility with the potential to elope (#5, #37, #41, #11, #9, #39, #10, #14, #102, #44, #19, #42, #29, #34, #21, #1, #46, #12). Findings, Cross Reference F689: During an interview on 12/07/2022 at 2:07 p.m. S4 DON confirmed no incident reports were done related to Resident #3's multiple elopements from the facility, but indicated they did investigate when he left. S4 DON was unable to produce investigation notes or witness statements related to Resident #3's elopements from the facility. S4 DON indicated she had contacted the Corporate Director of Nursing (was a different corporation at that time) and was told the resident had a purpose, an intent and knew where he was going when he left the faciity on [DATE]. The surveyor asked S4 DON if that was the case with a resident who had a BIMS score of 5 out of 15 at that time. S4 DON responded that was what corporate told her. S4 DON confirmed the facility did not have cameras or video footage of the hallways and facility exit doors. During an interview on 12/07/2022 at 3:33 p.m. S4 DON confirmed nurses did not do incident reports each time Resident #3 had been found outside of the facility and should have. S4 DON further confirmed no staff training was done after Resident #3's elopements from the facility related to completing incident reports, the wandering resident, or supervision of residents to prevent elopement and should have been. S4 DON further confirmed Resident #3 was not reassessed for elopement risk and his care plan was not updated after each of his 4 elopement episodes. During an interview on 12/07/2022 at 4:17 p.m. S4 DON indicated she could not confirm staff observed Resident #3 every 15 minutes as directed prior to being notified by a concerned citizen on 09/02/2022 at 6:50 p.m. that he was in his wheelchair on the highway. During an interview on 12/07/2022 at 7:00 p.m. S3 Corporate Risk Management in the presence of S1 Administrator and S4 DON indicated all residents were not reassessed until 12/05/2022 when she performed an audit on the 39 residents not residing on the locked unit to re-evaluate their BIMS scores and elopement risk. S3 Corporate Risk Management indicated the facility identified one resident at that time who was found to be at risk for elopement that was not already residing on the locked unit. The resident, #152, was moved to the locked unit on 12/05/2022. S3 Corporate Risk Management agreed the processes in place to date did not prevent Resident #3 from eloping. S3 Corporate Risk Management further confirmed thorough investigations were not performed after each of Resident #3's elopements, and the resident was able to elope 3 additional times after being placed on every 15 minute checks. S3 Corporate Risk Management further confirmed no processes had been changed/implemented and no updates to policies had been done to ensure no other residents at risk were able to elope from the facility.