This citation pertains to intake # 2592873.Based on interview, and record review, the facility failed to provide adequate supervision to prevent elopement and respond appropriately to an alarming exit door to ensure resident safety in 1 of 5 residents (Resident #101) reviewed for elopement/supervision, resulting in an Immediate Jeopardy when on 8/13/25 between 8:30 PM and 8:45 PM, Resident #101, who was an elopement risk with a prior recent history of elopement, exited the facility, unbeknownst to facility staff, and was found by a Certified Nursing Assistant (CNA) approximately 0.3 miles away from the facility, sitting on the front porch of a residential home. This deficient practice placed all residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death.Findings include:The facility failed to provide adequate supervision to prevent elopement for an exit seeking resident, Resident #101, who was an elopement risk with a prior recent history of elopement, and respond appropriately to an alarming exit door to ensure resident safety. Resident #101 was found by a Certified Nursing Assistant (CNA) approximately 0.3 miles away from the facility, down a 35 MPH (miles per hour) road, sitting on the front porch of a residential home on the opposite side of the street.The Immediate Jeopardy began on 8/13/25 when the facility failed to supervise Resident #101 and he eloped from the facility between 8:30 PM-8:45 PM. The Director of Nursing (DON) B and Regional Clinical Coordinator (RCC) V were notified of the Immediate Jeopardy on 8/19/25 at 3:28 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 8/19/25, but noncompliance remains at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance has not been verified by the State Agency.In an observation on 8/19/25 at 9:25 AM, completed a tour of the facility with DON B to review placement/functioning of wander guard devices for current residents identified as At Risk for elopement. Noted one resident within the facility wore a Fitbit style wander guard device on their right wrist.In an observation and interview on 8/19/25 at 9:42 AM, the front door/main entrance wander guard alarm system was tested, accompanied by Environmental Service Director I. Environmental Service Director I reported the door alarm/wander guard system was checked daily for appropriate functioning. Environmental Service Director I reported the front doors are unlocked during the day (between 7:00 AM-7:00 PM), however, if a resident wearing a wander guard were to approach the doors they would automatically lock. Environmental Service Director I reported an alarm would sound if a resident wearing a wander guard device were to attempt to exit the facility through the front doors while the door was ajar, or by pushing on the door for 15-seconds. This surveyor tested the front door wander guard locking system while holding an active Fitbit style wander guard device. Noted the front doors initially locked when approached with the Fitbit style device, however, after 3-4 approaches the automatic lock did not activate and this surveyor was able to open the front door without an alarm sounding. Regional Clinical Coordinator (RCC) V reported the Fitbit style device was an older device, no longer used by the facility. RCC V provided the newer style wander guard device, which appeared much more sensitive during observation and locked down every time when approached.In an observation on 8/19/25 at 10:22 AM, the fire exit door within the main dining room was observed with Environmental Service Director I. Noted the exit door must be pushed for 15-seconds to open which would activate an alarm (no code required to open the door by using the 15 second egress). No wander guard system noted on this exit door. Observed a keypad on the wall to the right of the main dining room fire exit door, with a grey flip-open panel labeled CODE FOR EMERGENCY EXIT. The box was easily opened and at eye level. Noted the code to exit the door posted within the flip-open panel.In an observation and interview on 8/19/25 at 11:26 AM, the fire exit door within the main dining room was observed with Environmental Service Director I. Again, noted the flip-open panel which contained the code to exit the door, posted on the wall to the right of the door at eye level. Environmental Service Director I entered the code and was able to open the door without activating the alarm system. Environmental Service Director I reported there was no wander guard system installed on this exit door, and he was unsure why the exit code was posted.Resident #101Review of an admission Record revealed Resident #101 was a male, with pertinent diagnoses which included cognitive communication deficit (a communication problem resulting from difficulties with cognitive function), dementia, depression, anxiety, arthritis, and insomnia. Further review of the admission Record revealed Resident #101 was not his own responsible party.Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 7/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated severe cognitive impairment. Further review of this assessment revealed Resident #101 had cognitive symptoms which included inattention and disorganized thinking, along with wandering behaviors.Review of a Care Plan for Resident #101 revealed the focus (Resident #101) is at risk for elopement R/T (related to): impaired cognition d/t (due to) advanced dementia, elopement score of 12 . revised 7/21/25, with interventions which included Apply wanderguard per order. Check placement, function and expiration date per facility protocol. Wanderguard to: left ankle . initiated 7/18/25 and revised 7/21/25, .Approach in a slow, calm manner and redirect away from exit doors as needed . initiated 7/21/25, .Distract resident when wandering into inappropriate areas by offering pleasant diversions, structured activities, food, conversation etc . initiated 7/21/25, .Invite and encourage (Resident #101) to participate in an activity in the day room or a group activity. May needs (sic) assistance to and from activities of interest . initiated 8/7/25, and .Provide structured activities, toileting, walking inside and outside with supervision as needed . initiated 7/18/25.Review of a Risk for Elopement assessment for Resident #101, dated 8/12/25, revealed a score of 13.0 indicating he was At Risk for elopement.Review of an Incident Report for Resident #101, dated 8/13/25 at 8:40 PM, revealed .This writer/RN (Registered Nurse (RN) N) attempted to administer scheduled medication at (8:30 PM). Resident was not in room. Had been previously seen walking in halls and sitting in day room. RN and (CNA T) checked halls to determine resident's location. Unable to locate resident. Code Search called at (8:40 PM). (Administration) and police notified. (Three) staff members .searched outside building including wooded areas and street. Resident not located, (CNA C) used vehicle to search further down street. Resident located by (CNA C), returned to (facility) approximately (9:00 PM). Resident pleasantly confused, assessment normal, denies pain or injury .Police reported to facility after resident located .Resident placed on constant 1:1 observation .Review of a Nurses Note dated 8/13/25 at 9:06 PM, revealed .RN attempted to administer medication, was not able to locate resident. Code search called at (8:40 PM), resident located outside the building by staff. (RN N) called 911 to report, follow up call to update that resident was located. Police reported to facility after resident located .In an interview on 8/19/25 at 11:00 AM, CNA E reported she saw Resident #101 walking throughout the facility the evening of 8/13/25, prior to his elopement. CNA E reported she heard an alarm sound at the front door at approximately 8:40 PM. CNA E reported she responded to the alarm and stated .I didn't go outside but I looked out the window at the doorway. I didn't see anybody there . CNA E reported she was unsure how long the alarm was going off prior to responding, as she had just come out of a resident's room when she heard the alarm. CNA E reported she had recently received education on the elopement policy as Resident #101 had a prior elopement a few weeks before and stated .I was supposed to go outside. I didn't remember that I was supposed to go outside and look to see if anybody was there . CNA E reported when staff realized Resident #101 was missing, another CNA left the facility in a vehicle and found Resident #101 down the road.In an interview on 8/19/25 at 11:08 AM, CNA L reported she was working the evening of Resident #101's elopement, on 8/13/25. CNA L reported she saw Resident #101 about thirty minutes prior to the elopement, in the activity room. CNA L reported she did not hear any alarms, and first became aware that Resident #101 was missing when a nurse called a CODE SEARCH and stated .we started looking for him .In an interview on 8/19/25 at 11:46 AM, CNA H reported she was working on a different unit the evening of Resident #101's elopement on 8/13/25. CNA H reported she observed Resident #101 wandering throughout the facility prior to the elopement. CNA H stated .I noticed he was wandering and wondered why someone wasn't following him or looking after him. When I had him (was assigned to him) I would watch him . CNA H reported when she first arrived, she observed Resident #101 near the front entrance, and as the night progressed she observed Resident #101 wandering up and down the halls and trying to go into other residents' rooms. CNA H reported Resident #101 often made statements about leaving the facility and stated staff had to .talk him out of it . or .make up something to get him to stay inside . CNA H reported sometime after 8:00 PM, a staff member asked if she had recently observed Resident #101. CNA H reported they all acknowledged it .had been a while . since anyone had observed Resident #101 within the facility, so staff began a search, and stated .we couldn't find him anywhere . CNA H reported several staff members left the facility in vehicles to search down the road, and the resident was ultimately located down the street from the facility on the front porch of a residential home.In an interview on 8/19/25 at 2:42 PM, Family Member Y reported she was notified of Resident #101's elopement on 8/13/25. Family Member Y reported she was told a staff member responded to a door alarm and deactivated the alarm, not thinking it was an issue. Family Member Y reported shortly after, staff realized Resident #101 was missing and went looking for him. Family Member Y stated .Thank God, they found him .In an interview on 8/20/25 at 8:27 AM, RN J reported she was in a resident's room the evening of 8/13/25 at approximately 8:20 PM and thought she heard a door alarm sound. RN J reported when she exited the room, she no longer heard the alarm. RN J stated .a CNA came around the corner and said she took care of the alarm, and everything was good . RN J reported she then continued with medication administration. RN J reported a short time later, another staff member came and asked her if she had recently seen Resident #101. RN J reported she recalled the alarm sounding earlier and went to clarify with the CNA what had set off the door alarm. RN J reported the CNA reported there was no one present at the front entrance when she responded to the door alarm, and indicated she had looked out the window, but had not exited the building to look prior to deactivating the front door alarm. RN J reported at that point staff called a CODE SEARCH at approximately 8:40 PM and a head count was initiated, along with a search for Resident #101 both inside and outside of the facility. RN J reported Resident #101 was found approximately fifteen minutes later, down the street from the facility sitting on the porch of a residential home.In an interview on 8/20/25 at 8:40 AM, CNA C reported she arrived at the facility for her shift on 8/13/25 at approximately 8:00 PM. CNA C reported she was not assigned to Resident #101, however, she did observe him walking throughout the halls. CNA C reported she did not hear any door alarms but realized there was an issue when a CODE SEARCH was called and staff began searching for Resident #101. CNA C reported she and RN N immediately went outside and began searching the perimeter. CNA C reported when Resident #101 was not immediately located, she took her car and began a search for the resident down the street. CNA C reported she located Resident #101 sitting on the front porch of a residential home, across the street from the church (approximately 0.3 miles away), on the opposite side of the road from the facility. CNA C reported when she found Resident #101, it was just starting to get dark outside.In an interview on 8/21/25 at 8:38 AM, RN N reported she was Resident #101's assigned nurse the evening of 8/13/25, at the time of his elopement. RN N reported prior to the elopement, she had observed Resident #101 in the activity room and walking throughout the hallways. RN N reported Resident #101 had a scheduled medication, which she prepared for administration at 8:25 PM. RN N reported she checked for Resident #101 in his room and in the hallway and was unable to locate him. RN N reported she asked RN J if she had seen Resident #101, and she had reported he had been in the area not long before. RN N reported she continued on and completed a loop around the facility. RN N reported when she approached RN J a second time without finding Resident #101, they decided to call a CODE SEARCH and complete a head count of the residents/begin a search for Resident #101. RN N reported the CODE SEARCH was called at approximately 8:40 PM on 8/13/25. RN N reported RN J recalled hearing the door alarm earlier in the evening. RN N reported she exited the facility to search for Resident #101 outside. RN N reported Resident #101 was found by CNA C on the porch of a residential home down the street from the facility.In an interview on 8/21/25 at 11:06 AM, DON B reported after Resident #101's first elopement in July 2025, he was placed on 1:1 observation for a period of time until he adjusted to the environment. DON B reported once the 1:1 observation was discontinued, staff were to supervise the resident as necessary and redirect Resident #101 away from the doors when exit-seeking. DON B reported Resident #101 wore a wander guard device due to elopement risk. DON B reported after Resident #101 was located on 8/13/25 after the second elopement, he was immediately placed on 1:1 observation which continued until his discharge from the facility on 8/15/25. DON B reported the CNA who responded to the door alarm on 8/13/25 (CNA E) acknowledged she should have exited the building to check outside when she responded to the door alarm with no one present and called a CODE SEARCH to begin a head count of the residents/ensure all residents were accounted for.Review of the policy/procedure Elopement, dated 4/26/22, revealed It is the policy of this facility to prevent to the extent reasonably possible, the elopement of guests/residents from the facility .Alarm Activation .If an employee hears a door alarm, he or she should .Immediately go (to) the site of the alarm .If no guest/resident is found to be exiting the facility, the employee should walk outside; conduct a visual observation of the immediate area to ensure that a guest/resident has not already exited the facility. If no guest/resident is observed, then the staff member will return into the building .In situations where the alarm sounds and a guest/resident is not found to have exited .Notify the licensed nurse immediately, and .Ensure that a head count is completed to ensure that all guests/residents are accounted for .The Immediate Jeopardy that began on 8/13/25 was removed on 8/19/25 when the facility took the following actions to remove the immediacy.1) Resident #101 was returned to the facility at approximately 9:05 PM on 8/13/25. Staff confirmed the wander guard was in place and functioning upon return to the facility. Staff were required to enter the door code in order for the resident to return to the facility. The door and wander guard were checked for functioning when Resident #101 returned on 8/13/25. The POA (Power of Attorney) for Resident #101 and the Physician were notified. Resident #101 was assessed with no injury noted on 8/13/25. An investigation was initiated, and the State Agency was notified.2) Resident #101 was placed on 1:1 supervision immediately upon return to the facility on 8/13/25. Social Services met with Resident #101's POA to discuss safe discharge for the resident. Discharge was planned for 8/15/25. On 8/15/25, Resident #101 discharged home with his wife.3) On 8/13/25, all doors were tested and noted to be in working order by the Licensed Nurses. The licensed nurse re-educated staff immediately on responding to door alarms and the need to exit the facility to observe if any resident is outside the facility that is an elopement risk.4) On 8/14/25, the Maintenance Director tested the front door and service hall door and alarms are sounding and doors lock down appropriately when checked with a wander guard.5) On 8/14/25, DON/designee initiated education with staff related to elopement, specifically the risk and expectation that staff will EXIT the facility when responding to a door alarm. Staff will walk the grounds and perimeter and observe the driveway to ensure no cognitively impaired residents are noted to be outside. Staff will be educated 8/14/25, and any staff member not educated on 8/14/25 will be educated prior to working their next shift. Staff were educated that failure to follow the policy and exit the building when door alarms are going off will result in disciplinary action up to/including termination. The CNA who did not follow policy on 8/13/25 was suspended and ultimately terminated for not following procedure. The charge nurse was given a written discipline for not ensuring the policy was followed.6) On 8/19/25, residents with wander guards were checked for placement and function. The Fitbit style wander guards were removed from the facility. One resident had their Fitbit style band replaced on 8/19/25 with the newer style.7) On 8/14/25, staff were educated to provide 1:1 observation to actively exit-seeking residents and notify the DON/Administrator if staffing needs to be adjusted/additional staff need to be provided.8) On 8/14/25, the DON/designee assessed all new admissions for elopement risk. No new residents were identified as an elopement risk at that time.9) On 8/14/25, Social Services checked the elopement books for accuracy with no concerns noted.10) The receptionist schedule was extended until 10:00 PM on 8/14/25. Doors will still lock at 7 PM, and the receptionist will be available to watch the door/assist families to exit until 10:00 PM. The front entrance door ONLY is unlocked and does not need a code to enter from 7:00 AM-7:00 PM. At 7:00 PM, the doors lock and require a code to be entered by staff in order to unlock the door. The door does have a release when the door is pushed for 15-seconds. When a wander guard is within 6 feet, the doors will lock down at all times of the day and if the resident is attempting to exit and pushing on the door handle, an alarm will sound.11) Beginning 8/14/25, the scheduler is to assign on the daily assignment sheet a staff member responsible for 1:1 observation of Resident #101.12) On 8/19/25, the door code label posted beside the exit door within the main dining room was removed.13) On 8/14/25, an elopement drill was completed.14) (Alarm Company Name) continues to service (Facility Name) regarding service hallway doors. Expectation for service doors to be changed out to new doors within 6-8 weeks from 7/24/25, and enunciators/strobes to be installed. The facility is waiting for a quote and to be put on the service calendar. (Alarm Company Name) is aware of the rush order. The service hall doors are also locked at all times and require a code to be entered to go through the doors. These doors have already been approved by BFS (Bureau of Fire Services).15) The Administrator/DON reviewed the elopement policy and deemed it appropriate on 8/14/25.16) The Administrator/DON initiated education with staff on 8/13/25, which included education on the elopement policy with stress on the expectation that staff WILL exit the facility when responding to a door alarm and observe for any cognitively impaired residents. The staff will walk the perimeter and observe the driveway to ensure no residents have left the facility unattended. Failure to do so will result in disciplinary action up to/including termination. Staff are to observe residents in house and those who are actively wandering/exit-seeking will be placed on 1:1 observation immediately with a call placed to the Administrator/DON. Nurses will ensure proper follow through when door alarms have sounded in facility. Staff were educated by 8/15/25, and any staff member not educated by 8/15/25 will be educated prior to working their next shift. The facility has educated 94/97 staff members, and the outstanding staff have not worked.17) An ad hoc (for a specific purpose) QAPI (Quality Assurance and Performance Improvement) meeting was completed on 8/14/25, with the Medical Director.18) The Maintenance Director/designee will complete elopement drills weekly x 4 on different shifts, including on the weekend for 30 days, then monthly per TELS (a system used to manage preventative maintenance and work orders) schedule. The Administrator/designee will question 5 staff members per week x 30 days and then monthly x 60 days on the elopement policy/procedure. The Administrator will review elopement drill findings in QAPI monthly x 90 days or until substantial compliance is achieved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake 2575758Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement and ensure safety in 1 of 4 residents (Resident #101) reviewed for safety/supervision, resulting in an Immediate Jeopardy when on 7/20/25 between 7:30 p.m. and 7:45 p.m., Resident #101 exited the facility, unbeknownst to facility staff, and was found by an off duty nurse approximately 0.3 miles away after sustaining a fall. This deficient practice placed all residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include:The facility failed to provide adequate supervision to prevent elopement for an exit seeking resident, Resident #101, who was an elopement risk. Resident #101 was found 0.3 miles away from the facility by an off-duty nurse and bystanders. Resident #101 was lying in an embankment holding onto a traffic cone with a bleeding skin tear on his lower right arm. The EMS (emergency medical services) report noted that Resident #101 was observed by bystanders to be walking in the road, weaving in and out of traffic. The road was 35 MPH (miles per hour) with no sidewalks. The Immediate Jeopardy began on 7/20/25 when the facility failed to supervise Resident #101 and he eloped from the facility between 7:30- 7:45 PM. The Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on 8/6/25 at 1:30 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 8/6/25, but noncompliance remains at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance has not been verified by the State Agency.Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #101's Nursing admission Evaluation dated 7/18/25 indicated that Resident #101 was ambulatory (able to walk), was noted to wander, had two or more predisposing diseases such as Dementia, OBS (organic brain syndrome- a condition characterized by cognitive and behavioral changes caused by damage to the brain), Alzheimer's, Depression, Mental Illness, or Expressive Language Deficits. Resident #101 was cognitively impaired, took 7 or more medications, was a new admission to the facility, and scored 11 or higher on the elopement risk assessment indicating that Resident #101 was at risk for elopement. Resident #101 had a wander guard placed due to elopement risk.Review of Resident #101's Care Plan revealed, (Resident #101) is at risk for elopement R/T (related to) impaired cognition d/t (due to) advanced dementia, elopement score of 12. Date initiated: 7/18/25. Goal: Will not leave the facility unattended through review date. Date initiated: 7/18/25. Interventions: Apply wander guard per order. Wander guard to the left ankle. Date initiated: 7/18/25. Approach in a slow, calm, manner and redirect away from exit doors as needed. Date initiated: 7/21/25. Distract when wandering into inappropriate areas by offering pleasant diversions, structured activities, food, conversations, etc. Date initiated: 7/21/25. Observe wandering behavior and attempted diversional interventions when wandering into inappropriate locations such as other resident room when not invited, behind nurses' stations, shower rooms, attempts at exiting the facility ect date initiated: 7/18/25. Provide reassurance/redirect as needed when in an area resident should not be in. Use calm approach. Date initiated: 7/18/25. Provide structured activities, toileting, walking inside and outside with supervision as needed. Date initiated: 7/18/25 .Review of Resident #101's Progress Notes dated 7/21/25 at 02:06 AM revealed, (Resident #101) observed by off duty RN (Registered Nurse) walking down the sidewalk. Police notified and transported to (Local Emergency Department) to treat and eval (evaluate). All appropriate parties notified. Resident returned to the facility at 22:10 (10:10 PM) accompanied by wife to room. Resident has an abrasion to right elbow. Wander guard to left ankle. Prior to elopement, resident continued with exit seeking. Observed before 1900 (7:00 PM) by receptionist of removal (sic) of wander guard to right ankle. B hall nurse replaced wander guard to left ankle.19:30 (7:30 PM) this nurse had visual redirection of exit seeking on C hall side door and visual of his wander guard in place. All staff was made aware to keep visuals on resident d/t exit seeking. Remains on continued visuals .Review of Resident #101's Incident Report dated 7/20/25 revealed, Allegation Statement: At approximately 8:00 PM, RN II contacted the Administrator (NHA) A to report that she was with a male on the roadside with a wander guard to his ankle. The male (Resident #101) was pleasantly confused and unable to tell the off-duty nurse with what his name was. NHA A contacted the facility to complete a head count while RN II remained with the male. Resident: (Resident #101). BIMS (Brief Interview for Mental Status) score of 2/15 indicating severe cognitive impairment. (Resident #101) was admitted to the facility on [DATE], after being hospitalized for a urinary tract infection. While at the hospital. (Resident #101's) wife requested placement for rehab with intention to transfer to long term care related to his progressing dementia. (Resident #101) is able to ambulate independently without the use of an assistive devices and requires supervision and cueing for ADL'S (activities of daily living) related to his cognition . Action Taken: Administrator (NHA) A contacted the facility to complete a full head count, (Resident #101) was taken to (local emergency department) by EMS (emergency medical services) for evaluation, facility nurse conducted an audit to ensure all wander guards were in place and functioning, facility nurse verified doors were locked and in working order, upon return to the facility, the primary nurse verified (Resident #101) wander guard was functioning properly, upon return from the facility, (Resident #101) was placed on a 1:1 for supervision . Intervention: After investigation, it was determined that (Resident #101) did exit the facility, he sustained no significant injuries, he was sent to the ER (emergency room) by ambulance for evaluation, he returned to the facility, and it was determined that his wander guard was functioning properly. He was placed on a 1:1 for supervision upon return. Conclusion: Root cause of the elopement was determined to be due to the staff turning the alarm off without walking outside the door and checking the perimeter . Review of Resident #101's EMS Prehospital Care Report Summary dated 7/20/25 revealed, Patient (PT) is a . male whose chief complaint is elopement. Patient is a resident at (Facility name), a local skilled nursing facility. POSITION PT FOUND/INITIAL SCENE FINDINGS: Dispatched priority 1 for a male that was walking in the road, weaving in and out of traffic. Arrived on scene of the side of the road to find patient lying supine (face up on back) in the grass. Bystanders state that patient was walking on the road carrying a traffic cone approximately 4 feet tall, then sat on the ground. Patient knows his name but is unable to answer any other questions appropriately .Patient has a small skin rear on his lower right arm, bleeding controlled. The bystander that found patient observed a monitor on patient's right ankle. Bystander reports that she is a nurse at (facility name) and believes that patient may be a patient at (facility name). Nurse called the facility and confirmed that patient is a resident there and staff was unaware that patient had eloped from the facility. Staff reports that they want patient taken to the hospital to be evaluated .In an interview and observation on 8/5/25 at 1:15 PM, NHA A walked outside of the facility with surveyor to show the location which Resident #101 was found by bystanders. This writer walked to the location where Resident #101 was found and noted the location to be 0.3 miles away from the facility. It was noted that there were no sidewalks, and the speed limit of the road was 35 MPH. Resident #101 had crossed the street of the facility. NHA A reported that she was unable to confirm from her investigation how Resident #101 had left the facility, because he was wearing a wander guard, which should have alarmed as he exited the building. NHA A reported that she could not determine if the facility alarm had gone off and staff turned it off without checking for a resident. NHA A confirmed that the facility alarm was not loud enough for staff to hear throughout the entire building and reported that they were looking at quotes to improve the alarm system. NHA A reported that she had been contacted by RN II on 7/20/25 around 8:00 PM, letting her know that she had found a man on the side of the road that had a wander guard on and might have been from the facility. NHA A reported that she called the facility right away to instruct the staff to complete a head count of all residents to determine if anyone was missing. NHA A confirmed that the facility staff were not aware that Resident #101 was missing until staff conducted a head count. In an interview on 8/6/25 at 8:17 AM, RN II reported that she was driving down the road from the facility with her husband on 7/20/25 when they saw two people standing near the road and pointing across the street at a man lying down on the side of the road near the facility. RN II reported that her husband turned around and went back to where the bystanders and man laying down were to see if they needed help. RN II reported that she observed Resident #101 lying on the ground in an embankment next to the road. RN II reported that she could tell from trying to speak with Resident #101 that he was very confused, and that he had told her his name was a name other than what his actual name was. RN II noticed that his arm was bleeding and reported that the bystanders had told her that they observed Resident #101 pick up a traffic cone and tumbled down twice into the embankment, and that they had called 911. RN II reported that she noticed Resident #101 was wearing a wander guard, so she immediately called NHA A to notify her that the facility might have had a resident elope. RN II confirmed that the facility had two doors that would alarm if a wander guard were to pass by them, which were the front door, and the back service door. RN II reported that the alarms for the wander guards were too low, and very hard to hear throughout most of the building. In an interview on 8/6/25 at 2:10 PM, Family Member (FM) KK reported that Resident #101 lived at home with her prior to admitting to the facility. FM KK reported that Resident #101 did wander a lot at home, especially at night, and that he had gone missing from their home before. FM KK reported that she did not know if the facility was aware of how much Resident #101 wandered, but that they did not ask her about his wandering when he was admitted . FM KK reported that she had requested Resident #101 go to a long-term care facility because she was no longer able to care for Resident #101 at home due to his wandering and increased confusion. FM KK reported that she met Resident #101 at the hospital the night that he eloped, and she was with Resident #101 when he returned to the facility. FM KK reported that when Resident #101 entered the facility, his wander guard did not set off the alarms at the facility. FM KK reported that she stayed with Resident #101 until he fell asleep that night, and she did not observe any staff members come assess Resident #101 or his wander guard while she was there. In an interview on 8/6/25 at 8:31 AM, Receptionist P reported that she had been working on 7/20/25 until 7:00 PM. Receptionist P reported that she had observed Resident #101 wandering throughout the lobby that evening, and between 6-6:30 PM, Resident #101 had sat down and removed his wander guard in front of her. Receptionist P reported that she immediately went and got Licensed Practical Nurse (LPN) DD and informed her that Resident #101 removed his wander guard. Receptionist P confirmed that after she left at 7:00 PM, the front doors to the facility were locked, and that an alarm would sound if a resident with a wander guard attempted to exit the facility. In an interview on 8/6/25 at 1:30 PM, LPN DD reported that she was working on 7/20/25 when Resident #101 eloped from the facility. LPN DD reported that she was not the nurse assigned to Resident #101 that evening, but she had been informed by Receptionist P that he had removed his wander guard, so she found Resident #101 in the facility, replaced his wander guard, redirected Resident #101 to his room, and told the nurse that was assigned to care for Resident #101. LPN DD reported that she recalled that Resident #101 was very highly exit seeking that night, and that she had observed Resident #101 attempting to open many facility doors, entering other resident rooms, and walking up and down the halls. LPN DD reported that the last time she recalled observing Resident #101 before he eloped was around 7:30 PM. LPN DD reported that she was passing medications at that time, and she did not recall hearing the door alarm. LPN DD confirmed that the door alarm was not very loud, and that staff were unable to hear the alarm throughout most of the building. LPN DD reported that she had learned that Resident #101 had eloped around 8:00 PM, when staff were informed that they needed to do a head count for all residents because a man had just been found outside of the facility with a wander guard on. LPN DD reported that they did confirm that Resident #101 was missing. In an interview on 8/5/25 at 5:08 PM, LPN HH reported that she was the nurse assigned to care for Resident #101 on 7/20/25 when he eloped. LPN HH reported that Resident #101 was highly exit seeking that night and was all over the place, and you had to keep your eyes on Resident #101 at all times because he was trying to get out of the front door, the service door, and going into other resident rooms nonstop. LPN HH reported that around 7:30 or so, she needed to begin her medication pass, so she had asked Certified Nursing Assistant (CNA) V to watch Resident #101. LPN HH reported that after she had completed a medication administration, she observed CNA V in the day room, and Resident #101 was not near her. LPN HH reported that she asked where Resident #101 was, and that they both began to look for him. LPN HH reported that just a few minutes later, she received a call from NHA A and was informed that they needed to complete a resident head count, and that is when she discovered that Resident #101 had eloped from the facility. LPN HH reported that she did not know why CNA V did not continue to watch Resident #101 when she had instructed her to do so. LPN HH reported that she believed that CNA V was the staff member assigned to care Resident #101 that day. In a follow up interview on 8/6/25 at 11:18 AM, LPN HH reported that she had told all staff working that night that Resident #101 was a high elopement risk and he needed to be watched closely. LPN HH reported that she did not hear the alarms going off at all that night. LPN HH confirmed that the facility alarms were not loud enough to hear throughout the building, and that she felt that many of the staff were de-sensitized to the alarm on the service door because it alarmed so often that staff were just putting in the code to get it to stop alarming. LPN HH reported that she had reported her concerns about the service door alarm to NHA A. LPN HH reported that the facility was not staffed adequately enough to safely supervise Resident #101 the night that he eloped. LPN HH reported that she did not observe Resident #101's wander guard when he returned to the facility from the hospital later that night, but she had scanned his wander guard, and it was noted to be working per the scanner. In an interview on 8/6/25 at 10:39 AM, CNA V reported that she did think she was assigned to care for Resident #101 the night that he eloped from the facility, but that she had been told by LPN HH to keep an eye on him. CNA V reported that she was not aware that Resident #101 was an elopement risk. CNA V reported that she thought that LPN HH meant that Resident #101 was on 15-minute checks, and she had had last observed Resident #101 around 7:00-7:15 PM when she was collecting dinner trays near his room. CNA V reported that when LPN HH found her without Resident #101 she was told that they needed to do a head count because he might have left the facility. CNA V reported that after the staff completed a head count, she found out that Resident #101 had left the facility. CNA V reported that she thought that Resident #101 might have followed a resident's family member out of the facility, because she never heard an alarm. CNA V confirmed that the alarms in the facility were not very loud, and staff were unable to hear the alarms throughout the entire building. CNA V confirmed that Resident #101 was exit seeking prior to his elopement, and that she had observed him wandering the halls, and trying to open all of the facility doors. CNA V reported that she felt that Resident #101 needed 1:1 supervision, and that she did not feel like the facility was staffed to accommodate his needs the night that he eloped. CNA V reported that she did not think that she was supposed to be providing direct supervision for Resident #101 when LPN HH asked her to keep an eye on him the night that Resident #101 eloped. CNA V reported that she was the staff member that opened the facility door when Resident #101 returned from the hospital after he eloped. CNA V reported that Resident #101's wander guard did not alarm when he entered the facility. CNA V reported that she had informed LPN HH that Resident #101's wander guard did not alarm when he entered the facility. In an interview on 8/5/25 at 12:11 PM, CNA EE reported that she had observed Resident #101 attempting to exit the facility and wandering around the building prior to his elopement on 7/20/25. CNA EE reported that was she was by told by LPN HH told at the beginning of her shift that Resident #101 was exit seeking, and that staff needed to watch him. CNA EE reported that she had last seen Resident #101 in the hallway before she went into another resident room, and when she exited that resident's room around 8:00 PM, she was informed that Resident #101 had left the building and was found down the street. CNA EE reported that she did not hear any alarms going off in the facility but reported that could have been because she was in a resident room, and you could not hear the alarms inside a resident room. CNA EE confirmed that she knew Resident #101 was exit seeking, and that he had tried to remove his wander guard earlier in the night. In an interview in 8/5/25 at 12:22 PM, CNA S reported that he was working the night that Resident #101 eloped, but he was not working directly with Resident #101. CNA S reported that he had been told earlier in the shift that Resident #101 was exit seeking, and he had observed Resident #101 wandering around the facility around 6:30-6:45 PM. CNA S reported that he learned that Resident #101 was missing when the facility called a code to count all residents. CNA S reported that he did not know how often staff were checking on Resident #101 that night, and reported that the facility is often short staffed, and unable to adequately supervise residents. CNA S reported that we do the best we can, but there is only so much we can do. CNA S reported that he did not hear any alarms going off, but he would not have been able to hear the alarms if they were going off, because he was in the back of the building, and you cannot hear the alarms from the back of the building. In an interview on 8/6/25 at 7:47 AM, LPN W reported that she was working on 7/20/25 when Resident #101 eloped. LPN W reported that Resident #101 was highly exit seeking and that she had observed him walking around the facility and trying to open doors and entering resident rooms. LPN W reported that Resident #101 needed constant redirection. LPN W was not able to recall the last time that she had observed Resident #101 prior to his elopement from the facility. LPN W reported that she had heard the service door alarm a few times that night but reported that was common and the door would often beep if not closed all the way. LPN W reported that she did not hear the front door alarm, but that she may not have because it was too low to hear in resident rooms or most of the building. In an interview on 8/6/25 at 12:04 PM, CNA J reported that she had worked the night that Resident #101 had eloped from the facility. CNA J reported that she did observe Resident #101 wandering around the facility prior to his elopement and attempting to leave the facility. CNA J reported that she did hear the front door alarm go off once during the night when she went into the hallway to grab a care item, but she was in the middle of caring for a resident, so she did not respond to the alarm, and returned to the resident's room that she was caring for. CNA J reported that when she left the resident's room that she was caring for, the alarm was off, and shortly after that, the facility began a head count because Resident #101 had been found outside. CNA J reported that the facility is often short staffed on nights, which makes it hard to adequately monitor residents such as Resident #101 that are highly exit seeking.In an interview on 8/6/25 at 3:26 PM, CNA D reported that she had worked the night that Resident #101 had eloped, but she was not assigned to care for him. CNA D reported that she had observed Resident #101 wandering throughout the facility that night and recalled LPN HH telling her that all staff needed to keep eyes on him because he was confused and exit seeking. CNA D reported that the last time she had observed Resident #101 was around 6:00 PM, and then around 8:00 PM she had learned that he was missing when the facility called a code to search for him. CNA D reported that she did not hear any alarms go off that night but reported that staff were not able to hear alarms in resident rooms or most of the building. CNA D reported that there had been several occasions where she felt that the facility was not adequately staffed to safely supervise residents with higher acuity needs, such as Resident #101. CNA D reported that the service door would alarm frequently if not shut all the way, and that staff would often have to put in the code to turn off the alarm because staff did not ensure the door was closed all the way. During an observation and interview on 8/5/25 at 3:25 PM with Maintenance Director (MD) Q toured the facility with surveyor to test the wander guards and alarms. MD Q reported that he was not the staff member that was performing audits to ensure that the alarms for the wander guards on the doors were working, and he was not sure if anyone else was. At 3:35 PM, the front door was tested and noted to automatically lock when a wander guard got close to the door. As the wander guard alarm went off, this writer walked down the hallway and noted that the alarm could not be heard past room [ROOM NUMBER] in the first hallway and room [ROOM NUMBER] in the second hallway. It was noted that the area where the alarm could no longer be heard was about halfway down the hallways of the first two halls in the building. At 3:53 PM, this writer and MD Q went to the service door to test the alarm on that door. It was noted that the door was not closed all the way, and when MD Q brought the wander guard to the door, the door remained open and did not alarm as the wander guard passed through the door. MD Q reported that if staff did not ensure that the door was closed all the way, that this error could happen. In an interview and observation on 8/6/25 at 8:33 AM, Director of Nursing (DON) B checked the service door with a wander guard with this writer. DON B showed this writer that if the service door was not closed all the way, but a code had been entered (a code was required to be entered to open the door) that the door had a six second time lapse where a wander guard could go through the door without the door alarming or locking. DON B reported that she did not know if anyone in the facility was auditing the doors to ensure that the wander guard alarms were in working order. In an interview and observation on 8/6/25 at 9:02 AM, Regional Nurse Consultant (RNC) U and NHA A observed the service door with MD Q and this writer. RNC U and NHA A reported that the service door was working as it was supposed to, and that it would be impossible for a resident to exit through the service door with a wander guard because staff had to be available to enter the code for the door to not alarm.The Immediate Jeopardy that began on 7/20/25 was removed on 8/6/25 when the facility took the following actions to remove the immediacy.1. Resident returned from (local) hospital on 7/20/25 at 10:10pm, the front door locks down and requires keypad code to enter/exit. Staff were required to enter code into the keypad in order for resident to enter facility. The door and the wander guard was checked for function when he returned on 7/20/25. 2. 7/20/25. One-on-one was provided to resident until deemed appropriate. 3. Resident POA was notified 7/20/25, Physician was notified 7/20/2025. 4. 7/21/25 IDT met with POA to discuss potential transfer to appropriate locked dementia unit. POA in agreement and is going to visit facilities.5. All doors were tested by nurses and are latching appropriately on 7/20/25. 6. Maintenance Director tested the front door and service hall door and alarms are sounding/door lock down as appropriate when checked with wander guard on 7/21/25. 7. (Local service provider) has sent a quote for replacing the service hall doors 7/21/25, facility is waiting for approval for Capitol improvement request. Doors will be ordered and replaced. The service hall door is locked at all times and requires key pad code entry. The door has been checked for function and closes and locks as intended. The key pad will be replaced which has an improved enunciator to allow staff to hear if alarms are sounding and educated to check to ensure no residents are following them when going through doors on 7/11/25. 8. Staff were educated to provide one on one with actively seeking residents on 7/21/25. 9. Signs were placed on front door to remind families to check that residents are not following them outside when they exit on 7/21/25.10. DON/designee reassessed all residents for elopement risk 7/21/25, no new residents identified. 11. DON/designee checked Wander guards for working order/expiration date 7/21/25, all wander guards in working order. 12. Social Services checked all elopement books for accuracy 7/21/25, all books accurate. 13. DON/designee reviewed care plans for residents with elopement risk 7/21/25, no concerns noted.14. (Local service company) (fire and security) came to facility and assessed wander guard system 7/21/25, no concerns with door safety, noted alarm is not loud, will provide quote to change out the keypads.15. (Local service company) disabled the door release button at the nursing station and at the receptionist desk 7/21/25. Nurses must release doors by inputting code into the keypad when visitors leave. Will observe to ensure this is disabled. Facility provided documentation that (local service company) came to the facility on 7/21/25. 16. Receptionist is scheduled from 7am-7pm to monitor front doors, doors lock at 7pm and unlock at 7am. Staff member is assigned to monitor doors when receptionist is on break/lunch. 17. DON/designee-initiated education 7/21/25 on elopement policy/response to elopement (100% completed by 7/22/25). 18. (Local service company) to provide quote for new wander guard keypad that will increase the enunciator volume. 19, (Local service company) has provided a quote to replace service hall door (7/21/25). 20. The maintenance director/designee will check wander guard doors for functioning 7 days per week. 21. Education initiated 7/21/25, any staff not educated by 7/21/25 will be educated prior to working next shift, 71/94 employees educated 7/21/25. (100% completed by 7/22/25). Staff were educated on elopement policy, responding to alarms, ensuring resident safety and doing exterior observation when responding to the door alarms, key pad code has been changed and maintenance disabled exit release at nurse's station and front desk so that staff have to let visitors out/in after 7 pm ensuring safety of residents and ensuring residents are not exiting with visitors/staff and staff to provide/initiate one-on-one with actively exit seeking residents. Staff will contact DON and/or NHA if there is a need for one on one to assist with adequate staffing.22. DON/designee reeducated licensed nurses on following physician orders, audit tool shift to shift between nurses to ensure MAR/TAR (medication administration record/treatment administration record) is complete and to retrieve the wander guard checker to complete task prior to leaving shift on 8/6/25. An additional Accutech machine is being ordered on 8/6/25 to allow each side of the facility access to an Accutech machine. An Accutech machine has been available and in working condition. The facility provided education to nursing staff on documentation of wander guards, and the expectation to place the resident on 15-minute checks if unable to test wander guard. 23. NHA/DON reviewed the Elopement Policy and deemed appropriate 7/21/25. Resident #104 Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included personal history of traumatic brain injury.In review of the Incident Report dated 7/11/25 for Resident #104 which revealed, (Resident #104) went through the service doors and was retrieved by staff. He was assisted into the building at the front lobby. Resident stated he was going to the store . Wander guard in place and functioning properly .In a follow up interview on 8/6/25 at 12:19 PM, NHA A confirmed that Resident #104 had a wander guard on and was able to make it through the service doors without staff knowing. NHA A reported that she had completed an investigation into the incident and determined that staff did not close the door all the way and ensure that a resident did not follow them. NHA A was not able to provide evidence of her investigation. Review of the facility's Elopement Policy last revised 4/26/222 revealed, Policy: It is the policy of this facility to prevent to the extent reasonably possible, that elopement of guests/residents from the facility . Procedure: The facility will evaluate guest's/resident's risk for elopement upon admission, weekly x 4, quarterly, and with a significant change. Periodic reviews will be completed as deemed necessary by the interdisciplinary team.2. After the Risk for Elopement is completed, and a guest/resident is deemed at risk for elopement, the licensed nurse will: a. Assure the guest/resident has an identification band with guest/resident's name, and facility phone number. b. If the facility has a wandering system, the wandering device will be checked for functionality prior to placement on the guest/resident according to manufacturer's specifications. c. Verification of the placement of the wandering device will be done on each shift and documented on the MAR (Medication Administration Record) by the licensed nurse. d. The Social Worker/designee will create and maintain a current log for all guests/residents that are at risk for elopement. Minimally, this log will be kept at the nursing station, reception desk and/or additional locations as deemed appropriate by the facility's interdisciplinary team. e. Verification of unit functionality will be tested by the midnight shift licensed nurse using wandering testing device and documented on the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #1234842Based on observation, interview and record review the facility failed to identify signs and symptoms of a stroke for 1 (Resident #112) of 3 residents reviewed for change of condition, resulting in an Immediate Jeopardy when Resident #112 did not receive timely medical intervention for a stroke on 7/15/25 who then suffered significant loss of function of her left upper extremity, developing unilateral spatial neglect (condition where a person has difficulty noticing or responding to stimuli on one side of their body), facial droop, and decreased ability to communicate verbally.Findings include:The facility failed to accurately assess Resident #112 for a change in condition on 7/15/25 at 12:00pm when Physical Therapist (PT) JJ reported to Director of Nursing (DON) B that the resident exhibited new onset of left sided weakness, exceptional fatigue and a significant decline in the ability to self-transfer.The Immediate Jeopardy began on 7/15/25 when the facility failed to assess Resident #112 for a change in neurological status despite multiple reports of stroke like symptoms resulting in Resident #112 suffering significant loss of function of her left upper extremity, developing unilateral spatial neglect (condition where a person has difficulty noticing or responding to stimuli on one side of their body), facial droop, and decreased ability to communicate verbally. The Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on 7/17/25 at 12:02pm. The surveyor confirmed by interview, and record review that the Immediate Jeopardy was removed on 7/17/25, but noncompliance remains at a scope of isolated and severity of harm due to sustained compliance has not been verified by the State Agency. Review of Treatment and Intervention for Stroke, www.cdc.gove/stroke/treament/index.html, revealed If you get to the hospital within 3 hours of the first symptoms of an ischemic stroke, you may get a type of medicine called a thrombolytic (a clot-busting drug) to break up blood clots. Tissue plasminogen activator (tPA) is thrombolytic. tPA improves the chances of recovering from a stroke. Studies show that patients with ischemic strokes who receive tPA are more likely to recover fully or have less disability than patients who do not receive the drug.Review of Impact of Time to Treatment on Endovascular Thrombectomy Outcomes in the Early Versus Late Treatment Time Windows, published 2023, https://www.ahajournals.org/doi/10/1161/STROKEAHA.122.040352, revealed The impact of time to treatment on outcomes of endovascular thrombectomy (EVT)(mechanical removal of clot in a blocked blood vessel) especially in patients presenting after 6 hours from symptom onset is not well characterized.increased time from symptom onset to treatment is significantly associated with lower change of independent ambulation and ability to be discharged home.Review of an admission Record revealed Resident #112 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: encounter for surgical aftercare following surgery on the circulatory system, aortic stenosis (narrowing of the valve in the large blood vessel branching off the heart), hyperlipidemia (high cholesterol), history of venous thrombosis (blood clot in a vein) and embolism (blood clot that has broken off and traveled into the blood stream), diabetes mellitus type 2 (condition in which the body cannot use insulin properly to regulate blood sugar levels), and morbid obesity.Review of a Minimum Data Set (MDS) assessment for Resident #112 with a reference date of 7/4/25, revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #112 was mildly cognitively impaired. Section B of the MDS revealed Resident #112 could always make herself understood with verbal expression. Section GG revealed Resident #112 required supervision for rolling side to side in bed.Review of a Care Plan for Resident # 112 with a reference date of 4/2/25, revealed a focus/goal/interventions of: Focus: (Resident #112) is at risk for cardiac complications r/t (related to)multiple cardiovascular diseases: hyperlipidemia, cardiac murmur, recent subaortic membrane resection (open heart surgery), aortic stenosis.Goal: Will be free from s/sx (signs and symptoms) of cardiac complications.Interventions:.observe/document/report to physician PRN (as needed) any s/sx of cardiac distress:.shortness of breath.In an interview on 7/16/25 at 2:31pm, PT JJ reported she conducted a therapy discharge assessment on Resident #112 on 7/15/25. PT JJ reported she had not previously provided therapy to the resident but had reviewed her therapy notes and was told by therapists who knew her well that Resident #112 was nearly independent with most tasks prior to her session on 7/15/25. PT JJ reported she recognized right away that Resident #112 appeared to be struggling with tasks that she had not needed assistance with during her prior therapy session. PT JJ reported Resident #112 did not have functional use of her left arm during the session, appeared exceptionally fatigued and was difficult to understand. PT JJ reported she went to DON B (who was caring for the resident that day) and inquired if Resident #112 had a history of having had a stroke. PT JJ reported she told DON B at that time that the resident appeared to have had a change in condition. PT JJ reported DON B told her to try to reapproach Resident #112 later because she was probably just tired. PT JJ reported she returned to Resident #112 a few hours later and again voiced her concerns to DON B. PT JJ reported during the second therapy session, Resident #112 required maximal assistance of 2 staff to transfer to bed, and she had previously been able to do so with only supervision assistance.In an interview on 7/16/25 at 4:21 DON B reported PT JJ came to her on 7/15/25 and reported Resident #112 had exhibited a change of condition that included left sided weakness during a therapy session that day. DON B reported she didn't notice any changes in the resident but had not cared for her before. DON B confirmed she did not complete a neurological assessment of Resident #112 at that time. DON B DON B reported when she spoke to Resident #112 at approximately 6:15pm on 7/15/25, Resident #112 thought she was having a panic attack and complained of shortness of breath.In an interview on 7/16/25 at 4:00pm, CNA F reported she cared for Resident #112 on 7/15/25 and noticed the resident required assistance of 2 staff to roll her in bed when she had been independent in prior days. CNA F reported Resident #112 also complained of pain but did not voice where the pain was, reported she was having a hard time breathing and she began mumbling and was not able to make herself easily understood. CNA F reported she told RN X that something else was going on, more than just anxiety, with Resident #112. CNA F noted that Resident #112 could not maintain her attention on simple care tasks and had become completely incontinent of urine.In an interview on 7/16/25 at 3:03pm, Registered Nurse (RN) C reported she was orienting to the position of Floor Nurse on 7/15/25 at approximately 5:00pm, when a CNA told her she was concerned about Resident #112 because she did not seem to be herself. RN C reported she did not know what Resident #112's baseline physical abilities were and did not complete a neurological assessment.In an interview on 7/16/25 at 4:41pm, RN X reported he cared for Resident #112 overnight on 7/15/25 into 7/16/25. RN X reported he did not know Resident #112 well and did not assess her during his shift. RN X reported he was told by DON B during a shift change report that Resident #112 was short of breath due to anxiety and had been put on oxygen.In an interview on 7/16/25 at 12:01pm, Registered Nurse (RN) O reported Resident #112 told her she was having the worst headache of her life during the morning medication pass on this date. When further queried, RN O reported Resident #112 said the headache started the previous day.During an observation on 7/16/25 at 9:30 AM, Certified Nursing Assistant (CNA) K assisted Resident #112 with personal cares while the resident was on the toilet. The resident's head was lying to one side onto her shoulder with her left arm limply hanging at her side. CNA K tried several times to have Resident #112 place her hand and arm on the railing next to the toilet while saying, You've got to help me. Put your arm up on the railing. Your head keeps flopping over and your arm is falling off. Pick it up and help me.In an interview on 7/16/25 at 12:21pm, Certified Nursing Assistant (CNA) K reported she provided morning care to Resident #112 early that day, around 9:00am. CNA K reported at that time, she noticed a significant decline in Resident #112's physical abilities in comparison to a previous date that she cared for the resident. CNA K reported during toileting, she noticed Resident #112's left arm was hanging at her side. CNA K reported she placed Resident #112's left hand on the handrail but it just fell off the rail when Resident #112 attempted to use it. CNA K reported Resident #112 appeared pale and lethargic. CNA K she told Licensed Practical Nurse (LPN) Y that something seemed wrong with the resident.In an interview on 7/16/25 at 4:10pm, LPN Y reported she was not the nurse caring for Resident #112 on 7/16/25 but CNA K came to her around lunch time and told her something was wrong with the resident. LPN Y reported she and CNA K could not find RN O, the nurse responsible for providing care to Resident #112 on 7/16/25. LPN Y reported some time around 11:45am, she assessed Resident #112 for possible stroke symptoms and found Resident #112's left arm was flaccid (condition in which the muscles do not contract), and she had no grasp in her left hand. LPN Y got a physician's order to send Resident #112 to the emergency room for further evaluation.Review of a Nurses Note for Resident #112 with a reference date of 7/16/25 at 1:14pm revealed resident assessed and resident stated she had the worst headache she has ever had, some blurry vision, chest pain, looked pale, vitals were all WNL (within normal limits).L (left) sided weakness noted on full left side, resident not able to hold left arm for 10 seconds without dropping, resident has been sent to. ED (emergency department).During an observation on 7/16/25 at 11:57am, an unknown male Emergency Medical Technician (EMT) assessed Resident #112's left sided weakness and stated to Registered Nurse (RN) O She (Resident #112) has had symptoms of a stroke since yesterday. There's nothing the hospital will be able to do for her. Review of Emergency Department History of Present Illness for Resident #112, with a reference date of 7/16/25 at 3:29pm revealed: Patient.presents from (skilled nursing facility name omitted) with concerns for stroke. They noted that patient had some slurred speech left-sided facility drop and left arm weakness.first noticed some left arm weakness yesterday when patient was participating in her physical therapy.Physical Exam: Patient with noted left-sided facial droop some slurring of the speech.does appear to neglect left side.does have weakness involving the left upper extremity.Information Gathering: I did consult (neurologist name omitted).he notes patient is not a candidate for any thrombectomy (removal of clot/blockage within blood vessel), very well outside any TNK (clot-busting medication) window.Final diagnoses: cerebrovascular accident (stroke).Review of a Physical Therapy Treatment Encounter Note for Resident #112 with a reference date of 7/11/25 at 3:21pm revealed Transfer training, toilet transfer at SBA (stand by assistance) .Review of an Occupational Therapy Treatment Encounter Note for Resident #112 with a reference date of 7/14/25 at 12:29pm revealed Patient participates in BUE (bilateral upper extremity) exercise with use of #1 wrist weight, completes 8 reps (repetitions).Review of a Physical Therapy Treatment Encounter Note for Resident #112 with a reference date of 7/15/25 at 12:00pm, revealed transfer training with min (minimal) A (assistance) to mod (moderate) A in bathroom.Comments: Patient is exceptionally fatigued during this session.required more assist than is typical. (DON B) notified of concerns of fatigue, increased assist and questionable decreased use of LUE (left upper extremity) during session.Review of CNA task documentation with a reference date of 7/14-7/15/25 revealed Resident #112 transferred from lying in bed to sitting at the side of the bed with supervision assistance on 7/14/25 at 4:35am. On 7/15/25 at 4:49 PM Resident #112's assistance level increased to needing 2 staff to complete the task. Resident #112 did not require assistance of 2 staff for this transfer any time prior to 7/15/25. Review of CNA task documentation with a reference date of 7/14-7/15/25 revealed Resident #112 transferred from the bed to a wheelchair with set up assistance on 7/14/25 at 4:35am but required assistance of 2 staff for the same transfer on 7/15/25 and 4:50pm and 11:27pm. Resident #112 did not require assistance of 2 staff for this transfer any time prior to 7/15/25.During an observation and interview on 7/17/25 at 8:48am, Resident #112 sat in a wheelchair in her room with her head turned and fixed to the right of midline (imaginary vertical plane that runs from head to toe). Resident #112's left arm and hand were supported on a pillow; her hand was swollen. Resident #112 reported she had a stroke and attempted to raise her left arm to shoulder height. Resident #112 raised her left arm approximately 2 off the pillow in a slow, uncoordinated motion and as she did so, her hand drooped downward and her arm fell back onto the pillow. No functional grip of left hand observed as the resident attempted to make a fist. Resident #112 confirmed she began feeling unwell, weak, and extremely fatigued on 7/15/25. Resident #112 reported she told a few staff members she did not feel well but she was not aware of all the stroke symptoms she was exhibiting at the time. Throughout the interview, Resident #112 spoke with a weak vocal quality and slowed speech. Resident #112 had to repeat herself several times to make herself understood. Resident #112's eye gaze remained fixed to her far right throughout the observation.The Immediate Jeopardy that began on 7/15/25 was removed on 7/17/25 when the facility took the following actions to remove the immediacy. 1. 1. Res #112 was assessed and sent to ER on [DATE] at 1:01pm and returned to the facility at 7/16/25 5:26pm, with a diagnosis of recent acute infarction(stroke). New order for an anticoagulant on readmission. Upon assessment of resident #112 on 7/17/25 with therapy resident is showing improvement.2. 2. DON B/designed completed assessments on all residents for change in condition, with review of progress notes and vital signs.3. 3. Nursing staff were re-educated on resident change of condition and assessing the resident and treatment on 7/17/25. Any licensed nurses will be educated prior to working their next shift.4. 4. CNA's were re-educated on reporting resident symptoms of a potential change of condition on 7/17/25. Any CNA not educated on 7/17/25 will be educated prior to working next shift.5. 5. An Ad Hoc QAPI meeting was held 7/17/25, including the Medical Director regarding review of the facility's process for identifying resident change of condition and documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake 2563197. Based on observation, interview, and record review, the facility to ensure safety and prevent a major injury 1 of 3 residents (R108) reviewed for safety, resulting in an Immediate Jeopardy when, on 7/2/25 at 5:04AM, R108 fell from a transferring position onto an exposed metal bracket at the end of her bed impaling her in the soft tissue of her left buttock entering the rectum cutting it and the anal sphincter and also suffering an open fracture of the pubis ramus. The injured tissues required surgical reconstruction and after complications, placement of an ostomy (surgery that creates a new opening in your body for waste to come out).Findings include:The Facility failed to identify environmental hazards and risks of an exposed bed frame bracket. On 7/2/25 at 5:40 AM, R108, who was a fall risk with two or more previous falls, was found impaled on the exposed bracket of her bed. The facility determined at the time of R108's fall on 7/2/25, there were eight additional resident beds that did not have the foot boards installed. An interview with Plant Maintenance (PM) M revealed the 8 beds did not have foot boards installed when they arrived and that only the bottom bracket where it attached was left on the bed. The Nursing Home Administrator (NHA) A reported not knowing how long the beds had been in use with the exposed bracket in place but added they have been in place longer than I've worked here.The Nursing Home Administrator (NHA) A was notified on 7/15/25 at 2:25 PM of the Immediate Jeopardy on 7/2/25 at 5:40 AM when R108 was found impaled on the exposed bracket of her bed after a fall. The surveyors confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 7/2/25 but noncompliance remained at scope of isolated and severity of actual harm due to maintenance not fully trained in bed maintenance and safety and sustained compliance had not been verified by the state agency. According to the Minimum Data Set (MDS) dated [DATE], R108 scored 9/15 (moderately cognitively impaired) on her BIMS (Brief Interview Mental Status). R108 was occasionally incontinent and had diagnoses that included right artificial knee joint, cognitive communication deficit, and a history of falling. Section J-Fall History on Admission/Entry or Reentry, indicated R108 had two or more falls since admission or prior assessment with no injury. Section GG-Functional Abilities and Goals indicated a wheelchair was used for mobility.Review of R108's Emergency Medical Service (EMS) Run-Sheet dated 7/2/25 revealed, .Dispatch Reason.penetrating trauma.impalement.musculoskeletal/skin.back.trauma injury.fall.sacral-midline.puncture/stab wound.patient was attempting to get out of bed despite being wheelchair bound, when she fell on the L-shaped corner piece of her metal bed frame.On EMS arrival patient was laying on her right side, staff members had lifted her off the metal piece and laid her on the floor. There was a large, coagulated pool of blood.the post had held her up off the floor.Review of R108's 5th District EMS Field Notes dated 7/2/25 reported the resident was impaled by metal bed frame approximately 3-4 inches.Review of R108's Trauma/Surgical Critical Care History and Physical dated 7/2/25 revealed, .brought in as a Tier I Trauma.suffering a mechanical ground-level fall with her left buttock landing onto her metallic bed frame.3 to 4 inches of the exposed bed frame had entered the patient's soft tissue of her left buttock.noted to be fair amount of exsanguination and blood loss.some form of injury to her anal canal or rectum.complaining of left gluteal and buttock pain.Physical Assessment.anorectal 4 cm radial laceration outside the anoderm in the left lateral position with extruding subcutaneous fat and blood.there is a comminuted fracture of the left inferior pubic ramus and ischial tuberosity with surrounding subcutaneous gas.soft tissue hematoma in the left buttock/perineal region.warrant further exploration and endoscopy.admit.Operating today for rectal exam under anesthesia, flexible sigmoidoscopy, possible exploratory laparotomy, possible bowel resection.Review of Investigation authored and provided by NHA A on 7/2/25 reported at approximately 5:40 AM, a nurse was in the hallway near the resident's room and heard a noise. Upon entrance to the room, the nurse noticed the resident had a fall at the end of her bed. The resident was sent to the ER for further evaluation. Once evaluated in the ER, the facility learned that (R108) had a fracture to her left inferior pubic ramus. It was noted the Investigation did not mention the penetrating trauma/impalement of a metal bracket to the resident's buttock that caused bleeding.Review of R108's Care Plan revealed:-10/15/2025, focused on Risk for Decline in Cognition and had impaired cognitive function or impaired thought processes related to and including dementia and cognitive communication deficit. The goal for the resident included having her needs met daily using interventions that included anticipate and meet needs as needed and anticipating needs from non-verbal indicators and past preferences as known.-10/3/2024, focused on Risk for Fall related injury and falls related to history of falls, decreased mobility, weakness, potential for shortness of breath due to COPD, osteoarthritis, and impaired cognition. Goals included the resident was to be free from injury related to falls using interventions that included the wheelchair next to the bed (11/16/24), frequent checks (11/10/24), and keep the resident's environment as safe as possible (10/3/24).-10/10/24 focused on Functional Ability Deficit and required assistance with self-care/mobility related to and included impaired balance, impaired mobility, decreased endurance, decreased standing balance, pain, history of falls and incontinent of bowel and bladder. The goal was self-care with improvement or maintain current level of function using interventions that included dependence on helper for ambulation/walking and bed mobility (substantial/maximal assistance) for lying to sitting on side of bed.During an interview on 7/15/25 at 9:42 AM, Registered Nurse (RN) N stated, The bracket from the end of the bed did not have a footboard. The bracket was impaled in (R108's) right side buttock looking like it was going to rip right through the skin. I don't think she was totally all the way on the floor. The bracket was holding her up off the floor. There was blood on the floor about plate size around her leg to buttock. R108 was a fall risk and was not steady on her own. I do believe she had fallen before. I was assigned to the other side of the building and coming towards the front. I was not asked to give a written witness statement. No one from administration talked to me about the incident.During an interview on 7/15/25 at 10:06 AM, Certified Nursing Assistant (CNA) E stated, I was not working the evening (R108) fell. She did not have a lot of falls. She used to fall but not lately.During an interview on 7/15/25 at 10:38 AM, RN Q stated, (R108) is my family and I work at the facility. (R108) had fallen onto the bracket that was supposed to hold the footboard to her bed. The footboard was not there. The bracket was 6 high. I was told the call light was on, she was able to use the call light baseline cognitively. Her wheelchair was at the end of the bed. She likes to have it by her side so she can use the handrail to help her get up. The metal bracket impaled in (R108's) left buttock. It went 3 into her rectum, it cut her sphincter muscle and cut her anus. The bracket went so far into her it fractured her left buttock bone, pubic rami. (R108's) primary nurse on 7/2/25 told me he and a housekeeping aide manhandled the bed to twist it and get it out of her. They lifted the head of the bed to pull the bracket out of her. (R108) was sent to the ER for evaluation and had surgery to stitch the rectum, anus, and sphincter back together. Two openings were left to drain fluids. (R108) also had a fractured a left pubic [NAME]. The drain did not drain well enough, so a wound vac was applied. She was discharged back to the facility on July 11th (2025). On July 14th (2025), (R108) was covered in stool. The wound vac was unable to work with the amount of stool coming out (R108), and it looked like it was sucking in stool and not fluids. From the path the metal bracket made directly to the pubic [NAME], stool followed it and caused an infection in the fractured bone. The stool was constantly flowing because of the injuries. (R108) had to go back to the hospital for surgery and have a permanent colostomy (a surgical procedure that creates an opening (stoma) in the abdomen through which a portion of the colon is brought to the surface, allowing waste to be eliminated into an external pouch) because the infection went into the bone.During an interview on 7/16/25 at 4:45 PM, RN X stated, I was in a resident room one or two door over from (R108) when I heard a crash. I went into (R108's) room and she was on the floor. She was going down on her right side. When I made my assessment there was something sticking up in her bottom, and it dawned on me it was the metal bracket of the bed. It was sticking up and I could see the shape of the bracket through her skin. It was a judgement call to try to get her off the bracket. I didn't want it to go through the skin and make more bleeding. Housekeeping Aide BB and RN N moved the bed to get (R108) off the bracket. The bracket entered between her butt cheeks. The blood was running out. There was something else that was coming out that looked like fat. It was yellow in color. It was adipose tissue. (R108) was supposed to have help to get up because she was unstable on her feet. That bracket was for a foot board. I think this accident would never have happened if the footboard had been on it like it was supposed to be. Why wasn't the footboard on there? The Administrator did not have me make a written witness statement. I showed the Administrator the bracket. There were metal brackets like the one (R108) fell onto on beds being used by other residents.Review of R108's Progress Note revealed:-7/2/25 5:40 AM, revealed, .a crash was heard.(R108) was observed lying on her right side with her left buttocks impaled on a bracket used to mount a footboard on the bed. The bracket had entered her butt checks and was pressing the lateral side of her buttocks out.the bed was moved to the point where she was no longer impaled.transported to (name of hospital) by ambulance.-7/11/25 8:24 PM, revealed, .arrived to the facility at 4:45 PM.full depth tunneling. 1st opening on side of rectum.2nd opening near labia.-7/14/25 00:00 AM, revealed, fall, fracture, buttock wound.hospitalized from 7/2-7/11 with left buttock wound secondary to inserted bed frame from a fall.left inferior pubic rami fracture.washout in operating room with reconstruction of anal sphincter on 7/2.-7/14/25 5:42 PM, revealed, 2:45 PM wound vac changed to coccyx attempted.soft stool surrounding wound site and drain tube area. Noted drain area on right lower buttock to be sealed shut and area swollen, firm, tender, and warm.resident is painful with direct touch to area. EMS to transport (to ER for evaluation).The Immediate Jeopardy began on 7/2/25 and was removed on 7/2/25 when the facility took the following actions to remove the immediacy:1. On 7/2/25, Resident 108 was assessed for injury post fall, and sent to ER via EMS. Family and Physician notified of incident.2. On 7/2/25 at 9:00 AM, the Maintenance director removed brackets off the bed of Resident 108. There were 8 beds identified that did not have footboards, those beds will be replaced. An order was placed for new beds that arrived 7/15/25.3. On 7/3/25, a new bed was delivered for Resident 108 and installed, the old bed removed.4. On 7/2/25, at 9:15 AM, The NHA and Maintenance director completed an assessment on all beds in the facility for any sharp edges and/or brackets. Any beds with brackets in place were immediately removed. No beds presented with safety issues as of 7/2/25.5. On 7/10/25, The RCC completed a 100% audit on all beds to assess for sharp edges/protruding brackets. There were no beds that presented a safety risk.6. On 7/2/25, education was initiated with staff via Onshift and in person to observe equipment for protruding parts/sharp edges and to report to NHA/Maintenance immediately. Staff are to remove equipment immediately from use and put work order into TELS. Any staff not educated by 7/2/25 will be educated on the next working shift. There were 94 staff members educated via Onshift on 7/2/25, 44 of 94 employees have wet signature for in-person training on 7/2/25.7. On 7/2/25, staff were educated to not alter equipment, including beds, to ensure resident safety. There were 94 staff members educated via Onshift on 7/2/25, 44 of 94 employees have wet signature for in-person training on 7/2/25.8. On 7/2/25, an Ad Hoc QAPI was held to review policy and deficient practice, including the Medical Director.9. Beginning 7/2/25, Maintenance/Designee will conduct a monthly assessment of beds per TELS schedule to assess any broken equipment, protruding/sharp edges ongoing. Audit to include missing equipment/broken equipment. The first assessment completed 7/2/25.10. On 7/2/25, the Maintenance Director completed an Entrapment Log assessment on all beds. Beds that had a discrepancy on the Entrapment Log were resolved by Maintenance on 7/2/25. The maintenance director was re-educated on 7/16/25 on the correct manner in which to conduct and document bed audits to ensure resident safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: #MI00138772. Based on interview and record review, the facility failed to ensure the safety and prevent elopement in 1 (Resident #35) of 4 residents reviewed for accidents/hazards, resulting in an Immediate Jeopardy when Resident #35, who had been assessed as an elopement and fall risk on admission and had a Brief Interview for Mental Status (BIMS) of 9, left the facility unbeknownst to facility staff and was found on [DATE] at 7:25 pm approximately 0.25 miles away at a neighbors residence, across a 35 mph road, after another resident notified the nurse that the wheelchair at the facility exit door belonged to R#35. Findings include: Review of an admission Record revealed Resident #35 was a male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: acute kidney failure, heart failure, chronic obstructive pulmonary disease (a lung disease that results in difficulty breathing), type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood) depression, and other stimulant abuse. Review of a Facility Reported Incident (FRI) report received by the State Agency on [DATE] at 9:08 PM revealed Incident Summary: Resident eloped from facility; full investigation to follow . Review of an Investigation Report received by the State Agency on [DATE] at 10:45 AM revealed, Allegation Statement: On [DATE] at 7:25 pm, a resident, (Resident #35) left the facility unsupervised. The alarm was sounding, his primary nurse, (Registered Nurse (RN) Z) came to the front door to see a wheelchair stuck in the doorway and a group of visitors walking to their car. The nurse stepped outside to check the parking lot; however, she did not see anyone other than the visitors getting into their car. The nurse returned to the facility and asked the nurse in the rehab hallway if the visitors were using a wheelchair. The nurse stated no, at that time a resident came to the nurse to say that (Resident #35) was at the end of the driveway. The nurse and a CNA (Certified Nursing Assistant) went to the end of the drive to assist the resident back to the facility, he refused. The nurse stayed with the resident and was able to redirect the resident back to his wheelchair, then assisted back into the facility. The resident was immediately put on 1:1 (one to one) supervision. Resident: (Resident #35) .BIMS 9 - indicating mild impairment . Review of a Witness Statement Form dated [DATE] and authored by RN Z revealed, Alarm at front door was going off. I went to turn off alarm & (and) empty w/c (wheelchair) @ (at) door. I went out to parking lot. People getting into vehicle. Didn't see anyone else. Came back in & asked (Licensed Practical Nurse (LPN) Y) if she had a person go out in a w/c. She said no. A resident said it was (Resident #35). I and (LPN Y) looked in bathroom. Then went outside. A couple was walking in p/lot (parking lot) toward door & asked if we were looking. They pointed in direction. I ran across parking lot. From top of hill/drive, (referring to the facility's steep driveway with multiple potholes at the bottom of the drive before the incline) I could see (Resident #35) down the street. I called out to him to stop. He did turn around & stop. He said he wasn't coming back. I couldn't make him. Said he had a place to go. Said we weren't doing anything for him. He sat down on the curb. We talked. Explained that we would call daughter. That he needed to talk to management. I called (Unit Manager (UM) J) (no answer). Called Nursing Home Administrator. Explained situation. Contacted 911 to get resident back into building. 2 aids (CNA N and CNA S) and (LPN Y) were outside with me trying to get him in. (CNA N) was able to get him back into w/c & on our side of the street. Police showed up & by then (Resident #35) said he'd come back inside. (LPN Y) & I pushed (Resident #35) in w/c back up hill & then he was reluctant once we got him to the door to go back inside. He stayed in foyer & refuse to leave. Review of Resident #35's Pre-admission Hospital Notes (Hospital Name Omitted) revealed a Progress Note filed [DATE] at 2:49 AM, Upon shift change at 1900 (7:00 PM) patient was very agitated and restless stating that he is going to take off and leave the hospital. RN (name omitted) and RN (name omitted) unsuccessfully attempted to redirect patient. Pt refused all meds and attempts to make more comfortable .Pt (patient) began making statements about self harm. Stating that he did not care if he got hit by a car or died in the ditch. Also stating that he did not want to wake up and had nothing to live for . Review of Resident #35's Admission/readmission Assessment dated [DATE] revealed, .Section E. Elopement Risk Assessment 1. History of Wandering or Elopement a. Elopement attempts at previous residence Yes b. History of wandering at previous residence Yes .d. Has made 1 or more attempts to elope in the past 90 days Yes 2. Delirium Acute reversible confusion a. Caused by medical illness such as infection, diabetes, cardiac problems, oxygen compromise, altered blood chemistry. Yes 3. Adjustment Problems a. Resident makes statements regarding wish to leave, wish to go home .Yes .9. Elopement Risk a. Is the Resident At Risk for Elopement? Yes . Review of Resident #35's Progress Note dated [DATE] at 5:30 PM and authored by Nurse Practitioner (NP) MM revealed, .In the last week and a half the patient has been seen by 2 physicians and his capacity has been determined incapable so they (sic) DPOA (durable power of attorney) may be interacted (sic) . Review of Resident #35's Nursing Progress Note dated [DATE] at 4:25 PM revealed, Note Text: Therapy notified me that (Resident #35) was in the front foyer sleeping on the couch. He had self-transferred to couch. I did a standby assist to make sure he got back to wheelchair and advised him he could head down for dinner. Review of a Resident #35's Care Plan in place on [DATE] revealed a focus of I am at an increased risk for falls r/t (related to) Deconditioning, Gait/balance problems with a date initiated of [DATE]. There was no care planned focus of elopement risk in place on [DATE]. In an interview on [DATE] at 2:09 PM regarding Resident #35's elopement on [DATE], Social Services Manager (SSM) S reported resident #35 had not been safe to be out by himself. SSM S reported Resident #35 had been down the street waiting for a friend to come by when the nurse found him. SSM S reported when a resident is assessed as being at risk for elopement, there should be a care plan in place to that effect. In an interview on [DATE] at 4:37 PM, RN Z reported had last seen Resident #35 approximately 20 minutes prior to his elopement when he took his medications and was assisted to the restroom. RN Z reported she had heard the alarm go off and went to the front entrance door to shut it off. RN Z reported when arrived at the front entrance door, saw an empty wheelchair off to the side so she went outside to look but didn't see anyone other than a family who was getting into their car and thought they had set the alarm off when they exited the building. RN Z reported went to confirm with the other nurse on duty if the family had been using the wheelchair and the nurse said no. RN Z reported there was another resident who had been standing up at the front nurses station who said that the wheelchair belonged to Resident #35. RN Z reported at that time, went to look for Resident #35 in his bathroom and when she realized he was not there, she ran to the door. RN Z reported at that point, there was another couple who was coming into the building across the parking lot. RN Z stated, They could tell I was panicked, and they asked me if I was looking for someone. They told me they had just seen someone go over the hill. RN Z reported located Resident #35 across the street down the road at (House Number omitted). RN Z reported had not called a Code (referring to an Elopement/Missing Resident Code) when realized Resident #35 had left the building. When queried as to how staff would know if a resident was at risk for elopement, RN Z reported they are usually exit seeking or something. When queried as to what type of communication documentation the facility used to alert staff to a resident at risk for elopement, RN Z reported it would probably be in a progress note. RN Z reported there was also a green binder in the front office area but was unsure if or how often staff was supposed to review it. RN Z reported any resident who was ambulatory had the potential to be an elopement risk. RN Z reported a majority of the elopement risks were communicated during shift-to-shift nursing reports. RN Z reported she had not been aware that Resident #35 had been an elopement risk. RN Z reported Resident #35 used to go up to the front lobby by himself and sit on the couch, but If I had known he was an elopement risk, I would not have allowed him to be in the front room. That would not be okay. In an interview on [DATE] at 2:56 PM, Resident #35, who was seated in his wheelchair in his room on the Memory Care Unit, reported he was waiting for his brother to pick him up this afternoon because he shouldn't be here (referring to at the facility). Resident #35 reported he was tired of being at the facility and he is going to walk out again if they can't do something about him being in the Memory Care Unit. Resident #35 reported on the day he got out of the facility, he just walked out by himself. Resident #35 declined to provide any additional details regarding how he was able to exit the facility at that time. On [DATE] at 4:30 PM, Regional Director of Operations (RDO) UU was verbally notified and RDO UU and Nursing Home Administrator (NHA) A received written notification of the Immediate Jeopardy that began on [DATE] due to the facility's failure to prevent the elopement of Resident #35. A written plan for removal for the Immediate Jeopardy was received on [DATE] and the following was verified on [DATE]: * During investigation of elopement on [DATE] the facility identified that the resident did not have proper care planning or interventions in place to reduce risk of elopement for a resident identified as an elopement risk upon admission. * The facility identified that residents residing in the facility were determined to be at risk. On [DATE], the facility assessed all residents for elopement risk and implementation of elopement care plans with appropriate interventions; proper assessments and care plans were implemented if applicable. * The elopement binder was updated on [DATE]. * Education of elopement and wandering policy and care planning of elopement with proper interventions was initiated on [DATE]; any facility staff member and agency staff member who did not receive education by [DATE] will receive education prior to the start of their next shift. All facility staff and agency staff who were present at the time of the incident were immediately educated. As of [DATE], all facility staff and agency staff have completed the necessary required education. Education is completed for all new hires prior to their first shift. * The EVS Director assessed the facility doors for proper function of the alarm system on [DATE]; deemed to be functioning appropriately. * The facility door code was changed on [DATE]. * The Administrator notified the DPOA/daughter of the incident and discussed proper interventions, she agreed with the implementation of the interventions. Law Enforcement, physician and Director of Nursing also notified. * Resident was placed on 1:1 supervision immediately until further interventions could be implemented. * Assessments were completed on the resident to ensure the resident did not experience any adverse effects of the elopement, including skin assessment, pain assessment and vitals signs were obtained. * On [DATE], the care plan for resident #35 was updated with proper interventions to reduce future risk of elopement. * Risk Management report was completed on [DATE]. * Witness statements were obtained by primary care staff on [DATE]. Actions to Prevent Occurrence/Reoccurrence: * The Elopement and Wandering Policy was reviewed by the facility Administrator and deemed appropriate. * Beginning on [DATE], education with facility staff and agency staff was initiated on the Elopement and Wandering Policy. Any facility staff and agency staff who did not receive the education by [DATE] were education prior to the start of their next shift. All facility staff and agency staff who were present at the time of the incident were immediately educated. As of [DATE], all facility staff and agency staff have completed the necessary required education. Education is completed for all new hires prior to their first shift. * Beginning on [DATE], education with licensed nurses was initiated on proper implementation of elopement care plans and interventions. Any facility staff and agency staff who did not receive the education by [DATE] were education prior to the start of their next shift. All facility staff or agency staff who were present at the time of the incident were immediately educated. As of [DATE], all facility staff and agency staff have completed the necessary required education. Education is completed for all new hires prior to their first shift. * Director of Nursing/designee will conduct an audit with three licensed nurses weekly for four weeks and then monthly for three months to ensure understanding of proper implementation of care planning and interventions for resident at risk of elopement, until substantial compliance has been maintained. Results of these audits will be submitted to the QAA committee for review and any further recommendations. * Director of Nursing/designee will conduct an audit with five random staff members once a week for fours week and monthly for three months to ensure understanding of elopement and wandering policy, until substantial compliance has been maintained. Results of the audits will be submitted to the QAA committee for review and any further recommendations. * Residents will be evaluated for elopement risk quarterly beginning [DATE], and as needed, new residents will begin assessment for elopement risk upon admission. The initial assessment and reassessment for all residents is deemed appropriate to capture any other residents that could potentially be at risk for elopement; implementation of possible interventions to reduce occurrence. All licensed nursing staffing have begun receiving education on completing the elopement assessment with proper implementation of interventions. * Results of audits will be reviewed with the QAA committee to ensure compliance and any further recommendations. In an interview on [DATE] at 08:22 AM, RN X reported working at the facility for several years and that the facility had not ever done a educational drill (virtual training) related to the elopements and/or the expectations for staff response to a door alarm that is sounding for an unknown reason. In an interview on [DATE] at 10:18 AM, Housekeeper (HSK) P reported that she had not received any education related to responding to a door that was alarming and reported, .I had some education about a year ago when I first started . HSK P reported that she was informed about Resident #35's elopement and stated, .they didn't talk about door alarms .I didn't get any papers .I had to sign something . HSK P reported that her responsibility if a door alarm was sounding, would be to check to see if there were any residents by the door and then to shut the alarm off. HSK P was not able to verbalize any further steps to ensure all residents were safe and accounted for. In an interview on [DATE] at 10:22 AM, HSK F reported that she thought that someone had talked to her about door alarms when she first started and stated, .I guess I would check the door and then shut the alarm off .I don't think there would be anything else . In an interview on [DATE] at 10:30 AM, Activities Director (AD) Q reported that she was very familiar with the residents that are at risk for elopement, and she would refer to the care plan to verify the elopement risk. AD Q reported that she signed an elopement paper, but when asked what she should do if there was a door alarming, reported that she did not know that answer and would have to go check with someone. Review of the facilities Immediate Jeopardy Abatement Removal Plan dated [DATE] revealed, .Education of elopement and wandering policy and care planning of elopement with proper interventions was initiated on [DATE]; any facility staff member and agency staff member who did not receive education by [DATE] will receive education prior to the start of their next shift . The interviews above from HSK P, HSK F, and AD Q indicate that the educate given was not effective and additional information was requested to removed the immediate jeopardy and ensure the safety of the residents. Addendum [DATE] In response to the survey team not being able to lift the immediate jeopardy, the following steps have been completed: * The Elopement and Wandering Policy was reviewed by the facility Administrator and deemed appropriate. * Re-education of all facility staff and agency staff on the Elopement and Wandering Resident Policy with completion of post-test to ensure retention of information. If a staff member fails to successfully complete the post-test, education will take place immediately to ensure comprehension. * Any facility staff and agency staff who did not receive the education and post-test by [DATE] will be educated prior to the start of their next shift. * Completion of an elopement drill on [DATE] on all shifts to ensure all staff respond appropriately in the event of a missing resident. Then weekly drills for four weeks to maintain compliance. * Elopement binders will be reviewed and updated. * The EVS Director assessed the facility doors for proper function of the alarm system on [DATE]; deemed to be functioning appropriately. * The facility is alleging compliance on [DATE] * As of 2:00 pm on [DATE], 34 facility and agency staff members were educated on the Elopement and Wandering Resident policy and completed a post-test. The remainder of the facility staff and agency staff will be educated and complete a post-test prior to their next shift. * A successful elopement drill was completed at 2:00 pm and the signatures recorded of those in attendance. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of no actual harm due the fact that not all facility staff have received the education and sustained compliance has not been verified by the State Agency.