**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00153910. Based on observation, interview and record review, the facility failed to assess a cognitively impaired resident (R401) after expressing desire to leave the facility and an attempt to exit a back door of the facility on 6/19/25. On 6/23/25 at approximately 8:30 PM, R401 was found after exiting the facility unbeknownst to staff. R401 was located outside the facility in a hospital gown pushing their wheelchair. This resulted in an Immediate Jeopardy due to the facility's failure to identify, assess, and implement interventions to provide resident safety and prevent elopement for residents at risk. The Immediate Jeopardy (IJ) began on 6/19/25. The facility was notified of the IJ on 7/1/25 at 2:30 PM and a removal plan was requested. Findings include: Review of an intake revealed on 6/26/25 an anonymous complainant reported on the evening of 6/23/25 at around 8:30pm, R401 walked out of the front door of the facility, The resident walked out of the facility and continued walking up [NAME] Rd which is the main road. The resident was outside, maybe 10-15 minutes, wearing a hospital gown that opens in the back, pushing her wheelchair. The resident got all the way around to the end of the building. On 6/30/25 at 11:35 AM, the Surveyor observed R401 sitting at the nursing station. R401 was interviewed and said she remembered going outside but did not recall anything else about the incident. Review of nurse progress notes dated 6/19/25 at 6:59 PM, Licensed Practical Nurse (LPN) E documented R401, stated she wanted to go home, I informed (sic) that she is a resident of (Name of Facility). I showed her her room she asked to go back to the nurses station where she was sitting. (R401) She was sitting for 15 minutes and then tried to leave out the back door. Record review noted, R401 was admitted on [DATE] with diagnoses that included fracture of right femur, history of falls, abnormal posture, alcohol dependence with alcohol induced dementia, osteoporosis, chronic kidney disease stage three, glaucoma, and sarcopenia (muscle loss). According to the Minimum Data Set (MDS) dated [DATE], R401 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out 15. A review of R401's care plans revealed no documented evidence of an elopement care plan in place on 6/19/25 when LPN E noted R401 attempted to leave the building. R401's Elopement care plan was initiated on 6/24/25, five days after R401's attempt to exit the building. The Elopement care plan was reviewed and revealed the following: - A revision date of 7/2/25, which documented (R401) is at risk for elopement and/or wandering R/T (related to): decrease in cognition, history of attempts to leave facility unattended, impaired safety awareness. The Elopement was created on 6/24/25. - An intervention for 1:1 supervision on afternoon shift was created on 7/1/25. -An intervention for 30-minute visual checks were created on 7/1/25. -The intervention for wander guard to right ankle was created on 6/24/25. -The intervention for distract resident when wandering into inappropriate areas by offering pleasant diversions, structured activities, food conversation was created on 6/24/25. -The intervention to observe wandering behavior and attempt diversional interventional when wandering into inappropriate locations was created on 6/24/24. Review of R401 elopement assessment, dated 4/19/25, revealed R401 was evaluated as a 0 for elopement risk. Review of R401 elopement assessment dated [DATE], R401 was evaluated as a 7. Seven equates to no elopement risk. R401 was reevaluated on 5/19/25. The results were a 7 no risk. R401 was not evelauted for elopment risk after R401 attempted to exit the facility two times on 6/19/25. Further review of progress notes dated 6/23/25 at 8:28 PM, LPN B documented (R401) Resident attempted to leave. Resident redirected to unit. One on one put in place for resident safety. There was no documentation that R401 had actually left the facility. On 6/30/25 at 12:50 PM, during an interview, the Director of Nursing (DON) denied any residents had eloped from the facility. The DON said there was a resident that had attempted to elope but did not actually elope. Upon further interview the DON confirmed R401 had exited the building and was found in front of the facility. On 6/30/25 at 1:00 PM, the Nursing Home Administrator (NHA) was interviewed. The NHA said they did not consider the incident with R401 to be an elopement because R401 did not leave the premises. The NHA was unable to present any evidence where R401 was found or how R401 exited the building and how long the resident was outside unsupervised. On 6/30/25 at 1:30 PM, certified nurse assistant CNA A was interviewed and confirmed on 6/23/25 after 8PM R401 was observed outside the facility unsupervised in a hospital gown and pushing a wheelchair. CNA A observed R401 outside of the facility while walking to another unit. On 7/1/25 at 9:00 AM, License Practical Nurse (LPN) B was interviewed and said she initially documented in a progress note on 6/23/25 that R401 had attempted to leave the facility. LPN B said she received clarification that R401 was found outside of the facility but did not make an addendum to the original progress note. LPN B said they did inform the Director of Nursing on 6/23/25 that R401 had left the facility and was found outside. On 7/1/25 at 10:05 AM, the Surveyor observed there was no receptionist at the front desk for 15 minutes with multiple visitors entering and exiting the building. This indicated residents could exit the facility unbeknownst to staff On 7/2/25 at 9:28 AM, during a second interview, the DON said there was no investigation into R401's elopement. The DON was queried about staff coverage when the receptionist was on break. The DON said when the receptionist takes a break, they call the unit, and the receptionist desk is left unmanned. On 7/1/25 at 10:30 AM, in a second interview, the NHA was queried about security footage. The NHA said the camera recording system was not functional and was unable to provide evidence of where R401 was located outside of the facility. On 7/2/25 at 11:28 AM, LPN E was interviewed regarding documentation of a nurse's note dated 6/19/25. The nurse's note revealed R401attempted to elope. LPN E explained during the interview that R401 attempted to elope twice on 6/19/25, the first time R401 reached the back door, and the second time approximately 15 minutes later R401 was stopped before reaching the back door. On 7/2/25 at approximately 2:00 pm, the DON and the NHA were informed that R401 had made verbalized leaving the facility with two physical attempts to exit the facility on 6/19/25 without interventions being but in to place. Subsequently, R401 exited the building on 6/23/25 unbeknowst to staff. The DON and the NHA did not provide a response. According to the facility Elopement Policy dated 4/26/22, Elopement occurs when a guest/resident who needs supervision leaves a safe area without authorization .the facility will evaluate guest/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. Upon exiting the facility on 7/2/25 at approximately 3:00 PM no additional information was provided regarding R401's elopement from the facility. Removal Plan. Resident identified to be affected by the alleged deficient practice Resident #R401 was assisted back into the facility on 6/23/25, placed on 1:1 supervision and Q30 minute visual checks Resident #R401 was assessed for Elopement Risk on 6/24/25 Residents with the potential to be affected by the alleged deficient practice. On 7/1/25 the Administrative Nurses reviewed the residents' most recent elopement evaluation to identify the residents who are at risk for elopement o On 7/1/25 the Administrative Nurses reviewed the residents identified at risk for elopement to ensure care planned interventions are in place to prevent elopement Systemic Measures to Prevent Reoccurrence o On 7/1/25 A QAPI Meeting was held to review the root cause of the elopement, with the NHA, the DON, the Medical Director (by phone), the Social Worker the Social Worker, and Unit Managers. o On 7/1/25 The Elopement policy was reviewed and deemed appropriate. Re-education of the staff on the elopement policy began on 7/1/25, staff must be re-educated before they return to work for their scheduled shift. The facility asserts the immediacy was removed on 7/1/25. The Immediate Jeopardy was removed on 7/2/25, based on the facility's implementation of the removal plan as verified onsite on 7/2/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00138511. Based on observation, interview, and record review, the facility failed to fully implement the elopement procedure when an alarm sounded but staff neglected to conduct an adequate search of the facility grounds, resulting in the likely occurrence of a serious adverse outcome to one resident (R101) who had a diagnosis of Dementia, was assessed at risk for elopement related to exit seeking and wandering, and had severely impaired cognition out of three residents reviewed for elopement. A citizen called the facility after Resident #101 (R101) was observed unattended outside of the facility at approximately 7:15 PM about 100 feet from a busy two-lane highway in one direction and a 6-to-7-foot drop into wetlands in the other direction. The Immediate Jeopardy (IJ) started on 7/13/2023 when a door alarm sounded but staff neglected to conduct an adequate search of the facility grounds. The Director of Nursing (DON) was notified of Immediate Jeopardy on 8/10/2023 at 4:51 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 7/14/2023, but noncompliance remained isolated with the potential for harm due to sustained compliance that has not been verified by the State Agency. The Immediate Jeopardy that began on 7/13/2023 was removed on 7/14/2023 when the facility took the following actions to remove the immediacy: - On 7/13/23 at approximately 7:00 pm resident #101 was observed by (Certified Nurse Aide M) sitting in the enclosed courtyard with other residents visiting. - On 7/13/23 at approximately 7:10 pm (License Practical Nurse [LPN] G) responded to Door #8 alarm that was sounding, looked outside and did not see resident #101, turned off the alarm and went to her unit to initiate a resident count. - On 7/13/23 at approximately 7:15 pm a passer-by saw resident #101 falling outside along the sidewalk. [NAME] -by called and notified the receptionist of resident outside. - On 7/13/23 Resident #101 was assessed by (LPN F) with no injury noted and assisted back into the facility at approximately 7:20 pm and was placed on 1:1 staff supervision to maintain safety. - On 7/13/23 at approximately 8:18 pm Physician and Responsible Party were notified of the incident. - On 7/14/23 (LPN G) and (LPN F) received individual education by the DON (Director of Nursing) on the Elopement Policy and to physically check outside surrounding area when responding to sounding door alarms and to announce a Code Search. - On 7/14/23 In-servicing was initiated by (the DON) on the Elopement Policy and response to door alarms and calling of Code Search if door alarming without identification of cause for alarm sounding. Education is continuing until all staff are completed. There are 139 employees out of 155 were re-in serviced by the DON/Designee since 7/14/23. The remaining employees will be educated prior to starting their shift. - On 7/14/23 132 (sic) 10 out of 112 Residents with Physician orders for (sensor alarms) were visually verified for proper placement and function, care plans and care cards have been reviewed and updated as indicated. - On 7/14/23 The (sensor alarm) system and all alarmed doors were checked with no variances noted for proper functioning and will continue daily per the Preventative Maintenance Program by Maintenance Department/Designee. - Continued compliance is being monitored daily through the morning clinical meeting, review of new orders, review of 24 hour report, resident at risk meetings, elopement drills per facility policy and through the facility's quality assurance program. Additional education and monitoring will be initiated for any identified concerns. Date of compliance: 7/14/2023 Findings include: During an observation on 8/10/2023 at 10:08 AM, R101 was observed sitting in a wheelchair near the nurse's station. A sensor bracelet, used to activate an alarm should the wearer exit a door, was observed on R101's right ankle. A review of the clinical record revealed R101 was initially admitted on [DATE] and readmitted on [DATE]. R101's diagnoses included psychotic disorder with delusions, vascular dementia with psychotic disturbance, and adjustment disorder with mixed anxiety and depress mood. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A Risk for Elopement assessment dated [DATE] resulted in a score of 12.0 which determined R101 was at risk for elopement. A physician order dated 7/6/2023 documented, Resident to wear (sensor bracelet) at all times. Review of R101's care plans documented in part the following: - Focus: (R101) is at risk for exit seeking/wandering related to multiple medication conditions including Dementia. Created on 7/3/2023. - Interventions: 1:1 sitter. Created 7/17/2023; (Sensor bracelet) to right ankle. Created on 7/3/2023; Observe wandering behavior and attempted diversional interventions when wandering into inappropriate locations such as other residents' rooms when not invited, behind nurses stations, shower rooms, attempts at exiting facility, etc. Created on 7/3/2023. A review of progress notes documented in part the following: 1. Nurse note of 6/30/2023 at 7:27 PM: Resident is noncompliant with asking for assistance when standing or ambulating. Resident continuously walks without walker or wheelchair throughout the day Resident was brought out to the nursing station to ensure safety and would grow frustrated with sitting in wheelchair and continued to get up out of wheelchair with no walker. 2. Nurse note 7/5/2023 at 6:40 PM: Patient is confused and needs re-direction multiple times during the shift. Patient noted to be using his side table to ambulate in the hallway. Patient instructed on using his wheelchair multiple times. 3. Social service note 7/11/2023: (R101) mentioned he was upset that his wife hasn't been up to visit. He also said that he was feeling abandoned by his family. Psych is following resident. 4. Nurse note of 7/13/2023 at 10:10 AM: Writer approached by social worker that multiple staff members have mention resident needing help to urinate (more frequently than usual). Resident confused and has delirium. Specimen to be collected for US C&S (urinalysis). 5. Nurse note of 7/13/2023 at 7:40 PM (This progress note was created on 7/13/2023 at 9:24 PM.): Resident observed outside, visitor brought back into building. Visitor stated resident fell. Assessment complete, no apparent injuries, no complaint of pain. 6. Nurse note of 7/15/2023 at 10:54 AM: Resident attempted to exit building, writer redirected patient from the door, and turned off the alarm at Door 12. A review of a facility document titled, Summary of Facility Investigation, undated but provided during the survey, documented in part the following: On 7/13/23 at approximately 7:15 PM the (sic) (R101) was observed outside of the building, on the side, by citizen. They stopped to assist the resident related to him falling on the sidewalk. They immediately called the building. The receptionist notified his nurse, (LPN) [Licensed Practical Nurse] F), who went outside to the resident. She assessed the resident than (sic) assisted him into the citizen's car and they drove to the front entrance During interviews and observations on 8/10/2023 beginning at 12:23 PM the Director of Nursing (DON) said at approximately 7:15 PM, R101 went to the restorative dining room in his wheelchair. The dining room was empty. R101 got up out of his wheelchair, opened the exit door, which had a delayed opening, and walked along the fence line. A nurse came, turned off the alarm, looked both ways outside of the door, and did not see the resident. The DON said the resident allegedly fell at the end of the walkway. A citizen driving along the main road, saw the resident on the ground, drove up the driveway, called the facility, and assisted getting the resident back into the facility. The DON said an elopement occurs when a resident leaves the facility without them being aware. The DON said LPN G should have activated the Code Search when the door alarm was activated but did not. When staff responded to the door alarm, someone should have gone out the door to find the resident. If the resident was not visible, then they should have called the Code Search and that did not happen. The facility learned about the missing resident when the citizen called the facility. During an interview on 8/10/2023 at 1:42 PM LPN C stated, I was going to clock off and heard the alarm in the restorative dining room. LPN C said LPN G was already in the dining room and couldn't shut the alarm off because she did not know the code. When LPN G went to get someone to turn off the alarm, I left. LPN C stated, I never looked outside and never even went to the door. During an interview on 8/10/2023 at 2:24 PM LPN G said she was in report with another nurse and heard the alarm for the restorative dining room door. The other nurse (LPN C) was on her way out and told me to turn off the alarm. When I opened the door, I looked one way and then the other and nobody was there. I turned off the door alarm. LPN G said she did not notice an empty wheelchair in the dining room. LPN G stated, I checked my unit, and it was fine. LPN G said she went to the [NAME] unit and was informed that one of their residents had left the building. LPN G said she did not go to the other two housing units, Cherry Hill and Lilly, to notify them to conduct a head count of their residents. LPN G stated, I did not activate 'Code Search' because I was unfamiliar with doing a page overhead for an elopement. I have been educated on the importance of a 'Code Search' even if there is nothing that you notice. During an observation and interview on 8/10/2023 at 3:10 PM of the outside property, Maintenance Director (MD) H estimated the following distances: - From the restorative dining room exit door to the end of the adjoining sidewalk was approximately 100 feet. MD H referred to the area at the end of the sidewalk as a service area in the back of the building. - From the service area in the back of the building to a 6-7 foot drop off into wetlands was approximately 15 feet. - From the service area in the back of the building to the main road in front of the building was approximately 200 feet. The main road in front of the building is a two-lane road with a speed limit of 50 MPH. On 8/10/2023 at 5:00 PM and 5:02 PM respectively, Staff Development Coordinator L and the DON confirmed that neither LPN F or LPN G were listed as receiving the 7/14/2023 training on the elopement policy. Verification of the education on the elopement policy for LPN F and LPN G was requested but not provided prior to the end of the survey day. During an interview on 8/14/2023 at 9:52 AM, the Nursing Home Administrator (NHA) said it was not an elopement if they see a resident leave and we go get him. The NHA acknowledged that those were not the circumstances regarding R101. During a record review on 8/14/2023 at 10:05 AM, the DON provided signed declarations from LPN F and LPN G that they received 1:1 education on 7/14/2023 regarding the elopement policy, responding to door alarms, and calling code search. During an interview on 8/14/2023 at 12:31 PM, LPN F said she was making rounds and checking on her residents when the facility's receptionist came and informed her that a resident was outside. When LPN F went outside, R101 was standing with a citizen. LPN F said the citizen had pulled up in the driveway and R101 and the citizen were positioned halfway between the back of the building and the main road in front of the building. The citizen offered to drive them to the front door. LPN F stated, He drove us to the front entrance, and we got out. (Staff) had a wheelchair and I put (R101) in the wheelchair and took him back into the facility. A review of the facility policy titled, Elopement Policy, dated 4/26/2022, documented in part the following: - Elopement occurs when a guest/resident who needs supervision leaves a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. - Alarm activation. 1. If an employee hears a door alarm, he or she should: a). Immediately go (sic) the site of the alarm; .c.) 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. 2. In situations where the alarm sounds and a guest/resident is not found to have exited: a.) Notify the licensed nurse immediately, and b.) Ensure that a head count is completed to ensure that all guests/residents are accounted for. - Missing Guest/Resident: Check the sign-out form to see if the guest/resident signed out without notifying the staff or left with family if not, call a code Search or designated code for the facility. On 8/14/2023 at 1:45 PM during the exit conference, the NHA and DON did not offer additional documentation or information when asked.