**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for one (R93) of two residents reviewed for death by neglecting to adequately assess/monitor a resident with an identified change in condition, timely notify the physician of resident's status and timely transfer the resident to a higher level of care, resulting in a delay in identifying and treating the resident with a history of respiratory distress leading to death in the facility. The deficient practice resulted in the increased likelihood of serious harm, serious injury and /or death to occur. Findings include:The Immediate Jeopardy (IJ) began on [DATE] when the facility staff failed to adequately assess/monitor R93 who had an identified change in condition and timely notify the physician of the continued decline.The IJ was identified on [DATE] and the Administrator was notified of the Immediate Jeopardy on [DATE] at approximately 1:47 PM. A plan for removal was requested at that time to remove the immediacy.The surveyor team confirmed by Observation, Interview and Record review that the Immediate Jeopardy was removed on [DATE] based on the facility's implementation of an acceptable plan of removal. The noncompliance remains at an isolated event with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency (SA).A review of R93's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: abscess of lung with pneumonia, COPD (chronic obstructive pulmonary disease) and type II diabetes. A Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was their own responsible party and noted as Full Code status.Continued review of R93's clinical record revealed, in part, the following:[DATE]: admission Evaluation: .R93.Clinical Evaluation.Mental Status: Alert.Orientation: Situation, Place, Person, Time.Clinical Evaluation Respiratory - Lung Sounds .that noted the resident did NOT (emphasis added) display any crackles.Stridor (high-pitched, noisy breathing sound that indicates a partial blockage or narrowing in the upper airway).and Wheezing in the upper/lower right and left lobes.Productive cough description: .coughing up clear mucoid secretions and had 02 running via a nasal canula. Interventions.monitored for signs and symptoms of respiratory distress and report to the MD (medical doctor) PRN (as needed)XXX[DATE]- Nursing Progress Note: Resident alert and responsive oriented X3 received no acute cardiac or respiratory distress 02 (oxygen) at 2L (liter).SP02 (blood oxygen saturation) 96% (normal levels run generally between 90%-100%).XXX[DATE] (late entry)- Physician Team: .visit for continuation of subacute rehab.presenting for continuation of subacute rehab due to.myelopathy (injury to spinal cord).denies SOB (shortness of breath.Medications.albuterol solutions .3ml inhale orally every 6 hours as needed for SOB.XXX[DATE]-Social Work: .her BIMS (brief interview for mental status) score is 14/15, indicating intact cognition.reported that she is on waiting list for subsidized apartments.goal to walk and complete ADLs (activities of daily living).XXX[DATE]: Social Work: .worker reported he spoke with resident.informed him that she plans to remain in the facility for placement until her functional mobility and health status improve.XXX[DATE]: Nursing Progress Note: .Resident returned to the facility from an appointment with (name redacted) in stable condition.No signs of distress.XXX[DATE] (12:06): Physician Team Note: .[R93].Chief Complaint: Upper back-left shoulder pain.respiratory difficulty.hospitalized for COPD.and bacterial pneumonia. reports shortness of breath requiring 2 liters of continuous oxygen.Assessment and plan:.history of COPD.hospitalization for COPD exacerbation with bacterial pneumonia.On physical exam, bilateral wheezes were noted with use of accessory muscles and poor air exchange. Patient is on 2 liters of continuous oxygen.Plan: Start scheduled albuterol nebulizer treatments every 4 hours.Decision made to initiate scheduled nebulizer treatments with albuterol every 4 hours in addition to existing PRN (as needed) inhaler. *It should be noted that following the physician visit on [DATE],no orders for scheduled nebulizer treatments were noted in R93's clinical record.A review of R93's MAR/TAR (Medication/Treatment Administration Record) showed no indication that Albuterol Sulfate was either administered as a PRN (as needed) or scheduled treatment for the entire month of [DATE]XXX[DATE] (1:07 PM): Nursing Progress Note: Resident said she was not feeling well, on assessment she had HR (heart rate) of 138 (average between 60-100 beats per minute), BP (blood pressure) 94/68, SPO2 of 89 with 2l via NC, her 02 was increased to 5L and the NP (nurse practitioner) was informed and she gave an order for .9% Nacl (sodium chloride used to maintain fluid balance) and labs ordered of bmp (basic metabolic panel and cbc (complte blood count) for Monday. (Authored by Nurse Y)[DATE] : Nursing Progress Note: Called Medical Director back concerning this patient. The patient has been seen on IV (intravenous) fluid and half a little gone and she started having crackles in her lungs and she was coughing. She also ordered a STAT chest X-ray and we faxed and called them and it was received. (Authored by Nurse Y)[DATE] (9:41 PM): Order: Chest x-ray to rule of <sic> pneumonia. *It should be noted that a STAT chest order was never completedXXX[DATE] (3:09AM): Nursing Progress Note: At approximately 2:05, writer entered resident's room to administer a scheduled breathing treatment (*it should be noted that there were no orders to administer scheduled breathing treatments at 2:00 AM). Upon entry resident was found unresponsive and not breathing. No pulse was detected. Code Blue was immediately initiated. Resident was last seen at 0100 during hourly rounds. CPR (cardiopulmonary resuscitation) was commenced per facility protocol. Emergency Medical Services (EMS) arrived and assumed resuscitative efforts. CPR continued under EMS supervision. Despite continued effort, resident was pronounced deceased by EMS at 2:50. (Authored by Nurse X). *It should be noted that there was no indication that R93's vitals were taken by Nurse X.On [DATE] at approximately 10:42 AM, a phone interview was conducted with Nurse X. Nurse X reported that they were a LPN (licensed practical nurse), employed for almost one year, usually worked the midnight shift and was no longer employed by the facility. Nurse X did not disclose the reason why they no longer were employed by the facility. Nurse X was then queried as to the death of R93. Nurse X noted that they came to work on [DATE] at approximately 11:00 PM and were informed by Nurse Y that R93 showed signs of a decline (trouble breathing, crackles and wheezing) during the day/evening shift. Nurse X further stated that Nurse Y reported to them that they had contacted the physician twice on the prior shift(s) and that the physician did not want the resident sent to the Hospital. Nurse ‘X noted that they saw R93 when they started the shift and they were breathing hard, and the resident did not seem like herself. Nurse X was asked if they recalled if they ever did a full assessment including vitals between the start of the shift (11 PM and 2:05 AM) as there was no indication in R93's record that it had been completed. Nurse X stated they might have but could not recall when. Nurse X was asked why they decided to provide a scheduled breathing treatment at approximately 2:05 AM as indicated in their note. Nurse X reported that they thought it would help R93 with their breathing. Nurse ‘X was asked when and how they determined there was an issue as to R93's breathing and did it occur at 1 AM as it had been noted that was the last time they were seen, Nurse X could not provide an answer. When Nurse X was asked if they contacted the physician regarding R93 having breathing issues and/or to inform them that the STAT X-ray had not been completed, they replied that they did not contact the physician as Nurse Y told them they did not want the resident sent out to the hospital. Nurse X ended the call by saying they discussed the incident with the Director of Nursing (DON) following the death of R93 but could not provide specific information.On [DATE] at 10:47 AM, Nurse X called back and asked if it would be okay/legal for her to have called 911 on [DATE] even when Nurse Y stated the physician told them not to send R93 to the hospital.A review of Nurse Xs personnel file noted that on [DATE], Nurse X was terminated for taking excessive breaks from facility during shift. Witnessed by the Administrator. *It should be noted that Nurse X did not have any other corrective action documents in their file prior to their termination.On [DATE] at approximately 3:35 PM, an interview was conducted with Nurse Y. Nurse Y reported they were a Registered Nurse (RN) and have been employed for the facility for about a year. Nurse Y was asked about R93 who had exhibited a change in condition on [DATE] and their death on [DATE]. Nurse Y reported that the resident noted they were not feeling well earlier in the day and when they did an assessment, they found an abnormal increase in their heart rate and decline in SP02 levels. They stated that they contacted Nurse Practitioner (name redacted) who ordered labs to be completed and ordered sodium chloride solution. Nurse Y stated that they administered the sodium chloride solution (MAR review shows it was administered at 4:04 PM) and also increased the resident's 02 to 5 L. Nurse Y further reported that the resident's breathing was improved once their 02 was increased. Nurse Y stated that when the sodium (IV) was halfway completed, they heard crackles without the use of a stethoscope and contacted the physician. The physician ordered a STAT x-ray (R93's clinical record indicates an order was completed on [DATE] at 9:41 PM). Nurse Y further reported that during the shift change at approximately 11:00 PM on Friday -[DATE], they informed Nurse X about R93's status, the order for the STAT x-ray and instructed her to contact the physician if x-ray services did not show up and/or if there were any changes to R93s condition. *It should be noted that Nurse Y never reported that the physician/physician extender told her that they should not send the resident to the hospital.On [DATE] at approximately 9:21 AM, an interview and record review were conducted with Medical Director (MD) Z regarding R93's death at the facility. MD Z reported that they were very familiar with R93, aware they had COPD, general wheezing and a history of smoking. However, they were surprised to hear of their death as they had seen them a few days prior and found them to be stable with some continuous wheezing needing addition breathing treatments (*It should be noted that additional scheduled breathing treatments/albuterol was not ordered) . MD Z was asked about being contacted on [DATE] regarding R93 and the need for a STAT x-ray. MD Z reported that while notes/orders indicate they were contacted, most likely facility staff contacted Nurse Practitioner (NP) AA as they were covering the weekend for them. MD Z stated that based on notes that the resident was showing signs of decline, nursing staff should have continued to monitor/ assess the resident and contact them/their extender of any changes. MD Z stated that when nursing staff heard crackles without the use of a stethoscope, most likely R93 had signs of Stridor (term used for noisy breathing that comes from the upper airway and can be heard without the use of a stethoscope) and had it not been resolved and an x-ray was not completed the resident should have been sent to the hospital.On [DATE] at approximately 11:00 AM, an interview was conducted with ADON C as the DON was not available during the Survey. ADON C was asked if they were aware of R93's change in condition and subsequent death. ADON C stated that they were on vacation when the incident happened. ADON C was asked about the facility protocol pertaining to STAT-x rays. ADON C reported that STAT is not always STAT and it depends on the company. When asked if R93 should have been sent to the hospital following noted crackles in their lungs, the ADON reported that most likely they would have sent them out.On [DATE] at approximately 2:29 PM, a phone interview was conducted with NP AA. NP AA reported that they were the on call NP on [DATE] and never saw R93 on that day. NP ‘AA stated that they recalled the order for a STAT x-ray and told the nurse to call back and/or send the resident to the hospital if nothing resolved. They further indicated that they were not contacted by any staff following the call that noted the order for the STAT x-ray.The facility policy titled Abuse (updated [DATE]) was reviewed and documented, in part, the following: .Residents have the right to be free from neglect.The facility will educate its staff.on prohibiting and preventing all forms of.neglect.identifying what constitutes neglect.recognizing signs of neglect.definitions:.Neglect: Failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish.The facility policy titled, Change in Condition Evaluation ([DATE]) was reviewed and documented, in part, the following: General information: An acute change in condition is a clinically important deviation from a resident's baseline in physical.or functional status. Acute changes in condition can occur abruptly, over several hours, or over several days.There are a multitude of tools to assist the Licensed Nurse with evaluating changes in condition.signs and symptoms, vital signs.cardiovascular status evaluation/changes.the nurse may recommend to the practitioner lab and/or radiology results related to the condition and monitoring.shortness of breath.The Immediate Jeopardy that began on [DATE] was removed on [DATE] at 12:44 PM when the facility took the following actions to remove the immediacy, including the following:1. Residents that currently reside in the facility were assessed by licensed nurses on [DATE] to include any acute condition change, lung sounds, and vital signs and stat orders have been completed. Residents that currently reside in the facility are stable with no acute changes noted.2. Nursing staff have been educated on Change of Condition Education and Abuse to include notifying the physician if any residents have a Change of Condition, including any change in respiratory status. Education was completed on [DATE]. A return demonstration has been completed with the nursing staff to ensure nursing staff is aware as to when to notify the physician with a change in condition.3. Nursing staff have been educated on when Stat orders are ordered and not completed within a 4 hour window to notify the physician that the stat has not been completed for further direction on the order. Education has been completed with Nurses by [DATE]. No nurses will work until the education is completed as of [DATE].4. No Nursing staff will work until Education is completed as of [DATE].5. Audits will be conducted by unit manager/designee on 8 residents per a week for 8 weeks to monitor signs of change of condition and to ensure stat orders are completed within a 4-hour window.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00136875 Based on interview and record review the facility failed to prevent the elopement of one resident (R901) of two residents reviewed for elopement, resulting in immediate jeopardy (IJ) when R#901 who was previously identified as an elopement risk and had severe cognitive impairment, exited the building and left the facility premises without staff supervision increasing the likelihood of serious injury, serious harm, serious impairment, or death. Findings include: On 6/1/23, a facility reported incident that was submitted to the State Agency was reviewed and indicated that R901 had eloped from the facility grounds without the knowledge of the facility staff on 5/14/23. On 6/1/23 at approximately 11:50 a.m., R901 was observed sitting in a chair in the main day room. R901 was queried regarding leaving the facility on 5/14/23 and they indicated that they were just passing through and that they were trying to get back to their job at the local TV station. R901 was queried where they were going to go once they got on the bus and they could not provide any specific answers and reverted back to their job at the TV station. On 6/1/23 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and had diagnoses including Dementia, Mild cognitive impairment and Adjustment disorder with anxiety. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 4/23/23 revealed R901 had a BIMS (brief interview of mental status) score of three indicating severely impaired cognition. A review of R901's plan of care revealed the following: Focus-Resident has been identified to be at risk for elopement. Res (resident) asks and seek to go to work [local TV station] or go to the social security office. He is able to ambulate without difficulty. He does exhibit exit seeking behaviors at times. Res has a wander guard in place. Date Initiated: 03/09/2021 .Interventions-· Frequent visual checks throughout each shift. Date Initiated: 03/09/2021 Wanderguard (an alert device to prevent elopement) as ordered. Monitor for placement q (every) shift and check for proper functioning q week .Take photograph of resident to maintain on file for identification purposes with family or resident consent. Date Initiated: 03/09/2021 . A Psychiatry note by the Psychologist with an effective date of 4/2/23 revealed the following: I certify that my clinical findings support that this client/clt is facility bound at this time due to: medical issues and memory issues which makes client unsafe to leave the facility alone and illness requiring supportive devices/special transportation/assistance of another person in order to leave their residence .He still has desires and ambition about going back to work at [local TV station) as an assignment editor (while this is unrealistic, this passion is very therapeutic for him). Note: this is his baseline. He has hx (history) of vascular dementia and high ordered processing issues. His insight into his memory problems are poor and this is longterm care .STM (short term memory) issues evident. Working memory issues evident. He presented w (with)/ confusion. Clt was oriented to person and place. He was not oriented to time. His time perception is poor. His insight appeared poor. Judgment appeared poor . A Nursing note dated 5/14/23 revealed the following: : Resident alert with some confusion, checked vital signs at the beginning of the shift. T(temperature) 98.1, BP (blood pressure) 148/96, P (pulse) 71, R (respirations) 18, SPO2 (oxygen saturation) ;97%, told resident his blood pressure was high, resident state that I should stop messing with the young girls Checked on resident after dinner was served, saw food by the bedside but resident was not in the room. Checked again on resident In about an hour, resident's food was still by the bedside but resident was not in his room. I quickly went to the Main dining room, did not find him, went to [R901's old room] which used to be his room, but he was no where to be found. Rushed to the front desk, where the nursing supervisor was sitting, asked him, if he had seen the resident. The nursing supervisor told me he saw him at door and he let him out. I, then went to [unit on the first floor] told the nurse over there to call code white (W) [code for a missing resident]. The nurse on [first floor nursing unit] nursing supervisor and I went outside looking for the resident. We went to the convenient store by the building and asked the store manager whether he seen the resident, we walked around the building and we could not find him. I came back to the facility, called 911 and gave the police the description of the resident. The police arrived on the facility about the same time the Administrator arrived. The Administrator and I gave the police report and description of the resident. On 6/1/23 a review of the county/probate guardianship verification system revealed R901 had a court appointed legal guardian for being a legally incapacitated individual. On 6/1/23 a review of the facility investigation pertaining to R901's elopement from the facility grounds was reviewed and revealed the following: Investigation Summary: On 5/14/2023 at approximately 7:15PM, the facility called a Code for a missing resident [R901] soon after realizing he was not in his room. [Nurse A] was assigned to resident [R901] and stated that he noticed his tray table was sitting in his room and he was not there. He checked the dining hall as well as his old room. He rushed to the front and discovered another staff had let him out in front. A Code W was called for a missing resident and the staff searched inside and outside of the building. 911 was called and the Administrator who arrived around the same time. [Weekend Nurse Supervisor C] stated he was sitting at the front desk doing some work when resident [R901] approached about going outside. [R901] signed the LOA (leave of absence) book and [Weekend Nurse Supervisor C] let him outside in front. [Weekend Nurse Supervisor C] stated he knows not to let out residents that are high risk for elopement. He stated he thought he was safe to go out and was not aware he was high risk. He also did not hear any Wanderguard Alarms set off. Resident [R901] was listed in the Elopement Binder as a high-risk resident and [Weekend Nurse Supervisor C] did not check the binder per Policy and Procedure. [Weekend Nurse Supervisor C] was placed under suspension immediately pending investigation and later termed due to poor performance .Resident [R901] family stated that he is very [NAME] and knows how to navigate the community, churches, and ask people for bus money to get places. [R901] exited the building at approximately 6:15PM and was discovered missing around 7:15PM when staff paged overhead the Code. [Staff member] called the Administrator at 7:24PM and the police were called around 7:30PM. The Administrator, Police, and daughter/Guardian of [R901] found him at 7:50PM at a bus-stop about a half-mile from the facility near the [Corner of two major roads] .He was wearing his Wanderguard on his right ankle . His-wanderguard Device was tested with the portable testing device but did not set off the alarm near the front door. The wanderguard had past its expiration date, so the anklet was swapped out for a newer device not yet expired . On 6/1/23 at approximately 10:22 a.m., Weekend Nurse Supervisor C (WNS C) was queried regarding R901's elopement on 5/14/23 and they indicated that they had been at the front desk and it was a busy day with visitors coming and going. They reported that they thought all residents at risk for elopement were residing on the second floor and that anyone on the first floor could sign themselves out and leave the facility. WNS C was queried if they had checked the elopement awareness binder at the front desk to see if R901 was elopement risk and they indicated they did not. WNS C was queried if they had heard R901's wandergaurd alert that they were by the door and they indicated they did not and did not see the wanderguard on R901 but that they thought the system might have been broken. WNS C was queried if R901 was permitted to be outside the facility without staff supervision and they indicated that they should not have been and that they were on the elopement program. On 6/1/23 at approximately 10:39 p.m., the Administrator was queried as to why they did not have copies of R901's letters of guardianship in their record and they indicated that they had a new Social Worker and they were starting to get trained on utilizing resources. The Administrator was queried if R901 was permitted to be outside the facility without supervision and they indicated they were not supposed to be and that WNS C should have checked the elopement binder to be aware of R901's status. The Administrator then indicated that education for all staff had been completed on leave of absence and elopement identification process as well as wanderguards being checked for functionality. The Administrator indicated that they were made aware of R901 sitting at the bus stop by their own family member and that the police and themselves arrived to the bus stop at approximately the same time along with R901's guardian to bring R901 back to the facility. The Administrator indicated the facility corrected the deficiency with education, audits, wanderguard device inspections and did a past non compliance with a date of alleged compliance of 5/22/23. On 6/1/23 a facility document titled Elopement Policy was reviewed and revealed the following: 1.0 POLICY-This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk to develop a person centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff . The IJ began on 5/14/23, it was identified by the survey team on 6/1/23 and the facility was notified of the IJ on 6/1/23, and a removal plan was requested. On 6/1/23, the State Agency completed onsite verification that the Immediate Jeopardy was removed on 5/14/23, however the facility remained out of compliance at a scope of isolated and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. On 6/1/23 Removal of the immediacy was confirmed onsite when the facility took the following actions: 5/14/23-Resident #901 was returned to the facility with no injuries by the staff and the police. Resident #901 was cooperative with staff and the Police. 5/14/23-Resident #901 was immediately placed on a 1:1 supervision 5/14/23-the Policy on Elopement was reviewed and deemed appropriate. 5/14/23-Education was initiated with all staff. Education was completed on 5/15/23 of all staff on being able to identify and are aware of the residents who are at risk for elopement with audits also in place. 5/14/23-Staff on shift educated and elopement drills initiated. 5/15/23- All Wanderguard Devices and Wanderguard door alarms were checked to be in proper working order. 5/14/23-All residents were re-evaluated for need for Wanderguard and provided a working Wanderguard Device. All current residents were assessed for elopement risk including those with severe impaired cognition/legally incapacitated. Those at risk for elopement had orders reviewed and the care plan updated to ensure staff is aware of elopement risk. The process for identifying those patients at risk for elopement was completed with education to the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00133024 and MI00133027. Based on observation, interview, and record review, the facility failed to implement effective interventions to prevent elopements for one (R707) of three residents reviewed for elopement, resulting in an Immediate Jeopardy (IJ) when R707, who had severely impaired cognition, a history of eloping through the second story window, and known exit seeking behaviors, eloped through the second story window of their room for the third time, was found a quarter mile away, bleeding from the mouth and arm, in approximately 32 degrees Fahrenheit weather, in the dark, near a highly trafficked road. R707 was taken to the hospital where it was identified that he sustained vertebral (spine) body compression fractures. This had the likelihood to result in serious injury, harm, and/or death. Findings include: Review of two Facility Reported Incidents (FRI) submitted to the State Agency on 11/10/22 revealed R707 eloped from the facility twice on that date (11/10/22). Review of R707's clinical record revealed R707 was admitted into the facility on [DATE] and discharged on 12/1/22 with diagnoses that included: Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R707 had severely impaired cognition and was independent with bed mobility, transfers, and walking. Review of R707's care plans revealed the following: A care plan initiated on 10/11/22 that read, Risk for elopement related dementia process and confusion as evidenced by prior attempts and history of elopement, attempts to get out of building, pulling handles of locked doors. Risk for injury due to wandering behavior throughout facility, observed in others' rooms. The care plan included the following interventions: Frequent visual checks throughout each shift (initiated 10/11/22), ONE ON ONE CARE RT (related to) ELOPEMENT (initiated 11/10/22), Place on timed monitoring if elopement attempts continue (initiated 10/11/22), Provide one-on-one staff monitor if resident appears to be involved in active attempts to elope from the building or unit (initiated 10/11/22), Q (every) 15 minutes check (initiated 11/29/22), Wanderguard as ordered. Monitor for placement q shift and check for proper functioning q week (initiated 10/11/22). Review of R707's progress notes revealed the following: A Behavior Note dated 10/5/22 documented, Received resident up and ambulating with his belongings in hand stating he is going home .Resident paced the hallway with his belongings all through the shift looking for the exit door . A Behavior Note dated 10/6/22 documented, Resident up half the night walking with his belongings wanting to go home, resident was redirected multiple times, resident would go back to room and out again with his belongings. A Psychiatry progress note dated 10/18/22 documented, .(R707) came from a group home where chart indicates he eloped. No behaviors noted per staff . A Nursing - Progress Note dated 11/10/22 at 4:45 PM, written by the Director of Nursing (DON), documented, Patient went out of the building unassisted. He was accompanied into the building by the assigned staff .Wanderguard was put in place. Patient stated that he got out for fresh air and did not want to go anywhere. He was not able to provide any details or answer any more questions 'juts <sic> let me rest. Will you? I am back, ok and I promise I wouldn't do it again' .Wanderguard .is checked every shift . A Nursing - Progress Note dated 11/10/22 at 11:50 PM, written by the DON, documented, Patient stated that he went out through the window. He does not know how he took out the screws to push the window to give him enough access to go through the window. He stated, 'I got out by jumping through the window' .Patient is not one on one around the clock until further notice . Daily progress notes between 11/11/22 and 11/25/22 documented R707 remained on one-on-one supervision and did not have any exit seeking behaviors or elopement attempts. An Incident Note dated 11/25/22 at 5:45 PM, written by the DON, documented, Assigned nurse stated that patient cut off his wander guard .Patient remains on one on one. He did not explain how he cut the wander guard off. A Nursing - Progress Note dated 11/29/22 documented, Resident transferred to (room number) tested positive for COVID. A Nursing - Progress Note dated 11/29/22 at 1:58 PM documented, .Resident is an elopement risk, and during the last part of the shift resident was up and down looking out the window, nurse redirected resident several times which was effective . A Nursing - Progress Note dated 11/30/22 at 7:09 AM documented R707 was on q 15 check (R707 previously received one on one supervision). An Incident Note dated 11/30/22 at 5:26 PM, written by the Administrator, documented, Interdisciplinary Management Team discussion about managing elopement risk with decision to remove the one-on-one sitter due to the resident being COVID positive and transfer to the COVID unit. Resident placed on 15 minutes checks with room located directly across from the Nurse's Station. Window screws were checked by the Administrator with Nurse present and were intact to prevent exiting the windows. A Nursing - Progress Note dated 11/30/22 at 10:10 PM, written by Nurse 'J', documented, .Resident came out of room to Nursing Station at about 7:50 PM, was re-directed back to his room. Resident came out again in about 10 minutes, walking in the Hallway. Resident was again redirected to his room. resident said, 'Good Night' and went to his room. Checked on resident in about 15 minutes and observed him pacing back and forth in his room. Checked on resident at about 8:55pm, this time he was not found in his room. I quickly searched all the rooms on 2 South, resident was nowhere to be found. Came down to the first floor to notify other staff members, called code WHITE (code for missing resident), Called 911 to notify (local police) about the incident. On 12/6/22 at 3:40 PM, an observation was made of the 2 North unit. The double doors that separate the unit from the center hallway required a code to enter or exit the unit. Once the code was entered, there was a 10 second delay where the door could be reopened before the lock was re-engaged. On 12/6/22 at 3:45 PM, an observavtion of R707's room where he resided from 10/5/22 until 11/29/22 when he was transferred to the COVID unit was made. The room was located on the second floor of the facility. A large window was observed to have several screws screwed into the panel where the window would slide open and closed. The screws were partially screwed in vertically to the panel which prevented the window from opening past the screws. However, when pulled, the screws did not appear secure and the panel they were screwed into wiggled and lifted up when the screws were forcefully pulled. A ledge approximately two and a half feet wide was located below the window. The facility parking lot was located outside the window to the north. The facility was located on a highly trafficked road that ran north and south. On 12/6/22 at approximately 5:00 PM, an unobstructed stairway leading to the basement was observed outside and was accessible from the parking lot. On 12/7/22 at 9:05 AM, an interview was conducted with Nurse 'L'. Nurse 'L' was R707's assigned nurse on the day shift (7:00 AM to 3:30 PM) on 11/10/22. When queried about R707's elopement on 11/10/22, Nurse 'L' reported her shift was done and she was not on the unit when it was discovered R707 was outside of the building. Nurse 'L' reported there was a lot going on on the 2 North unit on 11/10/22 and the double doors were propped open often that day due to maintenance being done. Nurse 'L' reported R707 did not exhibit any exit seeking behaviors and usually stayed in his room watching television. Nurse 'L' reported she was downstairs when another staff member brought R707 back into the facility through the front door. Nurse 'L' reported she asked R707 how he got out and he couldn't really say. When queried about the last time Nurse 'L' saw R707 during her shift, Nurse 'L' reported it was between 2:30 PM and 3:30 PM. Nurse 'L' did not see R707 leave the unit during her shift. On 12/7/22 at 9:25 AM, an interview was conducted with Certified Nursing Assistant (CNA) 'M'. CNA 'M' was R707's assigned CNA on the day shift on 11/10/22. When queried about R707's elopement on 11/10/22, CNA 'M' reported she was not in the building when it was discovered R707 left the facility. CNA 'M' reported R707 came out of his room two times during her shift and had his belongings packed in a bag. CNA 'M' reported she redirected R707 to his room each time. CNA 'M' did not report it to the nurse. CNA 'M' reported the last time she saw R707 was around 2:00 PM and he was seated on his bed. CNA 'M' did not see R707 leave the unit during her shift. On 12/7/22 at 8:45 AM, a phone interview was conducted with Nurse 'H'. Nurse 'H' was assigned to R707 on the afternoon shift (3:00 PM to 11:00 PM) on 11/10/22. When queried about R707's elopements on 11/10/22, Nurse 'H' reported she had already started her shift when a nurse brought R707 back to the unit after he was found outside and they placed a Wanderguard on his ankle. Nurse 'H' reported she was seated at the nurse's station which was located across from R707's room when R707 came out of his room with packed bags and stated, 'Let me out of here! My wife is outside.' Nurse 'H' reported she told R707 that he could see his wife the following day and redirected him to his room. Nurse 'H' further explained that about one to two hours later, the assigned CNA (CNA 'I')reported R707 was not found in his room and was brought back by police approximately 30 to 45 minutes after he was discovered missing. When queried about how R707 got out of the building, Nurse 'H' reported she did not see him leave the unit and R707 reported he removed the screws from the window in his room and climbed out from the second story window. Nurse 'H' reported police found R707 several blocks away from the facility. When queried about whether any additional interventions were implemented after R707 exhibited exit seeking behavior during that shift, Nurse 'G' reported no additional interventions were implemented other than checking on him. On 12/7/22 at 8:43 AM, a phone interview was attempted with CNA 'I', but was unsuccessful. On 12/7/22 at 9:35 AM, a phone interview was conducted with Nurse 'J'. Nurse 'J' was R707's assigned nurse on the afternoon shift (3:00 PM to 11:00 PM) of 11/30/22. Nurse 'J' reported he was the only staff member assigned to the 2 South unit which was used for residents who tested positive for COVID-19. When queried about R707's elopement on 11/30/22, Nurse 'J' reported he checked on R707 every 10 to 15 minutes and after dinner R707 came to the nurse's station and asked Where are the girls? Are the girls here?' (It should be noted that prior to this date, R707 had received one on one supervision since 11/10/22). Nurse 'J' reported he told R707 that 'the girls' were not there and it was just him (Nurse 'J') and redirected R707 back to his room. Nurse 'J' reported R707 came back out of his room and asked about the 'girls' and would not go back to his room when redirected. R707 wandered the hallway and then said, 'Good Night' and went into his room and closed the door. Nurse 'J' explained around 8:00 PM or 8:30 PM he planned to provide care to another resident and instead decided to check on R707. At that time, R707 was not found in his room, the bathroom, the adjoining room, or anywhere on the unit. Nurse 'J' reported he went to the first floor of the facility and another nurse called a code white and called 911. Nurse 'J' explained that some staff went outside to look for R707 and he was not on the facility property. A nurse and a CNA then got in their car to look for R707 and found him holding on to a sign at an apartment complex several blocks away, bleeding from his mouth and arm. Nurse 'J' reported the police came to the location resident was found and he was taken to the hospital. When queried about any additional interventions that were implemented when R707 was exhibiting exit seeking behaviors, Nurse 'J' reported he was checking on him every 15 minutes and did not see R707 leave the unit. Nurse 'J' reported he was aware that R707 had climbed out of his window when on 2 North and that he was taken off of one-on-one supervision on 2 South and he was the only staff member assigned. Nurse 'J' reported the Administrator checked R707's window earlier and said it was secure, but later they discovered the screen to the bathroom window was removed and the window was able to be lifted over the screw that was supposed to prevent the window from opening all the way. Review of the facility's investigations into R707's elopements revealed the following: An Investigation Summary conducted for the elopement that occurred on 11/10/22 at 4:05 PM, documented, (R707) was observed in the facility parking lot adjacent to the building at approximately 4:05 PM. He walked back in through the door and staff returned him to his unit and room. History: .diagnoses of Alzheimer's Disease .ambulated independently .He is considered an elopement risk related to dementia process and confusion as well as wandering behavior .(R707) was seen by another resident .around 4:05 PM. She stated she saw (R707) in the facility parking lot. CNA .was covering the front desk when (R707) walked in through the front entrance at 4:09 PM .(R707) was returned to his room under close supervision. The Director of Nursing immediately issued (R707) a Wanderguard bracelet .the doors and alarms were checked to ensure they were intact (Nurse 'L') was assigned to the Memory Care Unit (2 North) at the time of the incident and stated she did not see (R707) leave the Unit or hear any door alarms (It should be noted that Nurse 'L' reported she had left the unit after her shift was over and reported she was no longer on the unit when it was discovered R707 was outside of the facility) .(CNA 'I') stated that he did not observe (R707) leave the unit or hear any door alarms (It should be noted that CNA 'M' was the assigned CNA on the day shift until 3:00 PM) .(R707) was having a good day and went between his room and wandering the unit. He will often take his bag and belongings and walk around looking for the door. He may push on the door but not forcefully try to open it. None of the staff reported seeing (R707) wander through the facility outside of the Memory Care Unit .It was later determined that the resident had exited through his 2nd story window. The resident later articulated he had removed the screw and exited through the window .The investigation showed that the staff were unaware of his exiting via the window because it did not trigger door alarms . An Investigation Summary conducted for the elopement that occurred on 11/10/22 at 10:26 PM, documented, On 11/10/2022 at approximately 10:26 PM, the Administrator came to check on (R707) and the resident was missing .The staff checked the facility and externally around the facility and were unable to locate (R707) .The Administrator contacted (local police department) at 10:31 PM. The resident was found and returned by 10:51 PM walking down the sidewalk within blocks of the facility (It should be noted that the facility is located on a highly trafficked road) .(Nurse 'H') was assigned to the Memory Care Unit at the time of the incident and stated she did not see (R707) leave the Unit or hear alarms for Emergency Exit Doors or the Wanderguard .CNA 'I' was monitoring the resident on the Memory Care Unit from the hallway when (R707) was discovered to be missing. (CNA 'I') thought (R707) to be in his room resting at that time and was shocked since he did not observe (R707) leave the Unit or hear any alarms. None of the staff reported seeing (R707) wander through the facility outside of the Memory Care Unit or hearing any alarms .After returning to the Unit, the Administrator and staff walked the unit with (R707) to observe how he left the Unit. (R707) then clearly articulated that he exited his room window on the 2nd floor by removing the screw, exiting to the ledge and down to a brick wall and then the parking lot. He said he 'wanted some fresh air'. He explained that he is a retired [NAME] and used to lay bricks at high elevations .was placed on One-on-One supervision .The Maintenance Director immediately drove in to reinforce the screws for (R707's) window. He also audited all resident windows in the facility and replaced any screws .The investigation showed that the staff were unaware of his exiting via the window because it did not trigger door alarms or the Wanderguard. Based on the investigation, (R707 exited a few minutes prior to staff discovering he was missing (It should be noted that Nurse 'H' reported in an interview that one to two hours had passed between the time R707 asked to leave the building and when he was discovered to be missing) . An Investigation Summary for the elopement that occurred on 11/30/22 at 8:56 PM documented, On 11/30/2022 at approximately 8:56 PM, (R707) was discovered missing from his room. The facility activated the Emergency Procedure and notified the police. (R707) was found and taken via Emergency Medical Services to the hospital .(R707's) Care Plan stated that he has impaired cognition due to Alzheimer's Disease. He is considered a risk for elopement related to dementia process and confusion as well as wandering behavior. He is a former [NAME] who laid bricks including elevations. He is handy and comfortable with climbing and heights. He attempts to remove screws from windows and exit including climbing from the 2nd story ledge. He also removes his Wanderguard .On 11/30/2022 at approximately 8:56 PM, (Nurse 'J') discovered (R707) was missing from his room. He immediately searched his room and the unit The staff called 911 at approximately 9:00 PM. They notified the Administrator at 9:08 PM who also contacted the police at 9:11 PM .The staff searched inside and outside the building and .located (R707) outside a neighboring apartment complex. He was alert and said they he 'fell' and was bleeding from his right elbow, knees, and mouth. The EMS arrived shortly after at approximately 9:15 PM and took him to the hospital .(R707) tested positive for COVID-19 on 11/30/2022 (Progress notes documented R707 was moved to the COVID unit on 11/29/22) and was moved to the COVID unit. The IDT discussed the move and decided to discharge on e-on-one sitter while on the COVID unit. (R707) was located directly across from the Nurse's Station (it should be noted that R707 was near the Nurse's Station on 2 North, as well) and place on 15-minute checks and only a few patients on the unit. The Administrator checked the screws for the windows were intact due to the elopement risk of exiting windows. (Nurse 'J') was present. (Nurse 'J') stated that he was at the Nurse's Station when (R707) entered his room and closed the door. (Nurse 'J') checked on (R707) momentarily and discovered he was missing. (R707) had been wandering the Unit prior to going missing and (Nurse 'J') redirected him to his room .None of the staff reported seeing (R707) wander through the facility outside the COVID unit or hearing any alarms .The Administrator, Director of Nursing, and the Maintenance Director inspected the Unit and found the window screws were all intact. The screws are checked as part of an ongoing audit. It was noted that the screw for the window in (R707's) bathroom was drilled horizontally through the frame and not vertically like most other windows. When sliding the window, the screw prevented movement beyond 6 inches. With more force the window could be lifted within the frame over the height of the screw and could then be opened wide enough to exit .The screen also had been removed and was discovered on the floor in (R707's) room. The window was found in a closed position. (R707) exited that window to the 2nd story ledge and closed the window behind him. The Administrator walked the 2nd story ledge and found no easy way down to the main level. It appears he somehow lowered himself to a grassy area to absorb the fall .He told the staff he 'fell'. It is unclear if his injuries were from lowering from the 2nd story ledge and/or falling while ambulating at night .The Maintenance Director immediately drilled a vertical screw in the bathroom window .The facility completed an Involuntary Transfer Form due to the high risk of harm (R707) poses to himself and the inability of the facility to prevent .The investigation showed that staff were unaware of his exiting via the window because it did not trigger door alarms or the Wanderguard (It should be noted that by 11/30/22, R707 had exited his room on 2 North two times through the window). Review of a handwritten and signed statement by Nurse 'N' revealed R707 was located R707 holding on to an apartment sign' at cross roads that included the main road the facility was located on and (street name) which was approximately a quarter mile north of the facility. It was documented in the statement that there was a moderate amount of blood noted to mouth, elbows, and knees and R707 was wearing a T-shirt and pants (It should be noted that the temperature on the night on 11/30/22 was approximately 32 degrees F) . On 12/7/22 at 10:17 AM, an interview was conducted with the DON. When queried about how R707 climbed out of the window on 11/30/22 after climbing out twice prior to that date on 11/10/22, the DON reported R707 was taken off of one-on-one supervision when he was moved to the COVID unit because nobody wanted to sit with a COVID positive resident for eight hours a day. The DON further explained there were only four other residents on the unit so they could not justify assigning a CNA to that unit and instead only staffed one nurse (Nurse 'J') on 11/30/22 afternoon shift. When queried about what could have been done to prevent R707 from escaping through the 2nd story window a third time on 11/30/22, the DON reported one-on-one supervision, but he received 15-minute checks. The DON further reported that R707 was able to lift the window over the screw in the bathroom window and open it to climb out. On 12/7/22 at 11:11 AM, an interview was conducted with the Administrator. When queried about the root cause of R707's elopements, the Administrator reported it was due to the screws in the window not preventing the window from opening. The Administrator reported that R707 did not make any elopement attempts while on one-on-one supervision between 11/11/22 and 11/29/22 and after checking the window in R707's room on 2 South after he was moved to the COVID unit we felt the screws were holding so we removed one-on-one supervision. Review of R707's hospital records indicated R707 arrived at the hospital on [DATE] at 9:51 PM and was admitted inpatient on 12/1/22. An ED (emergency department) Provider Note documented R707 reportedly 'escaped' and fell outside. Has done this in the past .He does report nonspecific pain when palpating his low back .R (right) elbow with skin tears .Final Impression: .T12 (12th thoracic - upper back - vertebrae in the spine) and L2 (second lumbar - lower back - vertebrae) Vertebral body compression fractures. Review of a facility policy titled, Elopement Policy dated 8/2022, revealed, in part, the following: This facility ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .adequate supervision will be provided to help prevent accidents or elopements . The Immediate Jeopardy began 11/30/2022, was identified on 12/8/22 at 8:00 AM, the Administrator was notified of the Immediate Jeopardy on 12/8/22 at 8:16 AM and a plan to remove the immediacy was requested. The surveyor confirmed the Immediate Jeopardy was removed on 12/8/22 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team which included: -All current residents were reassessed for the need of one-on-one supervision on 12/8/2022 -Interdisciplinary Team (IDT) which includes Administrator, Director of Nursing, Infection Control Nurse, Wound Care Nurse, and clinical personal were educated by Regional Nurse Consultant on updated facility procedure about initiating and removing one-on-one supervision on 12/8/2022 -The facility will act to implement a new procedure for adding and removing one-on-one supervision which includes approval from the Regional Nurse Consultant/Designee and the Facility Medical Director by 12/8/2022. -Maintenance began the installation of anti-tamper screws with bumpers for windows in resident rooms and resident bathrooms in The Memory Care Unit and will be completed by 12/8/2022. Although the immediacy was removed the facility's deficient practice was not corrected and remained at a pattern with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency.