**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide adequate supervision for 1 of 1 resident (R1), who was at risk for elopement. R1 unknowing left a secured memory care unit and was found outside near the street which resulted in an immediate jeopardy. The facility implemented corrective action and is being issued at past non-compliance. The IJ began on 5/22/23 when R1 exited the building through the screen porch double doors of the secured memory care unit unsupervised. The facility's administrator, director of nursing (DON), and registered nurse clinical coordinator (RCC) were notified of the IJ at 5:37 p.m. on 5/31/23. The facility implemented immediate corrective action on 5/23/23, prior to the start of the survey and was issued as past non-compliance (PNC). Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified diagnoses including dementia (brain disease causing memory loss) and anxiety (condition causing persistent worry or fear). R1 had severely impaired cognition, disorganized thinking and inability to recall recent events. Furthermore, the MDS indicated R1 exhibited wandering behaviors that occurred less than daily but did not identify whether behaviors were significant enough to place R1 at significant risk for getting into a dangerous place. R1 required set-up to limited assistance of one staff to meet activities of daily living (ADLs), was ambulatory without use of assistive devices, but required limited assistance of one staff when ambulating off unit. R1's care plan, dated 1/17/23, indicated R1 was at risk for falls; had impaired cognition with memory loss, decreased attention span, and disorganized thinking. Care plan indicated R1 exhibited wandering and exit-seeking behaviors, and had a history of elopement Care plan interventions for R1 included staff would observe/monitor for changes in behavior, would monitor wandering activity, and would be always supervised when off the unit to reduce the risk of elopement. R1's physician orders, printed on 5/31/23, indicated staff to monitor R1's behaviors related to anxiety and wandering, to determine effectiveness of psychoactive medications (Risperidone, Buspar, and Citalopram). Behavioral assessment, reviewed from 5/17/23-5/31/23, indicated R1 displayed behaviors including being socially offensive towards others, was physically aggressive towards others, refused cares, wandered/paced, hoarding dirty clothing and napkins, rummaging, and going in and out of other residents' rooms without permission. During period reviewed, R1 exhibited behaviors 15 times over course of all shifts, staff provided interventions, R1's behaviors remained unchanged. Elopement risk assessment, dated 1/4/23, indicated R1 was at risk for elopement based upon factors including having a predisposing disease, was ambulatory, had intermittent confusion, took psychoactive medications, had a history of elopement in past 6 months. A fall risk assessment, completed on 3/31/23 and again on 4/16/23, indicated R1 was at risk for falls. The fall risk assessment identified R1 had two falls in past 2 months. Facility incident report, dated 5/22/23 at 8:01 p.m., indicated at approximately 4:45 p.m., licensed practical nurse (LPN)-Z returned to unit following break at 4:45 p.m., observed other staff bringing residents to dining area for dinner meal, heard staff member calling R1's name looking for her. LPN-Z began looking for R1 as well, observed the code keypad on wall next to double doors, marked Screen Porch, had a green colored light, indicating doors were not secured. LPN-Z indicated she was able to get through double doors of Screen Porch, held open both doors to wait for audible alarm to sound, which LPN observed audible alarm did not sound for either door checked. LPN-Z indicated exit from Screen Porch doors led outside of gated area, which R1 would have had access to facility yard, sidewalk, and road. LPN-Z returned inside facility, manually secured with keys both doors of the Screen Porch, ambulated towards front of unit, noted R1 being returned to unit per SW-A and administrator. Facility incident report indicated elopement having occurred on 5/22/23 between approximately 5-5:30 p.m. During a phone interview, on 5/30/23 at 4:32 p.m. family member (FM)-E indicated R1's cognition was poor, required staff assistance and reminders to meet ADL needs, required 1 staff to accompany R1 if going off memory care unit if R1 goes off unit. FM-E reported awareness of R1 displaying behaviors of anxiety, wandering, and exit-seeking; stated prior to recent elopement incident, R1 had attempted to elope one other time approximately 2 years ago. FM-E indicated she had been notified per staff on 5/22/23, R1 had eloped earlier that day from secure memory unit of facility through an unlocked door found, R1 was found outside in front of facility building per staff and was brought back to memory care unit per administrator. FM-E indicated nurse who contacted her informed her following 5/22/23 elopement incident, R1 was placed on 15-minute visual checks per staff and staff had ensured all doors to memory unit were now secured. During an interview, on 5/31/23 at 10:13 a.m., nursing assistant (NA)-A indicated was familiar with R1's care needs. NA-A stated R1 was mainly independent with ADLs, required constant reminders from staff throughout the day to complete ADL tasks, occasionally refused cares, wandered, and tried to open doors on unit frequently, required 1 staff to accompany R1 anytime when going off unit. NA-A stated staff relied upon secured system to ensure doors on unit were locked appropriately. NA-A indicated awareness of R1's care plan needs when wandering or exit-seeking, which included re-direction per staff, engage R1 with an activity. NA-A stated she was informed of R1's recent elopement incident, had occurred on 5/22/23 while NA-A was working in another unit of facility. NA-A reported she had been informed by other staff that R1 was found outside per administrator, unaware of how incident occurred as all doors on memory unit should have been secured. NA-A indicated R1 had an incident of elopement one other time, approximately 1 year ago. NA-A stated since R1's recent elopement on 5/22/23, staff were to check on R1's whereabouts every 15-minutes and all staff needed to complete two courses of elopement re-training online through Relias. While observed, on 5/31/23 at 10:33 a.m., it was noted all four doors to memory unit were secured, visualization of code keypad next to doors were all colored red, indicative of being locked. All doors to memory unit remained secured when tried to manually open. During an interview, on 5/31/23 at 10:48 a.m., maintenance (M)-A indicated maintenance staff were available to take care of maintenance issues, even after business hours, staff aware maintenance could be contacted with emergencies 24 hours per day, 7 days per week; if maintenance concerns arose non-emergently, staff aware to send work order through the TELS computer system. M-A reported doors to memory care unit were secured doors, held closed per magnetic hold, managed by Summit Fire. M-A indicated all secured doors have a code keypad on wall next to doors, required a certain code to unlock secured doors. M-A stated code keypad next to secured doors had a colored button to indicate whether the doors were secured, if button was red in color the doors were secured, if button was green in color the doors were unsecured. M-A reported if secured doors became unlocked, not only would the code keypad button turn green in color, but staff would then need to secure door manually with a key. M-A indicated if a power outage occurs, power outage will automatically unsecure doors to facility, which had occurred recently on 5/21/23, staff aware to lock all doors manually with key to ensure security of doors. M-A reported maintenance staff did not routinely check secured doors, only if a concern was brought to their attention or upon yearly inspection, stated there had never been a problem to check secured doors routinely until recently when a resident had eloped. M-A indicated awareness of an unsecured door on memory unit, Screen Porch doors affected, as a staff member noticed a button on code keypad next to doors on wall was colored green, indicative of doors being unsecured. M-A stated staff notified him of incident right away, staff had manually secured doors by locking them with key, unsecured doors were addressed per maintenance staff the next morning following the elopement incident and ensured to be working appropriately. Since recent elopement incident, on 5/22/23, M-A reported maintenance staff would check and keep a record log to ensure secured doors were working appropriately following a power outage. Maintenance was unsure why the door was not secured, but implemented routing door checks after a power outage and nursing staff to check them on each shift. While interviewed, on 5/31/23 at 11:09 a.m., licensed practical nurse (LPN)-A indicated she had worked on and off at facility for approximately 1 year, was familiar with R1's care needs. LPN-A indicated R1 was mainly independent, needed reminders to complete ADLs, shuffled feet when ambulating and required staff to accompany R1 when off unit for safety. LPN-A reported R1 was known to wander and exit-seek, exhibited sundowning behaviors daily around 3:00 p.m., where R1 became more anxious, confused, agitated, and would occasionally yell at staff and refuse cares. LPN-A reported R1 was at high risk for elopement due to her behaviors and elopement risk assessment completed. LPN-A reported awareness of R1's elopement incident that had occurred on 5/22/23. LPN-A reported when doors became unsecured, a clicking sound could be heard, the button on the code keypad on wall next to doors turned green indicating doors were unsecured. LPN-A indicated awareness if doors on memory care unit were unsecured, staff had to manually lock all the doors with a key, key located at nurse's station in the locked medication cart and notify maintenance. Since R1's 5/22/23 elopement incident, LPN-A also reported staff must visually check on R1 every 15-minutes. During an interview, on 5/31/23 at 11:53 a.m., social services (SS)-A indicated involvement in R1's 5/22/23 elopement incident. SS-A stated when she was leaving work for the day at approximately 4:50 p.m., she had gotten in her car, left employee parking lot, drove around to front of facility building, saw R1 on sidewalk about to approach street area at approximately 4:55 p.m. SS-A reported she immediately stopped car, got out of car, ran over to R1's location to keep R1 from crossing street. SS-A indicated she attempted to assist R1 back to facility, but R1 was resistive, R1 stated she needed to go home to find her kids. SS-A stated she had her cell phone with her, contacted administrator to inform of situation and need for assistance. Administrator immediately responded to assist with R1, administrator conversed with R1, administrator and SS-A assisted R1 back to facility at approximately 5:00 p.m. SS-A reported no injuries noted to R1 upon brief visualization following elopement incident. SS-A initially stated it was unknown how R1 eloped from secured memory unit, through investigation findings, staff determined double doors of Screen Porch had been unsecured, as licensed nurse on unit that day noticed button on code keypad code next to doors was colored in green, indicative of unsecured doors. SS-A reported Screen Porch doors were located outside of the memory care unit's fenced area and if R1 had used those doors to leave facility, R1 would have been able to ambulate on sidewalk or through the paved parking lot towards street in front of facility. SS-A indicated R1 was at risk for elopement as had left secured memory care unit one other time approximately 1 year ago. During an observation on 5/31/23 at 12:48 p.m., together with SS-A and Occupational Therapy (OT)-A, walked the route R1 had approximately taken when left the facility, OT-A measured approximately distance using a measuring wheel. R1 ambulated on uneven terrain including grass, a pavement, rock/sand debris, potholes, a parking lot containing construction equipment, onto a sidewalk that led in front of facility towards a busy street. SS-A identified approximate location site on sidewalk where she had found R1 standing, which was approximately 2 ft away from stepping into a busy street. Total distance measured per OT-A using measuring wheel was 186 yards. While observed, on 5/31/23 at 3:53 p.m., R1 was noted sitting at table in the living/common room area of secured memory unit, R1 was looking at a magazine provided per staff, R1 appeared calm in manner at time. Nursing staff present at nursing station, R1 within nursing staff view. Activity staff member observed occasionally interacting with R1 and other residents in living/common room area. During an interview, on 5/31/23 at 4:50 p.m., administrator indicated involvement with R1's 5/22/23 elopement incident, stated he received a phone call from SS-A at approximately 4:55 p.m., SS-A found R1 unsupervised on sidewalk in front of facility entrance, SS-A requested additional staff assistance to escort R1 back to facility, as R1 was being resistive. Administrator stated he immediately responded to SS-A's request for additional assistance, and able to converse with R1, administrator and SS-A assisted R1 back to facility's secured memory unit at approximately 5:00 p.m. Administrator indicated unawareness of how R1 eloped from secured memory unit, stated he initially believed secured doors to memory unit became unsecured following a power outage on 5/21/23. Administrator stated he had contacted the night nurse who had worked following power outage, night nurse had stated she had checked all doors on memory care unit and all doors were secured. Administrator reported investigation findings of R1's 5/22/23 elopement incident indicated staff had last visualized R1 in memory care unit on 5/22/23 at approximately 4:30-4:45 p.m. as staff were escorting other residents to dining area, staff realized R1 was not present in dining room. Administrator indicated staff in memory care unit immediately began unit room searches looking for R1 and calling out R1's name, LPN-Z working on unit that day noticed the Screen Porch doors button on code keypad on wall next to doors were colored green, indicative of unsecured doors. Administrator stated a staff member was about to leave memory care unit to go outside to look for R1, but administrator and SS-A were returning to memory care unit with R1. Administrator reported R1 had been out of facility unsupervised for no more than 15 minutes. Administrator indicated memory care unit relied on a magnetic-alarm system to ensure security of all doors on unit. Administrator further stated staff should have been trained at time of hire and/or orientation to unit floor on each resident's care plan and maintenance concern process, including what to do if a power outage occurs, staff should have received education to check all secured doors to memory unit as was expected to be performed daily on night shift. Administrator verified R1 should not have been off memory care unit unsupervised. Facility policy, titled Resident Elopement/Resident Missing, reviewed 3/22/23, consisted of all staff responsibility to prevent any resident who attempts to elope. The PNC IJ began on 5/22/23, was removed on 5/23/23, and verified the facility implemented the following actions; -15-minute safety checks for R1 - placed a small picture of R1 behind each nurse's station and at front desk to alert staff if R1 seen outside of secure memory care unit -physician evaluation of R1 to rule out any medical concerns and to further evaluate mental health condition, and medication changes made -created sign off sheets to ensure all doors were secured on memory care unit and required two staff signatures at each change of shift daily -staff completed re-education on elopement.