**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure comprehensive assessments were completed and interventions implemented for 1 of 1 resident (R68) who was reviewed for elopement. This resulted in an immediate jeopardy (IJ) when R68 left the facility without supervision and without staff awareness for at least 30 minutes. The facility implemented immediate corrective action and was issued as past non-compliance. In addition, the facility failed to provide proper positioning before eating or supervision while showering for 2 of 3 residents (R70, R37) reviewed for accidents. The IJ began on 8/23/22, at 9:20 p.m. when R68 left the facility the facility without supervision and without staff awareness. The director of nursing (DON) was notified of the IJ on 12/8/22, at 3:41 p.m. The facility implemented immediate corrective action on 8/24/22, prior to the start of the survey and was issued as past non-compliance. Although the immediacy was removed on 8/24/22, the facility remained out of compliance at the scope of isolated and severity of no actual harm with potential for more than minimal harm (D) that was not immediate jeopardy. Findings included: ELOPEMENT During review of the facility's investigation file, it was discovered R68 eloped from the facility on 8/23/22, at 9:21 p.m. when she exited through the emergency exit door; however, when the alarm sounded staff silenced their pagers and did not check the exit door or searched for any missing residents. R68 walked to the independent living facility and was observed standing outside the independent living facility's door seven minutes later (at 9:28 p.m.). The independent living residents opened the door and brought R68 inside. The staff at the long-term care facility were not aware R68 was missing until the independent living staff paged the long-term staff and informed registered nurse (RN)-G that R68 was at the independent living facility. RN-G then called the first floor to have the staff look to see if any residents were missing. RN-G went downstairs to the first floor and observed two of the independent living staff at 9:50 p.m. ambulating with R68. R68's quarterly Minimum Data Set (MDS) dated [DATE], indicated R68 was severely cognitively impaired with diagnoses of closed right femoral neck fracture with routine healing, dementia, and anxiety disorder. R68 was independent with walking in room, walking in corridor, locomotion on unit, and locomotion off unit. The MDS indicated R68 had not exhibited any wandering behaviors. R68's admission MDS dated [DATE], indicated R68 was severely cognitively impaired with a diagnosis of closed right femoral neck fracture with routine healing, dementia, and anxiety disorder. R68 required limited assistance of one staff with walking in room, walking in corridor, locomotion on unit, and locomotion off unit. The MDS indicated R68 had not exhibited any wandering behaviors. R68's discharge summary from Allina Health hospital dated 7/5/22, indicated R68 had a past medical history was significant for advanced dementia and presented to the hospital from a memory care unit. R68's Elopement Risk assessment dated [DATE], indicated R68 had short term memory loss, intermittent confusion, was disoriented to person, place, and time, and had impaired decision-making skills. R68 had wandering behaviors, restlessness, seeking behaviors, desire to go home, and verbalized seeking of things like home, car, people, etc. The Elopement Risk Assessment also indicated R68's care plan was reviewed and updated. R68's care plan dated 7/5/22, indicated R68 was at risk for elopement; however, no interventions were identified to prevent an elopement. R68's Progress Note (PN) dated 7/5/22, at 10:42 p.m. indicated R68's family member (FM)-A informed the facility staff R68 was an elopement risk. R68's PN dated 7/6/22, at 4:33 p.m. indicated FM-A and the social services household coordinator were unable to locate R68 in the gathering room, resident room, or therapy suites. R68 was located in another resident's room laying in bed. FM-A had previously noted R68 was an elopement risk. Further, indicated R68 remained extremely confused. R68's PN dated 7/7/22, at 8:06 p.m. indicated R68 continued to ask to go home and needed frequent orientation. R68's PN dated 7/27/22, at 1:38 p.m. indicated R68 had been wandering into another resident's room and need to be monitored and redirected to not go into the room. R68's PN dated 7/27/22, at 2:52 p.m. indicated R68 continued to wander into another room several times throughout the day and needed to be redirected to her own room. R68's Elopement Risk assessment dated [DATE], indicated R68 did not wander and had not demonstrated any exit seeking behaviors. Further, indicated R68 was low risk for elopement, even though R68 had progress notes that identified wandering behaviors. R68's PN dated 8/2/22, at 5:58 a.m. indicated R68 was observed wandering while well dressed around midnight. R68's PN dated 8/4/22, at 6:13 a.m. indicated R68 got up regularly throughout the night and wandered around. R68's PN dated 8/4/22, at 11:54 p.m. indicated R68 was wandering around, talking irrationally, and attempting to exit the building. R68's PN dated 8/6/22, at 6:23 a.m. indicated R68 was on 30 minute checks; however, the medical record lacked any evidence of the 30 minute checks were completed. R68's medical record lacked any evidence of a new elopement risk assessment being completed after several progress notes indicating R68 was wandering and exit seeking. The care plan lacked any evidence of interventions to prevent R68 from elopement. When interviewed on 12/8/22, at 12:19 p.m. the interim director of nursing (DON) stated the risk for elopement should have been communicated by the admission coordinator when the admission paperwork was screened so the IDT could have put interventions in place to prevent elopement. The interim DON further stated, the expectation was to initiate a care plan with interventions when a resident was identified as an elopement risk. The interim DON verified the care plan had a focus of R68 was an elopement risk, however no interventions were placed to keep R68 safe with her wandering behavior and elopement risk. The Wandering and Elopement policy modified December 2022, indicated information would be obtained from admission assessment, family/resident representative interviews, staff observations and social history. Further, indicated a care plan identifying wandering and elopement risk would be implemented on admission, on quarterly review, and as needed. The past noncompliance immediate jeopardy began on 8/23/22. The immediate jeopardy was removed, and the deficient practice corrected by 8/24/22, after the facility implemented a systemic plan that included the following actions: On 8/23/22, a body audit of R68 was completed which indicated no injuries. This was verified by record review on 12/8/22. On 8/24/22, a new elopement risk assessment was completed which indicated R68 was at risk for elopement. This was verified by record review on 12/8/22. On 8/24/22, R68 was transferred to the secure memory care unit. This was verified by observation on 12/5/22 through 12/8/22 and by record review on 12/8/22. On 8/24/22 through 8/28/22, audits were completed to ensure appropriate staff response to the door alarms. This was verified by record review on 12/8/22. On 8/24/22, the facility reviewed the elopement policy, and no changes were needed. This was verified by record review on 12/8/22. On 8/24/22, the nursing staff were educated on the elopement policy and how to respond to the door alarms. This was verified by staff interviews and record review on 12/8/22. On 8/24/22, the facility requested a quote for a delayed egress system (a system designed to prevent a door from opening immediately when someone attempts to exit) and received the quote on 9/9/22. This was verified by record review on 12/8/22. On 11/23/22, the delayed egress system with an alarm on the emergency exit door was installed. This was verified by observation and record review on 12/8/22. POSITIONING R70's quarterly MDS dated [DATE], indicated R70 was cognitively intact and required extensive assistance of two staff for bed mobility. Further, the MDS indicated no rejection of care or any other behaviors. R70's care plan dated 12/6/22, indicated R70 had an activities of daily living (ADL) deficit related to impaired balance and weakness with an intervention to assist R70 to an upright position for eating and set up the meal on the bedside table. The nursing assistant (NA) team sheets dated 12/5/22, indicated R70 required assist of one staff for repositioning; however, lacked any evidence of how to assist R70 with meal set up or positioning for meals. The NA team sheets updated 12/6/22, indicated R70 continued to require assist of one staff for repositioning and was updated to direct the staff to assist with meal set-up on bedside table and assist resident into an upright position while eating. The Resident Occurrence Report dated 12/5/22, at 12:20 p.m. indicated R70 spilled soup on right neck and right shoulder. Further, indicated the analysis as to cause of occurrence was R70 was in bed eating. The action to minimize reoccurrence was to encourage R70 to get out of bed for meals. The report lacked any evidence of the position R70 was in bed when the soup spilled. R70's progress note on 12/5/22, at 12:22 pm indicated R70 spilled soup on her right side of neck and right upper back. The intervention was to boost R70 up in the bed to finish her meal and applied a cool towel to the area. R70's progress note on 12/5/22, at 9:52 p.m. indicated writer received shift report of resident having redness on right shoulder due to soup spilled. The progress note lacked any evidence of an assessment of the area. During observation and interview on 12/5/22, at 6:00 p.m. R70 informed the surveyor soup was spilled on her right shoulder and pulled her hospital gown over to show the area. The area was red with a serous fluid-filled blister 3 cm in diameter. When the surveyor entered the room R70 was laying flat on her back in bed with her supper plate laying on her stomach. When asked if R70 always ate her meals laying flat [R70] stated, I can't find my bed controller. R70 verified the staff placed her plate on her stomach and did not assist with repositioning. R70's bed controller was found under her right thigh and the call light was on the floor. When interviewed on 12/5/22, at 6:02 p.m. RN-A stated they were aware of R70's incident and the burn, however, wasn't aware of a blister to the right shoulder area. R70's late entry progress note on 12/6/22, at 8:15 a.m. indicated the interim director of nursing (DON) assessed R70's right shoulder and noted a 1.1 cm x 1.1 cm serous fluid-filled blister on the top of the right shoulder and R70 reported tenderness to the area. When interviewed on 12/6/22, at 2:04 p.m. licensed practical nurse (LPN)-D stated when R70 spilled the soup the NA had taken the meal tray into the room and R70 was not positioned in an upright position. Further, stated after R70 spilled the soup when staff boosted R70 up in bed so she was in an upright position. When interviewed on 12/6/22, at 2:26 p.m. the interim DON stated when an incident happens a root cause analysis should be completed, interventions documented on the care plan and team sheets, and each shift nurse monitor the area and update the doctor with any changes as needed. When interviewed on 12/6/22, at 3:09 p.m. the nurse practitioner (NP) stated they were informed of the burn however, wasn't aware of any blisters forming. When interviewed on 12/7/22, at 7:22 a.m. NA-D verified R70's bed was not in an upright position when the soup was given to R70 on 12/5/22. The care plan policy and procedure modified November 2022, indicated the care plan should reflect what the resident desires for himself/herself and include unique interventions which meet the need of the resident. Further, indicated the care plan was to be changed and updated as the care changes for the resident and should be current at all times. SUPERVISION R37's annual MDS dated [DATE], indicated R37 was cognitively intact and required extensive assist of one staff for dressing and personal hygiene. R37's care plan dated 2/17/22, indicated R37 had an activities of daily living (ADL) self-care performance deficit and required one staff participation for bathing and to stay in the shower room with the resident. R37 had limited physical mobility and required one staff assistance until 12/9/22 for ambulation and transfers. The NA team sheets updated on 12/6/22, indicated R37 required assist of one staff for ADL's and the staff were to stay with R37 during the shower. When interviewed on 12/5/22, at 3:34 p.m. R37 stated, my care plan says I'm not supposed to be left unattended in the shower because I'm a fall risk, but they leave me unattended. Last Wednesday the staff left me in the shower alone with my wheelchair sitting right outside the shower with a towel on the arm of the chair. I had to transfer myself being wet and the floor wet to my wheelchair alone. R37 was afraid they would fall. During observation and interview on 12/7/22, at 7:33 a.m. R37 was in the shower room alone with the water off. R37 was wet from the shower and seated in her wheelchair, with no staff in the shower room. R37 stated she was left alone again and had to transfer to her wheelchair alone again. At 7:36 a.m. NA-E entered the shower room and stated, Oh I'm with her, here to help her dry off and get dressed. When interviewed on 12/7/22, at 9:38 a.m. LPN-D stated the NA's should stay with R37 throughout the whole shower according to the care plan. LPN-D verified the NA should assist R37 with washing, drying, and getting back into the wheelchair. When interviewed on 12/7/22, at 9:47 a.m. NA-E stated they were aware R37 required staff to stay throughout the whole shower. NA-E verified leaving R37 alone in the shower stated they had left the room due the need to speak with the nurse. When interviewed on 12/7/22, at 10:12 a.m. LPN clinical coordinator stated when the care plan and team sheets indicate staff should stay in the shower with R37, then the staff should bring all supplies needed and stay throughout the entire shower. When interviewed on 12/8/22, at 3:57 p.m. the interim DON stated the staff should follow the care plan and team sheets and stay with R37 throughout the entire shower. A policy for supervision was requested but not provided.