**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor and notify the physician following a change in condition for one of three residents, (R1) who had multiple episodes of vomiting that began on [DATE] and continued through [DATE] when R1 died. This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE] when R1's had a change in condition was not monitored, nor was the physician notified of R1's change in condition that started on the evening of [DATE] and continued through the morning of [DATE] when R1 passed away. The IJ was identified on [DATE]. The administrator and the director of nursing were notified of the immediate jeopardy at 10:47 a.m. on [DATE]. The immediate jeopardy was removed on [DATE] and the deficient practice was corrected on [DATE], prior to the start of the survey and was therefore past non-compliance. Findings include: R1's face sheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of schizoaffective disorder. R1's additional diagnoses included esophageal varies with bleeding, dysphagia, cognitive communication deficit, schizophrenia, peptic ulcer without hemorrhage or perforation, and personal history of a traumatic brain injury. R1's care plan dated [DATE] did not indicate R1 had a history of gastrointestinal (GI) bleeding, history of vomiting, or concerns with stomach problems. R1's minimum data set (MDS) dated [DATE] indicated R1 required substantial/maximal assistance with dressing and transfers, dependent upon staff for bathing and hygiene, and partial/moderate assistance with oral hygiene. MDS indicated R1 did not experience vomiting. MDS indicated R1 did not reject evaluation or care. R1's provider orders for life-sustaining treatment (POLST) dated [DATE] indicated R1 did not want resuscitation (DNR) if she did not have a pulse and was not breathing. The POLST indicated R1 wanted comfort-focused treatment and to allow natural death. R1's brief interview for mental status (BIMS) assessment dated [DATE] indicated R1 had a score of fourteen, which indicated R1 was cognitively intact. R1's vital sign documentation indicated licensed practical nurse (LPN)-C took R1's vital signs on [DATE] at 9:40 p.m. Those readings included blood pressure was 137/59, oxygen was 97% on room air, pulse was 88, respirations were 18, temperature was 97.8 on the forehead. Normal blood pressure is 90/60 to 120/80. Normal temperature is 97.8 to 99.1. Normal Pulse is 60 to 100. Normal respirations are 12 to 18. Normal oxygen is 95% to 100%. R1's medical record indicated no nursing progress notes for [DATE]. R1's progress note dated [DATE] at 9:02 p.m. indicated R1 stated she did not feel well, had an upset stomach, and refused to eat dinner. R1 had two episodes of vomiting and her abdomen was slightly distended. R1 had a large bowel movement and stated she felt better. The progress note indicated the licensed nurse heard bowel sounds in all four quadrants, blood pressure was 156/72 temperature was 97.8 degrees Fahrenheit, pulse was 85, respirations were 18, and oxygen was at 92% on two liters of oxygen. The note indicated licensed nurses would continue to monitor R1. R1's medical record indicated no nursing progress notes for the remainder of [DATE] nor the morning of [DATE] until 6:17 a.m. R1's electronic medication administration record (eMAR) dated [DATE] at 5:22 a.m. indicated R1 was vomiting. R1's medication administration record (MAR) dated [DATE], indicated R1 was to receive omeprazole at 6:00 a.m. but LPN-A documented 9 which meant other-see nursing note. R1's progress note dated [DATE] at 6:17 a.m. indicated R1 refused to have her incontinent brief changed. R1's progress note dated [DATE] at 10:24 a.m. indicated the director of nursing (DON) arrived and checked on R1, noting black emesis after postmortem care was completed. The DON swabbed R1's mouth, washed her face, helped the nursing assistants (NA) change her bedding, and notified the funeral home that R1 was ready to be transferred to the funeral home. R1 left the facility at 12:30 p.m. R1's progress note dated [DATE] at 2:42 p.m. indicated a NA reported to the licensed nurse at 7:30 a.m. that R1 had vomited when the NA was getting her up for the morning. The licensed nurse responded immediately and found R1 in her wheelchair and leaning forward with a NA supporting R1's back. The vomit looked coffee in color and smelled metallic. The licensed nurse asked NAs to put R1 back to bed for a better assessment. R1's vital signs were checked but were not reading and the licensed nurse placed a call to emergency services regarding R1's condition. The paramedics arrived around 8:30 a.m. and they pronounced R1 deceased . R1's emergency medical services (EMS) report dated [DATE] indicated EMS received a call at 8:07 a.m. indicating EMS staff was called for someone who was vomiting. The report indicated EMS arrived at the facility at 8:14 a.m. and got to R1 at 8:20 a.m. Upon arrival, EMS noted R1 was in her bed in her room with a towel tucked in her shirt and had black emesis on the towel and on her shirt. Facility staff stated that a nurse went to check on R1 and was found that she was not speaking when she usually spoke. The facility staff reported R1 had been vomiting. The report indicated facility staff gave EMS staff paperwork, including R1's POLST form. The last time facility staff checked on R1 was at 7:30 a.m. and had not spoken since that time. EMS staff noted R1 to be pale, cold to the touch, did not find a radial or carotid pulse, and was not breathing. Rigor had not set in yet as R1's jaw was malleable. EMS staff noted R1 to be a DNR and therefore had not started cardiopulmonary resuscitation (CPR). EMS placed a four-lead electrocardiogram (ECG) on R1 at 8:26 a.m. to assess R1's cardiac rhythm and determined R1 deceased . During an interview on [DATE] at 8:49 a.m., NA-C stated he worked with R1 on [DATE]. He asked R1 if she wanted to get up for the day and she verbally said yes. He asked R1 if she could grab the grab bars on her bed to assist herself in turning over so that NA-C could change her incontinent brief and she did. R1 usually said more in the mornings and could usually verbalize what she wanted. Once he got R1 in her wheelchair, she began vomiting black coffee stuff and he reported R1's vomiting episode to LPN-E. NA-C stated LPN-E went to R1's room and then she called EMS. When LPN-E called EMS, trained medication assistant (TMA)-A attempted to take R1's vital signs. Once paramedics got to the facility, they had pronounced her deceased . During an interview on [DATE] at 10:49 a.m., nurse manager (NM)-A stated her expectation is licensed nurses would notify the physician after every change in condition episode. She would be concerned about a change in condition when R1 was not feeling good on [DATE], she was vomiting on [DATE], and then died. She was unsure whether the licensed nurses notified the physician about R1's episode of vomiting overnight on [DATE] into [DATE]. NM-A stated she would expect the licensed nurse to notify the physician about a change in condition when the change in condition happens. She considered episodes of vomiting on and off for months a change in condition and the physician should be notified. NM-A stated she did not get a report on [DATE], [DATE] or [DATE] that R1 had been vomiting. NM-A stated she usually received a report about the residents when a change in condition happened. During an interview on [DATE] at 11:16 a.m., LPN-A stated she worked the overnight hours on [DATE] into [DATE]. She received report from LPN-D that R1 had vomited on the evening shift. She requested for NA-A to clean R1 up and after that, R1 had been resting. LPN-A stated she only saw R1 twice that shift. At 5:22 a.m. R1 had an order for omeprazole to be given at 6:00 a.m., but LPN-A had held it from R1 due to the report LPN-D had given her about R1 vomiting on the evening shift. LPN-A stated she wrote an eMAR note stating R1 had been vomiting. She did not notify the physician about R1 vomiting because she was told LPN-D had already notified the physician. She wrote a progress note at 6:18 a.m. on [DATE] that R1 had refused to have her incontinent brief changed but it did not concern LPN-A because R1 was able to make her needs known. She did not assess R1 after she had vomited throughout her shift because she was really busy with other residents yelling at each other and a phone call. LPN-A stated R1's episodes were out of her baseline and thought it was a change in condition. During an interview on [DATE] at 11:22 a.m., nurse practitioner (NP)-A stated R1 had an extensive history with GI bleeds. She was notified that R1 had been vomiting only after R1 had died. Last time she was updated about R1 was on [DATE], and that was about R1 being constipated. She is usually notified from the facility via phone, but the facility also had her pager in case of an emergency. She was concerned that the facility had not notified her about R1's vomiting. NP-A stated if she would have been notified about R1's episodes of vomiting on [DATE], she would have recommended R1 go to the hospital immediately. During an interview on [DATE] at 12:07 p.m., DON stated she received a phone call after R1 had passed on [DATE] and after EMS had left the facility. She did not recall what time she received the phone call. She arrived at the facility to assist with postmortem care. The DON further stated R1's first episode of vomiting, should have warranted a change in condition. Her expectations with a change in condition would be to assess vital signs at a minimum, assess the resident, notify the physician, and notify the family. Her expectation was that after every episode of change in condition, the physician would be notified, and those orders and recommendations would be followed. Her expectation was when the licensed nurses talk with family about the residents change in condition, the licensed nurse would give their recommendations if they were waiting for a physician to call back or state the recommendations from the physician. Licensed nurses would also ask the family their preferences about the resident being sent to the hospital and if they are ok with that. DON stated her expectation was after every change in condition, the licensed nurses would put a nursing order in for licensed nurses to check vital signs every four hours for the next twenty-four hours. Any of the licensed nurses could enter those orders since it is a nursing order. Her expectation was the licensed nurse would round on the resident at least every two hours. DON stated she found it concerning when the licensed nurses did not notify the physician after each episode of vomiting. During an interview on [DATE] at 1:00 p.m., LPN-D stated she worked the evening of [DATE]. R1 was at her baseline prior to dinner. At dinner, R1 refused to eat dinner, had an upset stomach, and stated she wanted to go to bed. R1 had vomited around 7:00 p.m. R1's vomit was brown in color but could not describe any more. LPN-D stated we cleaned R1 up after she vomited. This was not unusual for R1 to vomit. NA-C reported to her that R1 had a large bowel movement and had felt better. LPN-D stated R1 had vomited again around 8:00 p.m. LPN-D stated R1's vomit was brown in color but could not describe any more. She took R1's vital signs and they read within normal limits. She also assessed R1's bowel sounds because she had thought R1 was constipated. She did not notify the physician about R1's vomiting on [DATE] because it was not unusual for her to vomit. LPN-D stated after she took R1's vital signs at 8:00 p.m. she did not continue to monitor R1 because she got too busy. During a subsequent interview on [DATE] at 1:07 p.m., DON stated LPN-D had assessed R1 on the evening shift on [DATE] but she would have liked to have known what color the emesis was. She would have liked to see the licensed nurses assess R1 more. If the licensed nurses had continued to monitor R1, they would have put in nursing orders to take vital signs every four hours for the first twenty-four hours. The licensed nurses should have laid eyes on R1 at least every four hours. During an interview on [DATE] at 1:35 p.m., the administrator stated when a resident had a change in condition her expectation was the licensed nurse would monitor the resident, put monitoring nursing orders in, put a progress note in, and state what change of condition occurred. The administrator stated the physician would be notified of a change in condition along with the on-call supervisor, DON, and herself. During a subsequent interview on [DATE] at 2:40 p.m., LPN-A stated she did not recall what times R1 had vomited on her overnight shift on [DATE] to [DATE]. She held R1's 6:00 a.m. omeprazole dose due to the report she received about R1 vomiting during dinner time on the evening shift on [DATE]. LPN-D reported to LPN-A she had called the physician to report R1's vomiting episodes and the physician had recommended R1 to be monitored overnight. She would have expected LPN-D to put a progress note in the medical record about her conversation with the physician but did not look to see whether there was a progress note entered or not. She trusted LPN-D when she said she had notified the physician. She checked on R1 twice on the overnight shift on [DATE] to [DATE] but could not recall the times she checked on her. She checked on R1, when she was giving medications to other residents by slowly walking past R1's room. LPN-A stated both times she walked past R1's room, she had been sleeping. LPN-A stated she never went in R1's room during her shift. At 5:22 a.m. when she wrote the eMAR note about R1 vomiting, LPN-A stated she never attempted to give R1 her omeprazole dose because LPN-D recommended not to give R1 any medications. After her shift ended on the morning of [DATE], she gave report to LPN-E that R1 had vomited twice during her shift and LPN-D had reported R1's episodes of vomiting on the evening shift on [DATE]. LPN-A stated she was terminated from the facility two hours prior to this interview. She was terminated from the facility due to not following the charting procedures. LPN-A stated the last day she worked at the facility was on [DATE]. During a subsequent interview on [DATE] at 3:00 p.m., the administrator stated the facility investigated R1's death and concluded the licensed nurses did not assess or document the change in condition. The administrator stated LPN-A was placed on a leave during the investigation and was terminated from her position. During an interview on [DATE] at 9:56 a.m., LPN-E stated when she got to the facility on [DATE] at 6:30 a.m., she worked on a different unit. She was transferred to R1's floor around 7:15 a.m. where she received report from LPN-A that R1 had been vomiting all night. She asked LPN-A how she monitored R1 throughout the night and LPN-A did not respond. After she received report, and she started passing medications to residents. NA-C reported to her around 7:30 a.m. stated R1 had been vomiting and she was not looking good. She stopped passing medications and went to R1's room where she found R1 sitting in her wheelchair and was vomiting. R1's vomit looked like black coffee grounds. NA-D was supporting her back while she was vomiting. She requested to NA-C and NA-D to put R1 back in her bed so that she could assess her. Instead of assessing R1, she called EMS immediately. While she was calling EMS, she had instructed TMA-A to take R1's vital signs. After she got off the phone with EMS, LPN-E went to R1's room and attempted to take her vital signs but they did not read. R1 did not have a pulse but she was still breathing. R1 was not responding to her. Once EMS arrived around 8:00 a.m. they had pronounced her deceased . During an interview on [DATE] at 10:14 a.m., NA-A stated she was new to the facility and was still getting to know the residents. She worked with R1 during her overnight shift [DATE] into [DATE]. When she started her overnight shift on [DATE], she noted R1's call light was on. She went to R1's room where R1 stated she was not feeling well. She asked R1 if she wanted her to get LPN-A and R1 stated no. NA-A stated even though R1 had said she did not want NA-A telling LPN-A, NA-A told LPN-A that R1 was not feeling well. NA-A stated LPN-A stated R1 was not taking Zofran anymore, so she could not give it to R1. NA-A stated throughout the night during rounds, she would check on R1 to see if she had vomited. She had vomited several times throughout the night. NA-A stated the vomit was small and dark in color. R1 had vomited on her nightgown, so NA-A would have to assist R1 in changing her nightgown. NA-A stated she would give R1 a towel to vomit on. When she came back for the next round to check on R1, she would need to change her nightgown again and give her a new towel because she had vomited again. She told LPN-A throughout the night that she was concerned about R1 vomiting and didn't look good. NA-A stated she knew that the facility has sent other residents to the emergency department before, so NA-A knew that would be an option. Before the end of her shift on the morning of [DATE], she made sure R1 had a clean gown on. She worked directly with R1 overnight on [DATE] into [DATE]. When she started her overnight shift on [DATE], R1 did not have her call light on but NA-A had checked on her. R1 looked worse than she did on [DATE]. She told LPN-A again that R1 seemed to be worse than the night before and that is when LPN-A stated again that she could not give her anything because she was not prescribed Zofran. R1 had vomited several times during her shift. NA-A stated R1 would vomit on her blanket and pillow. The vomit was black in color. NA-A stated she brought R1 new sheets and new towels. During the last rounds of her shift, she had noted R1 looked way worse than she did earlier in the night. Before the end of her shift on the morning of [DATE], R1 was still vomiting. R1 was still able to talk and move. NA-A asked R1 if she wanted her to change her nightgown and R1 would take off her nightgown for her. She changed R1's incontinent brief throughout the night except when she refused once. R1 did not state why she refused to have her incontinent brief changed but noted she looked very uncomfortable. She reported R1's condition to the oncoming licensed nurse about R1's condition but could not recall the licensed nurse's name. NA-A stated she reported to the oncoming NA's about R1's condition but could not recall the NA's names. During a follow up interview on [DATE] at 11:38 a.m., LPN-A stated she remembered during her overnight shift on [DATE] into [DATE] that NA-A had told her something but she had forgot about it. She did not remember exactly what NA-A told her but R1 had not been feeling good. She was too busy working with other residents that she did not go into R1's room and assess her during her shift. LPN-A stated she did not recall if she told the oncoming morning shift on [DATE] about R1's condition. During an interview on [DATE] at 8:50 a.m., NA-A stated R1 started vomiting on [DATE] at 10:30 p.m. NA-A stated she was unsure whether R1 had been vomiting during the day on [DATE] but as soon as she got to the facility for her overnight shift on [DATE], R1 had already been vomiting. During an interview on [DATE] at 10:12 a.m., TMA-A stated on the morning of [DATE] he received report from LPN-A that R1 had been vomiting overnight. NA-C was getting R1 up for the day and once NA-C got her in her wheelchair, she began vomiting. He attempted to get R1's blood pressure and it could not read it. He could not find a pulse on R1. He did get an oxygen reading and that reading read sixty-two percent while on two liters of air. LPN-E instructed him to turn R1's air flow to four liters. TMA-A stated LPN-E called EMS. When EMS arrived, they pronounced her deceased . The facility's notification of changes policy and procedure dated 3/2024 indicated changes in a resident' condition or treatment be shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate. The policy stated, nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed, and the deficient practice corrected by [DATE] after the facility implemented a systemic plan that included the following actions: provided education to the licensed nurses from [DATE] through [DATE] on NA's charting needs to be done prior to the end of their shift, report to the nurse if NA's feel as though there is a change in the resident, and the NA feels as though something is not being addressed by the licensed nurse, to follow up with the NM or DON. Education was provided to the licensed nurses indicating nurse's assessments needing to be completed and physician notification needs to be done immediately. The audit indicated there was no orders for monitoring, the Physician was notified, a progress note was completed, and resident assessments were completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide adequate supervision to prevent an elopement for 1 of 3 residents (R1) reviewed for missing person/elopement. This resulted in immediate jeopardy when R1 exited the facility and was found on the ground on near a street intersection on the sidewalk by law enforcement (LE)-A, late at night. The facility was unaware of R1's absence from 11:20 p.m. until 11:47 p.m. which placed him at risk for serious harm, impairment, or death. The immediate jeopardy began on 4/29/23 at 11:20 p.m., when R1 left the facility unsupervised and was found at 11:47 p.m., outside the facility on the on the ground by law enforcement (LE)-A. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 5/16/23, at 4:41 p.m. The facility immediately implemented corrective action on 5/1/23 prior to the survey and was issued at Past Noncompliance. Findings include: R1's progress note dated 5/23/22, indicated staff met with R1 about a recent self harm incident over the weekend. R1 reported that he self-harmed because he spaced out after trying to remove the wander guard. The note included, the need for a wanderguard as resident has a history of going outside in the evening without (appropriate) clothing. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had diagnoses of nontraumatic intracerebral hemorrhage of the brain stem, seizure disorder, difficulty walking, agnosia (loss of the ability to identify objects using one or more senses), generalized muscle weakness, cerebral infarction (stroke), and psychiatric disorder. R1 is not cognitively impaired, independent with activities of daily living (ADLs), used a walker for mobility, was occasionally incontinent of urine, and had two falls without injury since the previous assessment. Further identified R1 was administered antipsychotic medication. R1's ADL care plan dated 11/20/20, identified R1 was ambulatory with four wheeled walker. R1's fall care plan dated 11/20/20, identified R1 was at risk for falls related to seizures and stroke. Further identified R1 had three falls since 2/21/23. R1's care plan dated 12/14/20, informed staff R1 had impaired thought process related to unspecified mental disorder to known physiological condition R1's communication care plan dated 1/21/21, identified R1 had hearing impairment. He required communication through writing and directed staff to use ADL cards, approach resident face to face, and provide white board or note pad. R1's activity care plan dated 5/13/21, informed staff R1 had weakened muscles with some paralysis and also had neurological neglect of one side of his body. R1's behavior care plan dated 12/16/21, indicated R1 needed frequent checks to determine resident needs and offer assistance if needed (12/30/21). Monitor/assess for delusional thinking, paranoia, and inform nurse manager/social services of changes to mood behavior (2/6/23). R1's care plan dated 3/14/23, indicated R1 refused assistance for cares, yelled at staff, and setting self down on the floor. R1's wandering care plan dated 4/18/23 identified R1 had a history of wandering due to episodic confusion/impaired cognitive function related to history of organic mood disorder and paranoia. Corresponding interventions included complete wander/elopement risk assessment quarterly/as needed to assess risk and assist resident to exercise regimen per physical/occupational therapy. R1's psychotropic medication care plan dated 12/14/23, identified R1's target behaviors as confusion, irritability, and agitation. R1's physician order dated 2/14/23, included R1's Wanderguard to be removed and document any behaviors in a nurse progress note every shift for 7 days; end date of 2/21/23. R1's Elopement Risk Evaluation dated 2/15/23, identified R1 had a habit/history of wandering or attempts to leave the building, was ambulatory, had diagnoses of a cognitive disorder. R1's antipsychotic medications, history of calling the police, somatic complaints, and history of self-harm was not identified as a risk factor on the assessment. The evaluation indicated R1 had a risk score of '3'. The evaluation tool directed if the score was 4 or greater include elopement plan. R1's progress note dated 2/15/23, indicated interdisciplinary team (IDT) met to review current status and elopement risk. Elopement risk assessment indicated R1 was low risk for elopement. R1 had not exhibited behaviors indicating risk since last quarter. IDT concluded trial removal of wanderguard at this time. Monitoring would be completed for seven days. There was no indication an assessment for on-going interventions was developed or implemented after the seven day monitoring had ended. R1's Elopement Risk Evaluation dated 3/4/23, was inconsistent with the evaluation dated 2/15/23. Indicated R1 did not have a habit/history of wandering or attempts to leave the building and identified R1 currently taking medications that caused confusion. The evaluation did not identify a history of somatic complaints or self-harm. The section labeled additional considerations was blank. R1's elopement risk was scored as a level '3'. R1's elopement care plan dated 4/18/22, indicated R1 was at risk for elopement related to impaired cognition, episodic confusion, and independently mobile with interventions to reduce the risk of elopement with a wander alert attached to right side of walker was discontinued on 3/14/23. R1's Wander/Elopement Risk Evaluation dated 4/10/23, indicated R1 was physically able to leave the building and was ambulatory with a walker. R1 was a risk for wandering/elopement however the section labeled Summary was blank. R1's evaluation lacked evidence staff included interventions or had revised the care plan to address R1's risk for wandering/elopement. R1's psychology visit note dated 4/24/23, indicated the physician had made the decision to increase R1's Zyprexa (antipsychotic medication) to 20 milligrams (mg) due to his delusional thinking that is somatic in nature. R1 reported his mood was stable and was strong on his feet. R1 was getting out of bed and walking again. This is a very positive change. A police report, dated 4/30/2023 at 12:53 a.m., included law enforcement (LE)-A was completing a routine patrol of the area surrounding the facility. On 4/29/23 at 11:47 p.m. LE-A observed a male (R1) on the ground with his walker and was at the corner of a street intersection. The male appeared in distress and was waving LE-A over. A nurse saw LE-A's squad emergency lights and came out (of the facility). She (nurse) stated [R1] is a resident there and he must have snuck out. The report indicated R1 had requested to go to the hospital for unknown an medical reason and complained his bed linens were always soiled. R1 was walked back into the facility to wait for emergency medical services (EMS). Once inside the facility LE-A asked the facility supervisor how it was possible [R1] who could barely walk was able to make it out of his room in Unit [unit number specified] on the second floor and walk out to the location that he was found. The supervisor stated he must have not locked the front door. LE-A took pictures of R1's room which appeared filthy. There were ants on the floor along with feces stains, his bed was soiled, and the room smelled of feces. On 4/29/2023, the temperature in St. Louis Park, MN was 45 degrees Fahrenheit (F) at 11:53 p.m. per the national weather service. On 5/15/2023, the surveyor observed the distance between the point R1 was found by Law Enforcement (LE)-A and the facility main entrance which was approximately 80 yards. R1's progress note dated 4/30/2023 at 2:45 a.m., Licensed Practical Nurse (LPN)-A indicated R1 had become agitated at an unspecified time and requested facility staff contact 911. R1's vital signs were stable. R1 started yelling at LPN-A to leave his room after she informed R1 he seemed to be okay and would need a reason to call an ambulance. LPN-A stated she intercepted R1 in the facility parking lot, where he fell onto his bottom and police happened to be driving by. The progress note indicated LE-A contacted paramedics and R1 was subsequently transported to the hospital for further evaluation. R1's representative was contacted who requested he resumed wearing his wanderguard. R1's Elopement Risk Evaluation dated 4/30/23, identified a risk score of 7 which directed staff to include an elopement care plan. Documentation indicated R1 was at risk for elopement, goals included, R1 will not leave the building, and family will be kept informed. The section Wander guard in place was not documented, however in the Additional Comments sections documentation included, Resident to resume use of wander guard. R1's Readmit Data Collection dated 5/1/23, indicated R1 was readmitted from the hospital with a closed non-displaced fracture of anterior process of right calcaneus (prominence on the heel bone). R1's progress note dated 5/2/23, included IDT met to review resident fall outside facility. Resident was sent to acute care hospital after being found. Team met to review R1's behavior of exiting the facility. After communication with power of attorney, it was determined that R1 would be more appropriate on a secure unit. R1's progress note dated 5/9/23, included R1 continues to have sporadic episodes of requesting to go to the hospital. Elopement risk completed with a score of 4.0. physician was notified of the same with orders received and a wander guard applied to resident's walker. Staff will continue to monitor and initiate frequent check with rounds at nigh and as needed. R1's revised care plan for wandering on 5/9/23, indicated the following interventions: Monitor R1's whereabouts every 2 hours. Document any noticed wandering behavior and attempted diversional interventions. R1's trigger for wandering/eloping were needing to go to the hospital. R1 behaviors can be de-escalated by offering coffee/snacks of choice, and getting family involved. During an interview on 5/12/2023 at 10:52 a.m., LE-A stated he had been patrolling the area on the night of 4/29/2023 at approximately 11:45 p.m. and was waved over by R1 who was sitting on the ground. LE-A stated R1 was located on the sidewalk of the northeast corner of Texas Ave S and 28th St W, before the entrance of the facility parking lot. LE-A stated there were several bystanders from the neighborhood, but no facility staff present. LE-A indicated he exited his squad car, helped R1 to stand, then returned to his squad car to turn on his emergency lights. LE-A stated he was with R1 for approximately 30-60 seconds before he noted LPN-A exiting the facility front doors. LE-A indicated when he spoke to LPN-A, she had stated they knew R1 had left his unit but were unaware R1 had left the facility. LE-A stated he does not know how long R1 had been outside the facility without supervision. R1's psychiatric visit note dated 5/8/23, indicated staff reported R1 left the building at night, wanting to go to the hospital, and fell while outside. He is currently on a secured unit pending cognitive screenings. R1 displayed some challenges with recall regarding hospitalization. During an interview on 5/15/2023, at 11:07 a.m., NA-C stated R1 had been agitated since approximately 10:00 p.m. on 4/29/2023, and had been using his call light to request assistance and contacting the police with unspecified concerns. NA-C notified LPN-A about R1's concerns. NA-C stated NA-E had told LPN-A R1 was not allowed outside the facility without supervision. NA-C stated neither she nor NA-E were made aware of any issues with R1 until LE-A arrived on the unit. During an interview on 5/9/23 at 3:07 p.m., and 5/15/23 at 1:18 p.m., LPN-A indicated on 4/29/23, R1's agitation and behavioral disturbances began around 10:00 p.m. LPN-A stated R1 was insistent on contacting the police but would not provide a medical concern for her to assess. LPN-A indicated R1 walked past the nurses station and got on an elevator shortly after midnight. R1 was wearing a long-sleeved collared shirt and shorts. LPN-A stated she was unaware R1 could not be in the community by himself. During an interview on 5/10/2023 at 9:46 a.m., the Director of Nursing (DON) stated R1 needed to be accompanied to all appointments by a family member or staff. The DON stated R1 was not safe to leave the facility independently. A facility policy titled Elopement Guideline, dated 2/27/2023, stated documentation of an elopement event must include all attempts to locate the resident and time specific entries detailing the initiation and results of these efforts. The policy states there should be a unit-wide search for the resident and the Administrator should be notified of the elopement. The policy indicates a facility-wide search should be completed, followed by a thorough search of the facility grounds involving all available facility staff. The immediate jeopardy that began on 4/29/23, was removed on 5/1/23 before the survey and was issued at Past Non-Compliance when the facility implemented the following: Completed an assessment of R1 for wandering, confusion, anxiety, paranoia, and behaviors that increased R1's risk for elopement. The facility updated R1 care plan to include a wanderguard on R1's walker, frequent checks, and identified triggers and intervention to decrease R1's behaviors associated with leaving the facility, and placed in a secure unit. All staff were educated on elopement policy, and code white missing person procedures. Licensed nursing staff were educated on how to complete a comprehensive assessment and care plan interventions for resident at risk for elopement.