**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to identify, comprehensively assess, implement individualized interventions for wandering, exit seeking behaviors, and elopement for 2 of 2 residents (R1, R2) who had a history of repeated exit seeking behaviors. The facility's failures resulted in immediate jeopardy (IJ) when R1 eloped from the facility, was found on a city street, and returned by a passerby. The immediate jeopardy began on 9/5/24 after R1 attempted elopement multiple times, the facility failed to complete comprehensive wandering/elopement assessments, monitoring system, and appropriate intervention resulting in R1's actual elopement on 9/21/24. The immediate jeopardy was identified on 9/26/24 and the chief executive officer and director of nursing (DON) were notified of the immediate jeopardy on 9/26/24 at 6:18 p.m. The immediate jeopardy was removed on 10/3/24 at 11:11 a.m., but noncompliance remained at the lower scope and severity level 2 (D), which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses that included Alzheimer's disease and had severe cognitive impairment. R1 did not have wondering behaviors. R1's progress note dated 4/3/24, indicated R1 was found walking to the elevator without shoes on, staff attempted to redirect, he became agitated, and upon reapproach was successfully walked back to his room. The note did not specify if R1 had been exit seeking and/or wandering. R1's Fall Risk assessment dated [DATE], contained a mental status section. The wanders box was selected with a checkmark with no other information identified. R1's quarterly MDS dated [DATE], indicated R1 did not have wondering behaviors even though the fall risk assessment dated [DATE] identified R1 wanders. The MDS indicated R1 was independent using a walker with ambulation of distances of 10 feet and required staff supervision/cues for distances of 50 to 100 feet. R1's record reviewed between 4/3/24 and 9/5/24, identified although progress notes identified a history of wandering behaviors the record did not include a comprehensive assessment of the wandering to identify trends/patterns and causal factors. Additionally, the record did not include a comprehensive elopement risk assessment. Further R1's care plan did not address R1's wandering and R1's risk for elopement until 9/11/24. R1's progress note dated 8/5/24, indicated R1 was yelling in the hallway and wanted to go in another resident's room and was successfully redirected by staff. R1's progress note dated 8/30/24, indicated R1 was observed ambulating in the hallway in his socks and underwear and redirection took several attempts before resident was agreeable to return to his room. R1's progress note dated 9/5/24 at 6:58 a.m., indicated R1 was wandering the hallway in socks and boxers without his walker and was effectively redirected by staff. R1's progress note dated 9/5/24 at 11:15 a.m., indicated R2 made multiple attempts to exit the front door of the facility pushing his walker into the door at least six to seven times. Several initial staff attempts at redirection were unsuccessful but activity assistance staff walked with him outside and then convinced him to return to his room and get [R1] back into the facility safely. R1's progress note dated 9/5/24 at 3:51 p.m., indicated resident wandered today and was resistant to staff to return to his room. A family member was called, and this helped the resident. R1's progress note dated 9/5/24 at 3:53 p.m., indicated resident wandered down to main floor and was going outdoors. R1's Fall Risk assessment dated [DATE], identified R1 wandered, but lacked further information about his wandering behaviors or elopement risk. During an interview on 9/26/24 at 10:20 a.m., director of nursing (DON) stated the facility had an elopement assessment that nursing staff are supposed to complete on admission. The assessment should also be done if residents have a change in condition like exit-seeking or if they elope, or if they show a risk. DON expected nurses to document behaviors like wandering or exit-seeking in a progress note. When residents were identified to have wandering behaviors, staff should complete 30-minute safety checks to determine the resident's where abouts and safety. The DON identified the safety risks associated with elopement was high, especially for residents who were confused or lack proper clothing or awareness. Residents who eloped are at risk for getting sick, seriously injured, hit by a car, exposed to weather, and confused residents were at serious risk for getting lost in the community. DON stated an awareness of R1's elopement attempt on 9/5/24 and noted on that day it became very evident he was very high risk for elopement. The DON expected an elopement assessment to have been completed at that time with interventions put in place like 30-minute checks. R1's quarterly MDS assessment dated [DATE], indicated R1 had wandering behaviors on one-to-three of the seven-day assessment period, used a walker independently, and did not use a wander/elopement alarm. The impact of wandering section does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility) question was left blank. Even though R1's MDS assessment dated [DATE] identified R1 had wandering behaviors, R1's record did not include a comprehensive assessment of R1's wandering/exit seeking behaviors that would identify R1's mannerisms, precursors, or behaviors for determination and implementation of individualized interventions for management of wandering/exit seeking behaviors. R1's care plan was not revised until six (6) days after R1 displayed exit seeking behaviors and did not address target behaviors associated with wandering/exit seeking. The care plan included a behavior focus initiated on 9/11/24 that identified R1 was an elopement risk/wanderer with a history of attempts to leave the facility unattended and impaired safety awareness. Interventions dated 9/11/24 included: - Assess for fall risk - Distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book -Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate -Monitor for fatigue and weight loss R1's progress note dated 9/18/24, indicated R1's primary provider, Doctor of Medicine (MD)-A, visited the previous day and was updated on attempted on [sic] behavior, increased confusion, and elopement risk (9/5/24). In review of R1's record, it could not be determined what R1's level of risk of elopement was as a result of the R1's increased confusion on 9/18/24 and not evident R1's care plan was revised. R1's progress note dated 9/21/24 at 3:44 p.m., indicated R1 took a nap and was disoriented upon waking, looking for his wife. Staff tried to redirect resident showing him pictures of his family, but it did not work. R1's progress note dated 9/21/24 at 8:30 p.m., indicated R1 went down in the elevator by himself and passed through front door and went outside during dinner time. R1 had refused to come to dinner three times, when staff went to his room after dinner, they found he was missing. Staff conducted a search. A visitor found R1 on a street in the neighborhood and returned him home to the facility. R1 was assessed and appeared stable with no new injuries noted. Family and the on-call physician were notified. R1's progress note dated 9/21/24 at 8:59 a.m. [sic] indicated contracted registered nurse (CRN)-A was notified by staff that R1 was not on his unit, a full house search was completed, and R1 was located by a visitor on a street in the neighborhood. R1 returned home to the facility with the visitor, did not appear to have any injuries, was started on safety checks every 30 minutes, and the medical director and on-call physician as well as family were notified. R1's first recorded Elopement Risk Evaluation dated 9/21/24 at 11:22 p.m. identified R1 had a history of attempting to leave the facility without informing staff, wandered, had wandering behavior that was a pattern or goal-directed, and the wandering behavior was likely to affect the privacy of others. The evaluation identified R1 had not verbally expressed the desire to go home/packed belongings/or stayed near an exit door, did not wander aimlessly or in non-goal-directed fashion, and was not admitted or re-admitted within the past 30 days with lack of acceptance of the situation. The two sections of the assessment with spaces to enter cognitive evaluation scores were blank. The question does the resident have a history of elopement or an attempted elopement while at home was marked no which was not accurate according to progress notes dated 9/5/24 and 9/21/24. The question Is the resident's wandering behavior likely to affect the safety or well-being of self/others was marked no which was not accurate according to progress notes dated 4/3/24 to 9/21/24 when R1 repeatedly demonstrated wandering behaviors while improperly dressed, attempted to elope once, and successfully eloped once. A facility Elopement Incident Report dated 9/21/24, noted R1's elopement on 9/21/24 and the corresponding progress note. It further indicated R1 was oriented to person only, had no pre-disposing environmental factors, had predisposing physiological factors including confused and impaired memory, and had none of the above selected from a list of predisposing situation factors. Facility records of R1's elopement lacked a comprehensive causal analysis for the probable root cause that led to R1's elopement for the determination of appropriate interventions to prevent re-occurrence of elopement. R1's physician orders included an order dated 9/21/24 at 11:30 p.m., resident is on 30 minutes safety check every shift. However, review of R1's record did not include an assessment that corresponded with the determination of 30-minute safety checks. During an interview on 9/26/24 at 10:20 a.m. DON was not able to identify how R1 was comprehensively assessed to determine 30-minute checks were an appropriate intervention for R1, how R1's needed level of supervision was determined, or how R1's known specific wandering behaviors were monitored. Regarding a root cause analysis of R1's elopement, the DON stated, we have talked about in our IDT [inter-disciplinary team] meeting but haven't sat down to do it. R1's care plan was not revised until 2 days after the incident and did not include target behaviors and interventions associated with wandering/exit seeking. R1's care plan for functional abilities and mobility included an intervention initiated on 9/23/24, [R1] is able to walk independent[[NAME]] with walker but needs assist and cues to specific destination, particularly longer walks as he will wander and get lost specially if he gets on the elevator. R1's care plan for behavior included an intervention initiated on 9/23/24: - Safety checks every 30 minutes - Report immediately to the nurse if resident is not on the unit - Photo at the reception desk. R1's care plan for behavior included interventions initiated on 9/24/24 that included: - Notify nurse if resident starts exhibiting exit seeking behaviors - Redirect resident if he is wandering. Review of R1's 30-minute safety checks documented on paper between 9/21/24 through 9/25/24 identified they were completed by staff member's initials and/or by initials with R1's location inside the facility. No other information pertaining to the checks was documented. Additionally, record did not identify and/or include a monitoring system and/or evaluation for of any wandering behavioral patterns or trends as directed by the care plan dated 9/11/24. During a return phone call interview on 9/27/24 at 3:09 p.m., security officer (SO)-A stated he worked on 9/21/24 and saw R1 go outside for some fresh air between 6:30 and 7:30 p.m. SO-A was then notified R1 was missing, and he was returned to the facility by visitors. When SO-A asked R1 where he had been going, R1 responded, I was going home. SO-A stated he was not aware at the time that R1 was an elopement risk. SO-A noted he was aware now because R1's photograph had been placed at the front desk and he had received training to redirect R1 or other residents at risk of elopement away from the front door but did not articulate targeted interventions specific to R1's known behaviors. During an interview on 9/26/24 at 11:33 a.m., contracted registered nurse (CRN)-A stated she was working on 9/21/24 when R1 eloped. CRN-A stated it was around 6:00 p.m. when R1 was noted missing, and they conducted a full house search. A visitor who had been at the facility for a community event located R1 a few blocks away from the facility on the corner of North [NAME] Ave. and 7th street. CRN-A explained that was a busy intersection, the visitor found R1 on the corner and visitor reported R1 had been afraid to cross the street. R1 was then returned to the facility with the visitor in the personal vehicle at approximately 6:40 p.m. CRN-A noted R1 was placed on 30-minute safety checks upon his return and found to be unharmed. CRN-A identified R1 was not safe alone in the community and was at risk of eloping. CRN-A stated R1 had left the facility because he was looking for his wife and stated she did not have a good answer to how 30-minute checks addressed this behavior except that staff engage him, listen to him. CRN-A noted she might have put him on 15-minute checks, but she knew he was so tired when he returned that he was safe being on 30-minute checks. She further stated she ordinarily would do assessments, find out what activities he likes, what interventions are on his care plan, find out what had been done in the past, and determine what he liked and disliked. CRN-A explained, 30-minute checks seemed to have been what the standard has been at the facility for other residents with behaviors. That's been what they've [facility staff] done . it is just what they've been doing in the facility and that's why they went with 30. She confirmed that she completed an elopement assessment when R1 returned the evening of 9/21/24, it should have been done prior, I was shocked when I didn't find more elopement assessments on him During an interview on 9/26/24 at 3:43 p.m., nursing assistant (NA)-A reported she was the nursing assistant for R1 on 9/21/24 starting at 2:30 p.m. At approximately 2:40 p.m. R1 was in the common area with no pants on looking for his wife and NA-A redirected R1 to his room. NA-A noted she saw R1 exit-seeking and wandering without pants on looking for his wife a second time around dinner and redirected R1 to his room and left him there alone. NA-A then joined LPN-A in the dining room to assist with dinner and stated she did not report these behaviors to the nurse, licensed practical nurse (LPN)-A. NA-A was notified after dinner by LPN-A that R1 was missing. NA-A was aware of R1's continued confusion and desire to leave the unit on 9/21/24 but was not aware of additional interventions. During an interview on 9/25/24 at 1:26 p.m., nursing assistant (NA)-C stated R1 seemed to be declining and he just wanders. R1 wanders or try to go down the elevator when he was looking for his wife, thought it was mealtime, or wanted to go to church. NA-C explained staff check on R1 every 30 minutes; checks were documented by initially next to times on a printed paper. NA-C did not indicate any further information was expected to be documented such as what R1 was doing or where he was at the time the check was performed. NA-C stated she had checked on him that morning (9/25/24) at 10:30 a.m., and then went in another room. NA-C stated she wasn't even in there 15 minutes and [R1] had already gone down the hall and to the elevator . he's just that quick. NA-C stated to know who wanders she would ask in report and check the care sheets NA's use. NA-C stated she wished they had a wandering alarm system but was not sure what else to do except just be really diligent about keeping an eye on [R1]. NA-C stated it was definitely not safe for R1 to go out the front door or outside the facility alone and was aware he had eloped from the facility the previous weekend. During an interview on 9/26/24 at 7:44 a.m., NA-B reported R1 had wandering tendencies, and it was common for R1 to wander while inappropriately dressed, more commonly in the evening. NA-B recalled a time R1 was in his underwear and socks by the elevator looking for something and she redirected R1 to his room. NA-B reported R1 sometimes left the unit on his own, and she would follow R1 if he was agitated. NA-B stated she had concerns about R1 attempting to leave the building independently. NA-B stated some residents had specific charting to complete regarding if behaviors were present, but R1's behavior charting was only as needed. During an interview on 9/25/24 at 4:00 p.m., licensed practical nurse (LPN)-A stated currently R1 had some confusion, but stated R1 was not at risk for elopement, did not have wandering behaviors, and was not aware of the previous elopement attempt on 9/5/24. However, LPN-A stated he worked on 9/21/24 when R1 eloped from the facility and was returned by a visitor; LPN-A was not aware of who the visitor was. LPN-A recalled the shift he worked on 9/21/24, he was not made aware of any earlier behaviors that had occurred that day. LPN-A stated earlier during his shift R1 had attempted to go down to church and was redirected. LPN-A did not endorse R1 attempting to go to church as wandering behavior, noted this was a typical behavior, and did not communicate to nursing assistants (NA) of R1's attempts. After dinner LPN-A went to check on R1 and noted him missing. After R1 returned LPN-A assessed R1 and noted no injuries. LPN-A stated he told the aides what happened and to prevent it from happening again, the intervention was checking him every 30 minutes but did not identify any specific behavior monitoring that was put into place. LPN-A was not able to articulate how residents were assessed for elopement risk and thought nursing leadership would follow-up on a need for increased elopement risk for R1. LPN-A identified currently it was okay for R1 to walk around the facility by himself because he doesn't go far. LPN-A articulated since R1's elopement on 9/21/24, current safety interventions were 30-minute checks and having a photograph of R1 at the front desk. He did not identify targeted behavior monitoring or interventions in place related to R1's known wandering behaviors, tendency to look for his family, and desire to go to church. During an interview on 9/26/24 at 7:43 a.m., LPN-C stated she was not aware of an official assessment for elopement. LPN-C stated she determined elopement risk by assessing cognitive status, ability, mobility, how alert residents were to their environment, and went from there. LPN-C stated, you just get to know your residents and you just inform staff to be mindful and keep an eye on them. LPN-C stated she would consult a resident's care plan to identify their wandering behaviors and it should note what staff are doing to decrease the changes of the resident leaving the facility or the unit. During an interview on 9/26/24 at 7:55 a.m., LPN-D stated to her knowledge there was no formal elopement assessment done for residents, but she thought it would be a good idea to have them. LPN-D noted staff would know if someone was an elopement risk or had wandering behaviors by knowing your residents. LPN-D stated she would check care plans for interventions related to wandering behaviors because behaviors can be very specific. During an interview on 9/26/24 at 1:53 p.m. DON and registered nurse (RN)-A, the DON confirmed the assessment completed on 9/21/24 was not accurate or complete. DON noted she would consider R1's wandering behavior likely to affect the safety or well-being of himself or others, though the assessment identified this was not likely. RN-A stated she was the MDS RN and had never completed elopement assessments, no one in this building has had an elopement assessment done. The DON stated R1 was not able to safely be out in the community independently. The DON stated she assessed R1's needed level of supervision by looking at his behaviors. DON was not able to further articulate how this assessment process worked, I don't know about the process. If residents require monitoring related to behaviors or falls, historically the nurses automatically implement 30-minute safety checks. DON stated there was no monitoring for R1's wandering behaviors in place prior to the survey. The DON stated she would expect updated interventions to be added to a care plan on the same day as an attempted elopement. She confirmed after R1's attempted elopement on 9/5/24 his care plan was not updated until 9/11/24. RN-A noted R1 later eloped on 9/21/24 and his care plan was not updated until 9/23/24 when 30-minute safety checks were added. RN-A confirmed R1's need to be escorted by staff when leaving the unit was not added to his care plan until after surveyors were on site. RN-A further noted that if specific wandering behaviors were not noted on care plans, staff would not know how to manage the behaviors. The DON was not able to identify how the interventions added to R1's care plan related to elopement risk were determined to be individualized, comprehensive, or effective in the absence of a comprehensive elopement risk assessment and behavior monitoring. During an interview on 9/26/24 at 3:49 p.m., MD-A stated she was aware R1 had eloped. MD-A identified R1 was not safe to be independent in the community and had dementia and a poor cognitive status. MD-A stated R1 was definitely an elopement risk with a history of wandering behaviors. If he eloped, MD-A stated she would be worried about R1 getting lost, falling, or getting hurt and worried about vehicles in the area, people in the downtown community, and cold or weather exposure. MD-A would expect elopement assessments to have been completed, immediate interventions to be implemented, behaviors to be monitored and documented, in addition to strategies to be in place to minimize the risk of further elopements. During an interview on 10/2/24 at 3:49 p.m., the facility's medical director stated he was aware of R1's elopement on 9/21/24. The medical director noted he would expect close monitoring of residents at risk for elopement, including close assessment of wandering behaviors and care planning. The medical director noted residents should be assessed to determine their elopement risk level including day to day behaviors, history, physical, risks such as dementia, and behavior management on admission and periodically. The medical director identified residents with dementia who are at increased risk of elopement as requiring increased monitoring from staff based on their behaviors. The medical director noted someone with a history or dementia and wandering should not be leaving the floor and they should not be leaving the facility . they should be escorted. The medical director stated a resident exhibiting behaviors like wandering in the hallway could be a risk to themselves or others and if they exited the facility could be at risk of getting lost, falling, getting injured due to weather conditions, getting in an accident, and identified the risk as quite high for the facility's location in downtown St. [NAME] and proximity to busy streets. R2 R2's MDS dated [DATE], identified R2 had severely impaired cognition and diagnoses including Alzheimer's disease with late onset and non-Alzheimer's dementia. R2 was ambulatory with substantial assistance from staff and utilized a walker. R2's Activity Assessment/Engagement Profile dated 6/19/24 identified R2 was able to make basic decisions, had a short attention span and did not follow directions. R2 was not identified as having precautions in place for fall prevention and elopement. R2's progress note dated 8/29/24, identified R2 came out of her room agitated and worried while calling out loudly several times, where is Patrick? The writer discovered Patrick was a six-year-old child that the resident was babysitting. Staff informed resident the child was safe at home with his mother and the mom was very appreciative of help. R2's fall risk assessment dated [DATE], identified R2 was disoriented, but the pre-populated wandering and intermittent confusion behaviors were not selected. R2's progress note dated 9/6/24 identified R2 attempted to get on an elevator going down which had a staff member in it. Staff attempted to distract R2, but she was determined to get back on and go to her old home stating, I just came yesterday, and I want to see my dog, we live next door. R2 and staff went down to the first floor and R2 did not recognize the area. R2 returned to her room with the assist of a second staff member but did not remain in her room. Staff assisted R2 to go downstairs again and helped R2 walk outside in the enclosed back garden for a few minutes. Staff then returned R2 to the unit who sat outside the nurses' station calmly. R2's progress note dated 9/6/24, identified R2 was crying on the phone with a family member (FM)-A stating she wanted to go home. FM-A was able to de-escalate. R2's record did not include a comprehensive elopement assessment nor an assessment that identified individualized target behaviors and interventions associated with wandering/exit seeking. Further, R2's record did not identify implementation of immediate interventions after R2's exit seeking behaviors on 9/6/24 and the care plan was not revised until 9/12/24, six (6) days after the incident. R2's care plan included a focus on behavior initiated on 9/12/24 identifying R2 was an elopement risk/wanderer as evidenced by history of attempts to leave facility unattended, impaired safety awareness, hearing and vision loss and intermittent confusion. Interventions dated 9/12/24 included: - Assess for fall risk - Disguise exits: cover doorknobs and handles, tape floor - Distract R2 from wandering by offering pleasant diversions, structured activities, food, conversations, television, and books - Identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. - Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. R2's record did not include an evaluation of R2's pattern of wandering and associated behaviors to ascertain effectiveness of interventions. During an interview on 10/3/24 at 8:51 a.m., NA-B reported she was aware of R2's wandering and R2 typically wandered in the evening and overnight. NA-B noted R2 would wander looking for food, but not necessarily leave the unit. NA-B stated there was a time R2 was looking for her dog and attempted to leave the floor on day shift. NA-B described R2 as confused and unable to make her basic needs met independently. NA-B stated she had not documented these previously observed wandering behaviors and just let the nurse know when and if she was having them. NA-B noted she would know if someone was an elopement risk by seeing if they tried to leave the unit. During an interview on 9/25/24 at 11:47 p.m., LPN-B stated sheets of printer paper were taped over the elevator buttons as a distraction for residents that staff did not want getting on the elevator alone. LPN-B identified R2 was a resident she did not want on the elevator by herself because she had been told by another staff member that R2 had a history of confusion and had previously tried to get on the elevator. During an interview on 9/26/24 at 9:12 p.m., LPN-C reported R2 had wandering behaviors, typically slept all day, would get up between 5:00 p.m. and 6:00 p.m. and wandered around the unit. LPN-C reported R2 had her picture by the front desk, which was generally something done for people at risk of leaving the building. LPN-C reported she thought this was sensible due to the risk of R2 wanting to leave and the risk of her leaving at night. During an interview on 10/3/24 at 8:44 a.m., family member (FM)-A stated she was aware R2 had been looking for her dog on 9/6/24 and noted I know she [R2] wants to come home. FM-A stated R2 should not leave the facility on her own and would not know how to get back. During an interview on 9/26/24 at 1:53 p.m., the DON and RN-A both stated R2 had a known tendency to look for her dog who died a long time ago. The DON stated there are days where R2 gets up and looks for her dog, she walks from her room to the dining room and reported an incident where R2 was looking for her dog on 9/6/24. RN-A stated R2 had gone down to the first floor on 9/6/24 and attempted to leave the facility. RN-A reported no elopement assessment had been completed and confirmed R2's care plan was not updated until 9/12/24. RN-A further confirmed R2's record did not contain any elopement assessments and no elopement assessment had been completed. The DON stated she would expect an immediate intervention to be added and for R2's care plan to have been updated and an elopement assessment completed on 9/6/24 following the attempted elopement. DON noted R2 would not be safe to go out into the community independently and would not be able to make her own decisions safely. The DON confirmed there was no monitoring in place for R2's wandering behaviors. The DON was not able to identify how the interventions added to R2's care plan related to elopement risk were determined to be individualized, comprehensive, or effective in the absence of a comprehensive elopement risk assessment and behavior monitoring. During an interview on 9/26/24 at 4:07 p.m., R2's primary care physician who was also the facility's medical director reported R2 had severe dementia and patterns of wandering in the hallway. The medical director noted R2 had severe cognitive limitations and impaired decision making due to dementia. He noted R2 would not be successful on her own in the community and would not be safe by herself. The medical director stated, she is an elopement risk and definitely needs monitoring of her wandering behaviors. The medical director expected elopement assessments would have been completed for R2, including an assessment following the elopement attempt on 9/6/24. The medical director further expected R2 would be being monitored and I would expect that she would have immediate interventions in place to reduce the risk of elopement. An untitled facility policy regarding elopement dated September 2024 included: All residents are to be assessed for elopement risk and those found at risk will have a resident care plan that addresses the issue . 2.) A Resident Elopement Risk Assessment will be performed at the following times: At time of admission, quarterly, annually, significant change in condition or in Resident behavior, after an elopement attempt, after return from a hospital stay of at least 24 hours, verbalizing desire to leave the facility, anytime a staff member feels a need to reassess a Resident. 3.) If found to be at risk, implement Plan of Care . In the case of an elopement: . 11.) Update Reside[TRUNCATED]