Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision and ensure environmental safety to prevent Resident #1, a vulnerable resident, from exiting the facility unnoticed and unsupervised for one (1) of three (3) residents reviewed. Resident #1 On 3/23/25, Resident #1, who had a Brief Interview for Mental Status (BIMS) score of eight (8), physically pushed out and removed the window screen in his room and exited the building. Resident #1 exited the facility unnoticed and was last seen inside the facility at 6:00 AM by a Certified Nursing Assistant (CNA) and was found at 6:30 AM by facility staff (Dietary Cook) who was reporting to work. The resident was observed by the [NAME] walking around side of the building and was approximately 130 steps away from the building. Resident #1 was wearing shorts only and no shoes. The facility's failure to provide supervision and ensure environmental safety put Resident #1 and other vulnerable residents at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 3/23/25, when Resident #1 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 4/2/25 at 2:40 PM ad provided an IJ Template. Based on the facility's implementation of corrective actions on 3/23/25, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of 3/24/25 prior to the SA's entrance on 4/2/25. Findings include: A review of the facility's policy, Accident and Incidents, dated 2/19/2017, revealed, .It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and those residents receive supervision and assistance devices to prevent accidents whenever possible . A review of the facility's policy, Emergency Procedure-Missing Resident, dated 3/2023, revealed, .Resident elopement resulting in a missing resident is considered a facility emergency . A record review of the facility's investigation, dated 3/25/25, revealed that on 3/23/25 at 6:30 AM, the Dietary [NAME] was entering the facility and noticed a gentleman walking from the side of the building. The gentleman approached the dietary cook at this time, but he was unable to understand him. The [NAME] asked the man to sit on the curb so that he could get some assistance. A housekeeper was within range of the facility entry door and confirmed that the man was a resident of the facility. The housekeeper notified the nurse on duty that the patient was sitting outside his room on the curb. The resident was escorted back into the facility by the Nurse Supervisor and housekeeper. The resident was unable to explain what he was doing. Through staff interviews and investigation, it was determined that the Nurse on Duty last saw the resident at approximately 4:30 AM when she gave him his medications and treatment. The resident was calm and appeared to have no signs of any type of agitation or anxiousness. Certified Nurse Aide (CNA) #1 observed Resident #1 attempting to enter another resident's room at approximately 6:00 AM on 3/23/25 and re-directed the resident. At some point after the encounter with the Nurse on duty and the CNA, the resident opened a window, removed the screen, and exited the building to get air. The weather was approximately 63 degrees and he was wearing shorts. Upon re-entering the building, the resident was assessed with no signs or symptoms of any injuries and no psychosocial harm found. A record review of the admission Record revealed the facility admitted Resident #1 on 3/5/25 with diagnoses including Squamous Cell Carcinoma of the Skin and Lip. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated his cognition was moderately impaired. A record review of the Evaluation Bundle dated 3/6/25, signed by Registered Nurse (RN) #2, indicated the resident was not identified as a wander/elopement risk. A record review of a weather report via https://www.timeanddate.com revealed the temperature at the time of the elopement was approximately 63 degrees On 4/2/25 at 6:40 AM, during an interview with the Assistant Director of Nursing (ADON), she confirmed that on 3/23/25 at 6:30 AM the Dietary [NAME] entered the back employee entrance and noticed a man dressed in shorts, no shirt, and no shoes walking from the west side of the facility. She stated the cook was unable to understand the man's speech and asked a housekeeper to confirm his identity. The housekeeper confirmed the individual was Resident #1. The cook stayed with the resident while the housekeeper retrieved the nurse, who assessed the resident for injuries. The resident was then able to walk back to his room independently. The nurse notified her immediate supervisor, who then contacted the Administrator. On 4/2/25 at 7:00 AM, during an interview with RN #1, she explained that Resident #1 did not exhibit elopement behaviors prior to the incident. She stated that around 4:30 AM on 3/23/25, she found the resident in an empty room and redirected him back to his room, completed wound care, and administered pain medication. Later that morning, the housekeeper notified her that Resident #1 had been found outside near the back entrance. She assessed the resident, noted no injuries, and assisted him back to his room. On 4/2/25 at 7:20 AM, during an interview with Housekeeper #1, she confirmed that on 3/23/25 around 6:30 AM, the Dietary [NAME] asked her if the man outside was a resident. She confirmed that he was and immediately ran to get the nurse. On 4/2/25 at 7:30 AM, during an observation of the area from Resident #1's window to the area he was found, the Assistant Director of Nursing (ADON) confirmed the resident had walked approximately 130 feet from his room to the rear entrance of the facility. On 4/2/25 at 8:00 AM, during a phone interview with CNA #1, she reported that at approximately 6:00 AM on 3/23/25, she observed Resident #1 attempting to enter another resident's room. She redirected him back to his room. At 6:30 AM, she was informed by the housekeeper that the resident had been found outside. She and the nurse assisted him back inside. On 4/2/25 at 8:30 AM, during a phone interview, the Dietary [NAME] confirmed that on 3/23/25 at approximately 6:30 AM, he observed a man walking around the back of the facility and was unable to understand him. He asked a housekeeper to confirm if the individual was a resident. Once confirmed, he remained with the resident until staff arrived. On 4/2/25 at 8:45 AM, during a phone interview with CNA #2, she confirmed that on 3/23/25, she saw Resident #1 sitting on the curb with the Dietary [NAME] as she parked her car. The resident's nurse and CNA #1 brought him back inside. On 4/2/25 at 12:00 PM, during an interview with the Administrator, she confirmed CNA #1 had redirected Resident #1 at 6:00 AM, and that he was later found outside at 6:30 AM. She stated the resident had not been previously identified as an elopement risk and he had been at the facility for a little over two weeks. She confirmed the facility performed a full assessment of the resident, accounted for all residents, conducted a Quality Assurance and Performance Improvement (QAPI) meeting the same day, and implemented corrective actions including in-services, reassessments, window safety checks, and elopement drills on all shifts. She confirmed that she reported the incident to the State Agency and the Attorney General's office. On 4/2/25 at 12:30 PM, during an interview with the Director of Nursing (DON), she stated Resident #1 was evaluated on admission and determined to not be at risk for elopement. She confirmed that he had not exhibited wandering or exit-seeking behavior since his admission, which was 18 days prior to the date of the incident. On 4/2/25 at 1:00 PM, during an interview with the Maintenance Director, he confirmed that after being informed of the elopement, he inspected all doors, windows, and keypads. He installed L-brackets on resident room windows to prevent them from opening more than six inches and conducted elopement drills for all shifts. He also confirmed attending all required in-services. On 4/2/25 at 3:00 PM, during an interview with the Nurse Practitioner (NP), she confirmed that Resident #1 was not identified as an elopement risk and had not exhibited any behavioral issues since his admission date of 3/5/25. The facility submitted a corrective action plan as follows: On 3/23/2025 at 6:35 AM, the Registered Nurse (RN) escorted the resident into the facility and assessed him with no signs or symptoms of injuries with vitals within normal limits. On 3/23/2025 at 6:50 AM, the Director of Nurse (DON) was notified by the nurse supervisor that the resident was outside on the curb and escorted back into the building. DON instructed the nurse supervisor to transfer Resident #1 to the secured unit for increased observation; as well as using a current daily census to perform a head count on all residents, and all residents were accounted for. On 3/23/2025 at 7:50AM, the Administrator was notified of the incident. On 3/23/2025 at 7:55 AM, the Administrator contacted the Maintenance Supervisor to inspect all windows. On 3/23/2025 at 9:15 AM, the Maintenance Director reported to the facility to inspect the windows, all doors, windows, and keypads were working properly. On 3/23/2025 at 9:28 AM, the Administrator notified the State Agency. On 3/23/2025 at 11:50 AM, Licensed Social Worker interviewed Resident #1; he stated he just wanted to get air, and the Licensed Social Worker found no psychosocial harm. On 3/23/2025 at 12:15 PM, the Maintenance Director placed L brackets on all resident windows, which are metal shaped so that the windows are unable to open greater than six inches. On 3/23/2025 at 12:30 PM, an Emergency Quality Assurance Performance Improvement (QAPI) meeting was held that included the Administrator, Medical Director, DON, Regional Director of Operations, Regional Nurse Consultant, Unit Manager, Infection Preventionist, and Staff Development. The QAPI team discussed the adverse event, reviewed the immediate actions taken, reviewed policy and procedures. No changes were made to the policies and procedures. It was determined through staff and resident interview Resident #1 exited the facility by opening the window and removing the screen and going out for air. It was determined the Maintenance Director placed L brackets on all resident windows, which are metal shaped so that the windows are unable to open greater than six inches. QAPI Minutes Included: On 3/23/2025 an in-service was conducted by the Administrator for all staff prior to their oncoming shift and via telephone on missing residents, elopement risk policies, whom and when to notify if there is a missing resident, elopement books and arm band placement on each resident. On 3/23/2025 all windows were verified to be in proper working order by the maintenance supervisor. All windows were secured with L shape brackets to prevent residents from exiting the facility. Maintenance will perform weekly visual inspections for four weeks and monthly thereafter to ensure that all windows and screens are in proper working order. On 3/23/2025 Elopement drills were completed on all shifts (7A-3PM, 3P-11P, 11P-7A) by the maintenance supervisor and Assistant Administrator. Drills will be continued weekly for four weeks and monthly thereafter and will be brought in for review and recommendations during monthly QAPI. Any findings will be addressed immediately by the Administrator and/or Director of Nursing. On 3/23/2025, all staff will be in-serviced for elopement/wandering. No staff will be allowed to work until they have received the in-service. On 3/23/2025, the Nurse on duty moved Resident #1 to the secure unit, every one hour checks were put into place and fresh air walks were initiated. On 3/23/2025 100% of all residents were assessed by the Licensed Practical Nurse to verify that anyone deemed at risk for wandering or elopement proper interventions were in place. In-house census of 146 residents reviewed at this time and there was a total of 58 residents deemed at risk. On 3/23/2025 100 % audit completed for all care plans to verify that any resident deemed a wandering or elopement risk were identified and updated. On 3/23/2025 the Licensed Social Worker assessed Resident #1 to determine that there were no findings of psychosocial harm. Validation: The SA validated through interview and record review view, that all corrective actions had been implemented as of 3/23/25, and the facility was in compliance as of 3/24/25, prior to the SA's entrance on 4/2/25.

Based on interviews, record reviews, and facility policy review, the facility failed to implement care plan interventions related to wandering/elopement risk for one (1) of four (4) resident care plans reviewed. Resident #1. The facility's failure to implement care plan interventions resulted in Resident #1 exiting the facility unsupervised and unnoticed by facility staff. Facility staff took Resident #1 to the therapy gym at approximately 9:50 AM on 8/8/24. She was determined to be missing at 9:55 AM and was found at 10:23 AM, about one (1) mile from the facility. During the investigation, the SA identified an Immediate Jeopardy (IJ) which began on 8/8/24 and existed at 42 CFR: 483.21(b) Comprehensive Care Plans - F656 - Scope and Severity J. This situation placed Resident #1 and other residents at risk for wandering and elopement, at risk for likelihood of serious injury, serious harm, serious impairment, or death. The SA notified the facility's Administrator of the IJ on 8/13/24 at 3:00 PM and provided the Administrator with the IJ template. Based on the facility's implementation of corrective actions on 8/8/24, the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on 8/9/24, prior to the SA's entrance on 8/12/24. Findings Include: A review of the facility's policy, Care Plans, Comprehensive Person-Centered, reviewed on 10/2022, revealed, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . A record review of the Comprehensive Care Plan date initiated 6/28/24 revealed Focus: I am an elopement risk/wanderer r/t (related to) impaired safety awareness, I wander aimlessly .Interventions/Tasks: Distract resident from wandering by offering pleasant diversions such as structured activities, food, conversation, television, book. Date initiated 06/28/2024 . A record review of the admission Record revealed the facility admitted Resident #1 on 06/17/2024 with current diagnoses Altered Mental Status. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/23/24 revealed Section E identified that the resident wandered on one (1) to three (3) days, but the wandering was not considered to have a significant impact on the resident. A record review of the . Wander Evaluation dated 06/28/2024 revealed the resident was at risk for wandering. A record review of the Progress Notes revealed that on 06/28/2024 at 3:48 PM, Social Services (SS) moved the resident to a new unit due to exit-seeking behavior on the Rehabilitation unit. A record review of the facility's investigation, Resident Incident Timeline, revealed that on 08/08/24 at 9:55 AM, the staff identified that Resident #1 was not in the therapy gym where she had been escorted to receive therapy services. The staff were notified that the resident was missing. After searching the building and perimeter, it was determined that the resident had left the facility. The facility called a Code W (elopement) within the facility. The missing resident procedures were initiated, and the resident was located at 10:23 AM, approximately 1 mile from the facility, walking in a residential area. On 08/13/2024 at 1:30 PM, during an interview with Licensed Practical Nurse (LPN) #1, who was also the Care Plan Coordinator, she confirmed that Resident #1 was not identified as an elopement risk upon admission. However, following the 06/28/2024 Wander Evaluation, the resident was identified as being at risk. LPN #1 confirmed that Resident #1's care plan was individualized to ensure the resident's safety. She explained that care plans are designed to provide individualized care for residents and summarize a person's health condition, treatment, and care. She added that she expected all nursing staff in the facility to implement care plan interventions for the residents' safety. During an interview on 08/13/2024 at 2:00 PM with the Director of Nursing (DON), she confirmed that care plans are very important and should be individualized for each resident. She emphasized that care plans tell the story of the resident's condition and treatment plan. The DON stated that she expected the care plan nurse to perform correctly and individualize each resident's care plan, and for all care staff to follow the care plans. She confirmed that the facility staff failed to follow the care plan by not distracting and monitoring the resident as required. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 8/12/24: On 8/13/2024 at 3:00 PM, the State Agency presented an IJ template which notified the Administrator that the facility failed to provide supervision necessary to prevent an elopement for Resident #1, a vulnerable resident, who left the facility unnoticed and unsupervised and failed to implement care plan interventions related to wandering/elopement risks. On 8/8/2024 at 9:55 AM, the staff identified that the resident was not in the therapy gym where she was escorted to receive therapy services. The staff were notified that the resident was missing, after searching the building and perimeter, it was determined that the resident had left the facility. Missing resident procedures were initiated and the resident was located at 10:23 AM by the facilities FNP (Family Nurse Practitioner) and the SDC (Staff Development Coordinator) approximately 1 mile from the facility walking in a residential area. On 8/8/24 at 9:55 AM, RCNA (Rehabilitation Certified Nursing Assistant) noted that resident was not sitting in the chair by the rehab door. The CNA searched the therapy gym area then went back to the Serenity Unit to see if resident was there. Rehab CNA asked staff if resident had returned to the unit: staff noted resident had not returned. All staff immediately began to search for resident on the Serenity Unit. At this time the LPN #1 (Licensed Practical Nurse) on the unit directed all staff to conduct a search of all areas of the building and perimeter. On 8/8/24 at 10:00 AM, code W (elopement) initiated protocols which notified all staff to begin searching. Staff members were assigned by Administrator and DON (Director of Nursing) to search inside and outside of building. Staff members were directed to search the outside perimeters in the direction of the woods and surrounding residential areas. On 8/8/24 at 10:23 AM, LPN #2 and the NP called DON to report the resident safely walking in a residential area about 1 mile east of the facility. Resident was returned to the facility at 10:30 AM. On 8/8/24 at 10:25 AM, staff completed a headcount compared to the daily census and accounted for all residents. On 8/8/24 at 10:30 AM, the Nursing Home Administrator notified state agency of the elopement. On 8/8/24 at 10:35 AM, the resident was returned to her unit, assessed by LPN #1 and a full body audit was completed. No signs or symptoms of injury, face was noted to be flushed, and resident took fluids cooperatively. NP assessed resident on unit, ordered labs, and UA (result negative). NP contacted the psychological NP for medication after ruling out acute episode. Resident is own Resident Representative (RR) and there was no next of kin to notify. On 8/8/2024 at 10:45 AM, the resident was assessed by the LSW (Licensed Social Worker) with no psychosocial harm found. On 8/8/24 at 11:00 AM, the Administrator and DON checked all doors and keypads for proper functioning. All were secure with no issues found. On 8/8/24 at 11:15 AM, the inside door code was changed and will be used for emergency exit only. Entrance and exit through therapy door are now restricted to visitors and staff. All visitors must enter and exit through facility's main entrance. All staff must enter and exit through back door of facility. On 8/8/2024 at 12:00 PM, the Administrator notified the Attorney General's office of the incident. On 8/8/24 at 12:30 PM, Quality Assessment and Performance Improvement (QAPI) committee meeting was held involving missing resident. Staff in attendance were Medical Director, Administrator, Director of Nursing (DON), Assistant DON (ADON)/Infection Preventionist, Housekeeping Supervisor, Regional Nurse Consultant, Business Office Manager, Certified Dietary Manager, Social Services Director, Social Services Assistant, Admissions, Staff Development Coordinator, Medical Records. It was determined through staff interviews and resident interview that the resident exited the facility through the Rehabilitation (gym) door as visitors and staff frequently enter and exit these doors. Through root cause analysis by the DON and Administrator, we determined that the resident exited by following another person out the door before the door was able to close completely; the resident was sitting in a chair five feet from the door. The resident has been known to wander on her unit and exit seek. The resident also stated to the Social Worker on 8/8/24 during their interview that she went for a walk and exited the door. On 8/8/24 the QAPI committee reviewed the incident, actions taken, and the policy was reviewed with no recommendations for change. On 8/8/24, 100% facility staff in-service completed by Staff Development Coordinator, ADON, and Housekeeping Supervisor began regarding elopement/missing resident policies prior to returning to work. On 8/8/24, 100% of all residents assessed for elopement risk by ADON and Staff Development. Twenty-seven new residents were added to elopement/wandering list. On 8/8/24, 100% audit performed of care plans for those identified for elopement risk to include visual monitoring and arm bands conducted by Regional Nurse Consultant. Twenty-seven new residents added to elopement/wandering list. On 8/8/24, 100% audit of wandering residents book completed by Social Services to ensure all pictures are current. On 8/8/24, Elopement drills were performed on all shifts (7A-3P, 3P-11P, 11P-7A) by the Director of Nursing and the Staff Development Coordinator. On 8/8/24, outside keypad to therapy door disabled and removed. Inside door code changed and will be used for emergency exit only. On 8/8/24, entrance and exit through therapy door is restricted to visitors and staff. All visitors must enter and exit through facility's main entrance. All staff must enter and exit through back door of facility. All corrective actions were completed on 8/8/24 and the facility alleges the IJ was removed on 8/9/24. Validation: The State Agency (SA) validation of the Removal Plan was made on-site during the Complaint Investigation (CI) MS #26122 through record review and interviews on the 8/14/24. The SA determined all corrective actions were completed on 8/8/24 and the IJ was removed on 8/9/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, facility policy reviews, and the facility's investigation, the facility failed to provide adequate supervision to prevent Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. The facility's failure to provide supervision resulted in Resident #1 exiting the facility unsupervised and unnoticed by facility staff. Resident #1 was brought to the therapy gym at approximately 9:50 AM on 8/8/24 and left unattended. She was determined to be missing at 9:55 AM and was found at 10:23 AM, about one (1) mile from the facility. During the investigation, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 8/8/24 and existed at 42 CFR: 483.25 (d)(1)(2)- Free of Accidents Hazards/Supervision/Devices (F689) - Scope and Severity J. This situation placed Resident #1 and other residents at risk for wandering and elopement, likely for serious injury, serious harm, serious impairment, or death. The SA notified the facility's Administrator of the IJ and SQC on 8/13/24 at 3:00 PM and provided the Administrator with the IJ template. Based on the facility's implementation of corrective actions on 8/8/24, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 8/9/24, prior to the SA's entrance on 8/12/24. Findings Include: A review of the facility's policy, Accidents and Incidents, dated August 7, 2013, revealed, Policy: It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and that residents receive supervision and assistance devices to prevent accidents whenever possible . A review of the facility's policy, Emergency Procedure-Missing Resident, reviewed 03/2023, revealed, Policy Statement: Resident elopement resulting in a missing resident is considered a facility emergency. Policy Interpretation and Implementation 1. Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety . A record review of the facility's investigation, Resident Incident Timeline, revealed that on 08/08/24 at 9:55 AM, the staff identified that Resident #1 was not in the therapy gym where she had been escorted to receive therapy services. The staff were notified that the resident was missing; after searching the building and perimeter, it was determined that the resident had left the facility. The facility called a Code W (elopement) within the facility. The missing resident procedures were initiated, and the resident was located at 10:23 AM, approximately 1 mile from the facility, walking in a residential area. Upon returning the resident to the facility, the Nurse Practitioner (NP) performed a thorough assessment, with labs and urinalysis performed. The resident's face was noted to be flushed, and the resident took fluids cooperatively. It was determined through staff and resident interviews that Resident #1 exited the facility through the Rehabilitation door, as visitors and staff frequently enter and exit through these doors. During an interview with the Administrator on 08/12/24 at 10:10 AM, it was confirmed that on 08/08/24 at approximately 10:00 AM, Resident #1 exited the facility through the rehabilitation unit and was located approximately 1 mile from the facility at 10:23 AM. The resident had been assisted to the therapy gym at approximately 9:50 AM by a Certified Nurse Aide (CNA) and she was sitting in her favorite chair looking outside the double doors. The NP and Licensed Practical Nurse (LPN) #2 found Resident #1 with a flushed face and brought her back to the facility. Resident #1 was calm while entering the automobile and spoke about robbing a bank. Upon returning to the facility, she was evaluated by the NP, with labs and urinalysis performed. Resident #1 drank water cooperatively. The weather on 08/08/24 at 10:00 AM was clear skies and a temperature of 92 degrees with no rain. The resident wore a cap, jeans, a short-sleeved shirt, a cardigan, and open-toe slides. Following the incident, all residents were accounted for, checked for any problems, and assessed for elopement risk. The resident had no family and was her own Responsible Representative (RR). The facility immediately notified the State Agency (SA) and Attorney General's Office (AGO). The facility began in-services for all staff on Elopement. The Administrator confirmed they held an emergency Quality Assurance and Performance Improvement (QAPI) meeting and began implementing corrective actions. The Administrator stated the facility began to have additional elopement drills and in-serviced all employees on elopement and supervision of residents. The Administrator provided the SA with copies of the statements received regarding the investigation and the sign-in page of the QAPI meeting that was held on the afternoon of the incident to discuss the incident and steps needed to prevent this from happening again. The facility conducted an investigation and submitted it to the SA and AG office. Following their investigation, they determined there were no signs of abuse or neglect. Through a root cause analysis by the Director of Nursing (DON) and Administrator, it was determined that the resident exited by following another person out the door before the door was able to close completely; the resident was sitting in a chair five feet from the door. The resident had been known to wander on her unit and exhibit exit-seeking behavior. During an interview with the DON on 08/12/24 at 10:20 AM, it was confirmed that Resident #1 was admitted to the facility on [DATE], was very weak, and was not initially identified as an elopement risk. She was admitted to the rehabilitation unit for therapy. During her stay, Resident #1 showed signs of improvement and began entering other residents' rooms, carrying laundry, and making/remaking beds. On 06/28/24, a second wandering evaluation was performed, and she was deemed a wandering risk. On 08/12/24 at 10:30 AM, during an interview and observation drive-through with LPN #2 of the route from the facility to the location where Resident #1 was found, the distance was determined to be 1.1 miles. LPN #2 pointed out where Resident #1 was found at the end of the sidewalk, and stated the resident was dressed in pants, a shirt, and a gray sweater with open-toe shoes. During the observation, there were sidewalks on either side of the road, but not on both sides. There were 3-4 cars on the road at the time of the observation. A large waterway was observed along one side of the route, with two signs indicating Caution Alligators and Snakes May Be Present. It was confirmed that when Resident #1 was found, the NP assessed her and observed no injuries. LPN #2 confirmed that when it was determined that Resident #1 was missing from the facility, a Code W was called throughout the entire facility. All staff began to search for Resident #1, and the NP and LPN #2 started driving in search of her. LPN #2 drove west of the building for approximately one mile and found her at the end of the sidewalk. On 08/12/24 at 10:52 AM, during an interview with Rehabilitation Certified Nurse Assistant #1 (R-CNA #1), she revealed that she learned Resident #1 was missing when walked from Resident #1's unit to the Rehabilitation unit and the Speech Therapist (ST) questioned if she had seen Resident #1, but she had not. After not locating Resident #1 in her unit, she immediately reported to the Administrator, and Code W was called, initiating a search for Resident #1. R-CNA #1 confirmed that Resident #1 always sat in the Rehabilitation Unit facing the double doors. She also confirmed that outpatients, staff, and families frequently used the rehab door. On 08/12/24 at 1:05 PM, during an interview with the Maintenance Director, it was revealed that he checked all doors daily, and all doors closed and locked as required. All doors to enter or exit the building required a code. Since the incident with Resident #1, the facility removed the numeric keypad from outside the door to prevent staff and visitors from entering unless a staff member inside the facility let them in. On 08/13/24 at 1:01 PM, during an interview with the Social Worker (SW), it was confirmed that on 06/28/24, when Resident #1 showed signs of wandering, a second wandering evaluation was performed, and the facility then placed Resident #1 in another unit. On 8/13/24 at 1:59 PM, during an interview with CNA #2, she confirmed she assisted Resident #1 to the therapy gym on 8/8/24 at approximately 9:50 AM. She was aware the resident was an elopement risk, and she advised the therapy staff the resident was sitting in her favorite chair waiting for therapy services. A record review of the weather report from the website https://www.wunderground.com/calendar/us/ms/biloxi/KGPT revealed that it was 92 degrees on 08/08/24 at 10:00 AM. A record review of the admission Record revealed that the facility admitted Resident #1 on 06/17/24 with current diagnoses including Altered Mental Status. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/23/24 revealed a Brief Interview for Mental Status (BIMS) score was five (5), indicating that the resident was cognitively impaired. A review of Section E, which addressed behavior, showed that the resident wandered on one (1) to three (3) days, but the wandering was not considered to have a significant impact on the resident. A record review of the Progress Notes revealed that on 06/28/24 at 3:48 PM, social services moved Resident #1 to a new unit due to exit-seeking behavior on the Rehabilitation Unit. A record review of the Wander Evaluation dated 06/17/24 revealed the Resident #1 was not at risk for wandering. A record review of the Wander Evaluation dated 06/28/24 revealed Resident #1 was identified as at risk for wandering as she had grown stronger and was able to ambulate independently on the unit. She expressed a desire to go home which formerly was Tent city for homeless. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 8/12/24: On 8/13/2024 at 3:00 PM, the State Agency presented an IJ template which notified the Administrator that the facility failed to provide supervision necessary to prevent an elopement for Resident #1, a vulnerable resident, who left the facility unnoticed and unsupervised and failed to implement care plan interventions related to wandering/elopement risks. On 8/8/2024 at 9:55 AM, the staff identified that the resident was not in the therapy gym where she was escorted to receive therapy services. The staff were notified that the resident was missing, after searching the building and perimeter it was determined that the resident had left the facility. Missing resident procedures were initiated and the resident was located at 10:23 AM by the facilities FNP (Family Nurse Practitioner) and the SDC (Staff Development Coordinator) approximately 1 mile from the facility walking in a residential area. On 8/8/24 at 9:55 AM, RCNA (Rehabilitation Certified Nursing Assistant) noted that resident was not sitting in the chair by the rehab door. The CNA searched the therapy gym area then went back to the Serenity Unit to see if resident was there. Rehab CNA asked staff if resident had returned to the unit: staff noted resident had not returned. All staff immediately began to search for resident on the Serenity Unit. At this time the LPN #1 (Licensed Practical Nurse) on the unit directed all staff to conduct a search of all areas of the building and perimeter. On 8/8/24 at 10:00 AM, code W (elopement) initiated protocols which notified all staff to begin searching. Staff members were assigned by Administrator and DON (Director of Nursing) to search inside and outside of building. Staff members were directed to search the outside perimeters in the direction of the woods and surrounding residential areas. On 8/8/24 at 10:23 AM, LPN #2 and the NP called DON to report the resident safely walking in a residential area about 1 mile east of the facility. Resident was returned to the facility at 10:30am. On 8/8/24 at 10:25 AM, staff completed a headcount compared to the daily census and all residents were accounted for. On 8/8/24 at 10:30 AM, the Nursing Home Administrator notified state agency of the elopement. On 8/8/24 at 10:35 AM, the resident was returned to her unit, assessed by LPN #1 and full body audit was completed. No signs or symptoms of injury, face was noted to be flushed, and resident took fluids cooperatively. NP assessed resident on unit, ordered labs, and UA (resulted negative). NP contacted the psychological NP for medication after ruling out acute episode. Resident is own Resident Representative (RR) no next of kin to notify. On 8/8/2024 at 10:45 AM, the resident was assessed by the LSW (Licensed Social Worker) with no psychosocial harm found. On 8/8/24 at 11:00 AM, the Administrator and DON checked all doors and keypads for proper functioning, all were secure with no issues found. On 8/8/24 at 11:15 AM, inside door code changed and will be used for emergency exit only. Entrance and exit through therapy door are now restricted to visitors and staff. All visitors must enter and exit through facility's main entrance. All staff must enter and exit through back door of facility. On 8/8/2024 at 12:00 PM, the Administrator notified the Attorney General's office of the incident. On 8/8/24 at 12:30 PM, Quality Assessment and Performance Improvement (QAPI) committee meeting was held involving missing resident. Staff in attendance were Medical Director, Administrator, Director of Nursing (DON), Assistant DON (ADON)/Infection Preventionist, Housekeeping Supervisor, Regional Nurse Consultant, Business Office Manager, Certified Dietary Manager, Social Services Director, Social Services Assistant, Admissions, Staff Development Coordinator, Medical Records. It was determined through staff interviews and resident interview that the resident exited the facility through the Rehabilitation (gym) door as visitors and staff frequently enter and exit these doors. Through root cause analysis by the DON and Administrator, we determined that the resident exited by following another person out the door before the door was able to close completely; the resident was sitting in a chair five feet from the door. The resident has been known to wander on her unit and exit seek. The resident also stated to the Social Worker on 8/8/24 during their interview that she went for a walk and exited the door. On 8/8/24 the QAPI committee reviewed the incident, actions taken, and the policy was reviewed with no recommendations for change. On 8/8/24, 100% facility staff in-service completed by Staff Development Coordinator, ADON, and Housekeeping Supervisor began regarding elopement/missing resident policies prior to returning to work. On 8/8/24, 100% of all residents assessed for elopement risk by ADON and Staff Development. Twenty-seven new residents added to elopement/wandering list. On 8/8/24, 100% audit performed of care plans for those identified for elopement risk to include visual monitoring and arm bands conducted by Regional Nurse Consultant. Twenty-seven new residents added to elopement/wandering list. On 8/8/24, 100% audit of wandering residents book completed by Social Services to ensure all pictures are current. On 8/8/24, Elopement drills were performed on all shifts (7A-3P, 3P-11P, 11P-7A) by the Director of Nursing and the Staff Development Coordinator and will continue for 4 weeks then monthly for QAPI review and recommendations. Any findings will be addressed immediately by the Administrator or DON. On 8/8/24, outside keypad to therapy door disabled and removed. Inside door code changed and will be used for emergency exit only. On 8/8/24, entrance and exit through therapy door is restricted to visitors and staff. All visitors must enter and exit through facility's main entrance. All staff must enter and exit through back door of facility. All corrective actions were completed on 8/8/24 and the facility alleges the IJ was removed on 8/9/24. Validation: The State Agency (SA) validation of the Removal Plan was made on-site during the Complaint Investigation (CI) MS #26122 through record review and interviews on the 8/14/24. The SA determined all corrective actions were completed on 8/8/24 and the IJ was removed on 8/9/24.