**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.09(I) Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent elopement (when a resident leaves the premises or a safe area without authorization) for 2 (Residents 1 and 2) of 3 sampled residents. The facility census was 198. The facility Administrator for Emerald Nursing and Rehab [NAME] was notified on 07/02/2024 at 5:30 PM of an Immediate Jeopardy (IJ) which began on 06/29/2024. The IJ was removed on 07/02/2024, as confirmed by surveyor onsite verification. Findings are: A record review of the facility's undated Missing Resident/Elopement Procedure revealed all nursing staff were responsible for knowing the whereabouts of residents for which they were assigned. Each resident was required to advise the nurse in charge when the resident left the building. Residents were not permitted to leave the building alone unless a physician order was present. Residents identified as cognitively impaired and assessed as an elopement risk were to be provided with an elopement prevention device and all personnel were responsible for promptly going to the location and determining the cause of an activated audible door alarm. In the event a resident cannot be located the charge nurse of the missing resident was to activate the elopement procedure, contact the Administrator and Director of Nursing immediately, and assign staff to search the building and grounds. The Administrator/Designee was responsible for initiating (starting) detailed documentation of all actions taken and efforts made to locate the resident immediately after or at the time of the event and contacting the State Department of Public Health. A record review of the facility's Elopement Education dated 03/28/2024 revealed that lists were provided at the nurse's stations for residents that were currently at risk for elopement. If the staff had concerns of a resident wandering or wanting to leave, management needed notified. An elopement book at the receptionist desk identified residents as well. For residents that wanted to leave the building, staff was to notify the reception desk to ensure they sign out and were safe to do so. A. A record review of Resident 1's Clinical Census dated 07/02/2024 revealed the resident was admitted to the facility 06/17/2024. A record review of Resident 1's Medical Diagnosis dated 07/02/2024 revealed the resident had diagnoses of: Unspecified Sequelae Of Nontraumatic Subarachnoid Hemorrhage (a brain bleed), Alcohol Dependence, Uncomplicated, Alcoholic Liver Disease, Other Seizures (uncontrolled jerking or shaking events), Unspecified, Type 2 Diabetes Mellitus Without Complications (uncontrolled blood sugar), Depression, and Pain. A record review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) with a Target Date of 06/24/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) 9 of 15 which indicated the resident was moderately cognitively impaired (difficulty with mental function and skills). The resident was independent with mobility and all activities of daily living (ADL) except eating. The resident had wandered (walked around aimlessly) 1 to 3 days in the lookback period. A record review of Resident 1's Nursing admission Data Collection - V 2 dated 06/17/2024 revealed the resident had a history of exit seeking, wandering away, or getting lost. The resident had a pertinent diagnosis of Dementia (confusion) Alzheimer's disease, Anxiety disorder, or Delusions and was capable of independent mobility. The resident was a potential elopement risk. A record review of Resident 1's Clinical Physician's Orders dated 07/02/2024 revealed the resident had a wanderguard safety device (device worn that would set off an alarm if the resident got close to an alarmed door). The Clinical Physician's Orders did not reveal the resident had a physician order to leave the building alone. A record review of Resident 1's Care Plan with an admission date of 06/17/2024 revealed the resident had impaired cognitive function or impaired decision making. The resident was at risk for elopement related to cognition and wandering with a goal of the resident would not exit the facility unaccompanied by staff or family through the next review date. The risk for elopement intervention was the resident was currently wearing a wandering device on the left wrist. A record review of Resident 1's Progress Note dated 06/17/2024 at 12:40 PM revealed Social Services (SS) documented the resident was unaware why he was at the facility, and nobody told the resident anything, they just dropped the resident off. SS did tell the resident there was concerns with memory and cognition. SS encouraged the resident to check out the building and that the resident could not exit the front door alone. The resident was observed checking out various areas of the building and getting familiar with things. SS notified the front desk that the resident may be checking out the building and if the resident was in the lobby unsure which direction to go, help guide Resident 1. A record review of Resident 1's Progress Note dated 06/17/2024 at 5:59 PM revealed Resident 1 was assessed as an elopement risk. A record review of Resident 1's Progress Note dated 06/27/2024 revealed the resident believed the resident had a flight to catch in Omaha and packed up belongings. The resident was not easy to redirect. The resident was confused and unaware what city the resident was in. The resident went to the first floor looking for the main entrance. The resident was assisted back to the 2nd floor by a Nursing Assistant (NA) and was not able to find own way back. A record review of the facility's Waunderguard Master Resident List dated 06/28/2024 revealed Resident 1 was on the list for having a wanderguard. A record review of Resident 1's Progress Note dated 06/29/2024 at 12:07 PM revealed the resident had increased confusion and constantly seemed lost. The resident had been packing belongings all night and the staff was not able to redirect. The resident was constantly wandering in the hallways without direction or purpose. The management was notified, and the resident was being moved to Station 5 (the locked memory care unit) for safety related to increased confusion and wandering. A record review of the facility's Incidents By Incident Type dated 01/02/2024 to 07/02/2024 did not reveal resident 1 had an Elopement Incident. A record review of the facility's unnamed reportable incidents list dated 04/03/2024 through 07/01/2024 did not reveal Resident 1 had an elopement. A record review of the facility's undated Elopement list for the previous 6 months did not reveal Resident 1 had eloped. A record review of Resident 1's Progress Notes dated 06/17/2024 to 7/1/2024 did not reveal the resident had eloped from the facility. A record review of the facility's unnamed resident sign-out list dated 06/27/2024 - 06/28/2024 did not reveal Resident 1 signed out of the facility with Resident 2 on 06/29/2024 at 9:47 AM. An observation on 07/02/2024 at 7:00 AM revealed the front door to the facility was unlocked and no staff was in sight until entering the administrative offices. In an interview on 07/02/2024 at 10:14 AM, Rec-F confirmed there is a book kept in the cabinet at the receptionist's desk that contained a list of residents with wanderguards and a list of residents with Community Access Passes, a photo of the resident, and the resident's demographic information. The book indicated if a resident could leave the facility and where they were allowed to go, and the wanderguard list indicated the resident was not to leave the facility without staff or family. Rec-F confirmed Rec-F does not refer to the binder that contained the wanderguard list, Community Access Passes, resident photos, and resident demographics. In a telephone interview on 07/02/2024 at 11:50 AM, Nursing Assistant (NA)-B that was scheduled to be working Station 4 on 06/29/2024 confirmed NA-B was not working on Station 4, NA-B was transferred to Station 5. NA-B confirmed NA-B knew Resident 1 and the resident had a wanderguard on that should have gone off when the resident attempted to leave the facility. NA-B confirmed the staff on Station 4 was running around looking for the resident on that date after being unable to locate [gender]. NA-B confirmed Resident 2 went in and out of the facility all day. In a telephone interview on 07/02/2024 at 12:07 PM, NA-C that was scheduled to be working Station 4 on 06/29/2024 confirmed that NA-C left for a break and Residents 1 and 2 were outside as NA-C left the facility. NA-C confirmed Resident 1 had a wanderguard and should not have been outside of the facility, but NA-C confirmed NA-C did not notify anyone. When NA-C returned to the facility after the break, NA-C heard Residents 1 and 2 were at Zestos on the other side of South Street. NA-C reported the incident to the charge nurse. NA-C was then instructed to take Resident 1 to station 5 as soon as possible. NA-C confirmed there was supposed to be a list of residents with wanderguards but NA-C doesn't check it and NA-C did not know what residents were on the list. NA-C revealed nobody was checking the wanderguards and NA-C was unsure who was supposed to be checking the wanderguards. In a telephone interview on 07/02/2024 at 12:23 PM, NA-D that was scheduled to be working Station 4 on 06/29/2024 confirmed that NA-D was very busy that day and heard that Residents 1 and 2 had gone across the street but was not sure when Resident 1 took Resident 2 across the street. NA-D confirmed that none of the staff realized the residents were gone. NA-D confirmed the staff let Resident 1 and 2 do what they want. NA-D confirmed that after the incident, the staff took Resident 1 directly to Station 5, the locked unit. NA-D confirmed some residents could go out and some could not. NA-D confirmed NA-D was unaware how to determine what each resident was allowed to do. NA-D confirmed the nurse lets the staff know who can go out by themselves. NA-D confirmed the staff is unaware of when the residents leave the floor. In an interview on 07/02/2024 at 12:48 PM, Unit Director (UD)-E confirmed UD-E was on call at the time of the incident, but not at the facility. The Social Worker was at the facility and reported to UD-E. UD-E confirmed that Resident 2 talked Resident 1 into taking Resident 2 across South Street to Zestos. UD-E confirmed that Resident 1 had a wanderguard bracelet on at the time and was not sure why it did not trigger the alarm system. UD-E confirmed that every nurse's station had a list of residents that wear a wanderguard. UD-E confirmed UD-E tested the wanderguard and it worked, but if the wanderguard bracelets get close to expiration, they get glitchy and don't always read correctly. UD-E confirmed that Resident 1 was younger, ambulates without an assistive device unhindered (without being slowed or more difficult), and talked like the resident knew what they were saying. Resident 1 was very deceptive and that may be why the staff allowed the resident to leave the facility. UD-E revealed the Director of Nursing (DON) confirmed [gender] was working on the investigation and report on 06/29/2024. In an interview on 07/02/2024 at 3:56 PM, the DON confirmed that while investigating the Resident 1 and Resident 2 incident on 06/29/2024, the DON reviewed the progress notes for Resident 1 and seen Resident 1 had increased confusion, was exit-seeking more, and was packing the resident's things up to leave, so the DON decided it was best to get Resident 1 to a locked unit. In an interview on 07/08/2024 at 3:28 PM, Resident 2 confirmed that Resident 2 did not know that Resident 1 had a wanderguard bracelet on or that Resident 1 was not supposed to leave the facility. Resident 2 confirmed that Resident 2 had gone across the street several times before and it was not an issue. Resident 2 confirmed that Resident 2 was in a wheelchair at the time and Resident 1 pushed [gender] across the street. Resident 2 confirmed Resident 2 signed in and out but was unaware if Resident 1 did. Resident 2 confirmed 2 staff members from the facility came to Zesto's to tell the residents to go back to the facility. Resident 2 confirmed Resident 2 had not been told they could not go across the street. In a telephone interview on 07/02/2024 at 11:37 AM, Rec-A confirmed Resident 1 came to the reception desk where Resident 2 withdrew 60 dollars to go across the street to Zesto's to get ice cream. Resident 2 signed themselves out in the unnamed resident sign-out list dated 06/27/2024 - 06/28/2024 and went outside. Resident 2 then came back in the facility and Resident 1 and Resident 2 got together and were leaving the facility. Rec-A confirmed that another resident with a wanderguard set off the alarm. Rec-A then cleared the alarm and a line of people left the facility that included Resident 1 and Resident 2. Rec-A confirmed that Resident 2 was sitting outside smoking and Resident 1 was also there. Rec-A confirmed that Rec-A thought Resident 1 was just a visitor and did not think anything about it. Later, 2 staff entered the building and told Rec-A that Resident 1 was out and had a wanderguard on. The 2 staff went to get the residents and the residents were at Zesto's. Rec-A confirmed there is a list of residents that says where the resident is allowed to go at the receptionist desk and Resident 1 was not on there yet due to Resident 1 was a new resident. Rec-A again confirmed Rec-A thought Resident 1 was just a visitor pushing Resident 2 around. Rec-A confirmed it can get too busy in the lobby and 1 person cannot watch all the people coming and going. Rec-A confirmed there was a master list of residents with wanderguards in the computer and that the staff has to pull up the resident's Electronic Medical Record to see a picture of a resident. In an interview on 07/02/2024 at 1:35 PM, the facility's Administrator confirmed the facility has the security video of Residents 1 and 2 leaving the facility and the receptionist knew where the residents were going, so the Administrator confirmed that the facility's management group determined it was not an elopement. The Administrator confirmed that it was not until 10:55 AM that the Administrator was contacted by the facility. The Administrator confirmed that the facility's receptionist was the one that made the determination that it was safe for Resident 1 and Resident 2 to leave the grounds to go across South Street to Zesto's. In an interview on 07/02/2024 at 8:01 PM, the Clinical Consultant (CC) confirmed that the receptionist that was working on 06/29/2024 should not have turned off the wanderguard alarm system to let Resident 1 leave the facility. B. A record review of Resident 2's Clinical Census dated 07/02/2024 revealed the resident was admitted to the facility 11/10/2023. A record review of Resident 2's Medical Diagnosis dated 07/02/2024 revealed the resident had diagnoses of: Presbyopia (eye disease), Myopia, Unspecified Eye (nearsighted), Nonexudative Age-Related Macular Degeneration, Bilateral, Stage Unspecified (chronic eye disease), Morbid (Severe) Obesity Due To Excess Calories (very overweight), Non-Pressure Chronic Ulcer Of Other Part Of Left Foot Fat Layer Exposed (deep left foot wound), Acquired Absence Of Other Left Toe(s), Chronic Obstructive Pulmonary Disease (COPD), Unspecified, Chronic Combined Systolic (Congestive) And Diastolic (Congestive) Heart Failure (CHF), Unspecified, Type 2 Diabetes Mellitus Without Complications (uncontrolled blood sugar), Depression, and Pain. A record review of Resident 2's MDS dated of 04/23//2024 revealed the resident had a BIMS score of 13 of 15 that indicated the resident was cognitively aware. The resident was needed partial/moderate staff assistance with most ADL's except eating and oral hygiene (cleaning). The resident needed setup assistance with all areas of mobility. The resident required the use of a walker or wheelchair. The resident had 2 or more falls with injury in the lookback period. The resident did not wander. Resident 2 did have oxygen. A record review of Resident 2's Care Plan with an admission date of 12/27/2023 revealed the resident had the following focus areas: functional deficit with current ADL's, at risk for falls, impaired visual function, appropriate for long term care related to the need for 24/7 (24 hours per day, 7 days per week) supervision/care and the potential for a mood problem related to depression. A record review of Resident 2's Nursing admission Data Collection - V 2 dated 04/23/2024 did not reveal the resident had a history of exit seeking, wandering away, or getting lost. The resident did not have a pertinent diagnosis of Dementia (confusion) Alzheimer's disease, Anxiety disorder, or Delusions and was capable of independent mobility. A record review of Resident 2's Clinical Physician's Orders dated 07/02/2024 revealed a provider order of: May go out of facility with responsible person with all meds (medications) PRN (as needed). A record review of the facility's Incidents By Incident Type dated 01/02/2024 to 07/02/2024 did not reveal resident 2 had an elopement incident. A record review of the facility's unnamed reportable incidents list dated 04/03/2024 through 07/01/2024 did not reveal Resident 2 had an elopement. A record review of the facility's undated Elopement list for the previous 6 months did not reveal Resident 2 had eloped. A record review of the facility's unnamed resident sign-out list dated 06/27/2024 - 06/28/2024 revealed Resident 2 signed out of the facility on 06/29/2024 at 9:47 AM but did not sign back in. A record review of the Community Access Pass Master List dated 06/21/2024 revealed Resident 2 was on the list and was approved to sit out front only. An observation on 07/08/2024 at 3:28 PM revealed Resident 2 was exiting the public restroom walking with a 4 wheeled walker. The resident went to the receptionist desk and got the resident's cigarettes, then continued to the smoking area in the facility's courtyard. The resident walked very slowly and was short of breath. In an interview on 07/02/2024 at 10:14 AM, Rec-F confirmed there is a book kept in the cabinet at the receptionist's desk that contained a list of residents with wanderguards and a list of residents with Community Access Passes, a photo of the resident, and the resident's demographic information. Rec-F confirmed Rec-F does not refer to the binder that contained the wanderguard list, Community Access Passes, resident photos, and resident demographics. The book indicated if a resident could leave the facility and where they were allowed to go, and the wanderguard list indicated the resident was not to leave the facility without staff or family. Rec-F confirmed Resident 2 had a Community Access Pass, but the resident was approved to sit out front only. In a telephone interview on 07/02/2024 at 11:50 AM, Nursing Assistant (NA)-B that was scheduled to be working Station 4 on 06/29/2024 confirmed NA-B was not working on Station 4, NA-B was transferred to Station 5. NA-B confirmed NA-B knew Resident 2. NA-B confirmed the staff on Station 4 was running around looking for the residents (Resident 1 and 2). NA-B confirmed Resident 2 went in and out of the facility all day. In a telephone interview on 07/02/2024 at 12:07 PM, NA-C that was scheduled to be working Station 4 on 06/29/2024 confirmed that NA-C left for a break and Residents 1 and 2 were outside as NA-C left the facility. NA-C confirmed Resident 1 had a wanderguard and should not have been outside of the facility, but NA-C confirmed NA-C did not notify anyone. When NA-C returned to the facility after the break, NA-C heard Residents 1 and 2 were at Zestos on the other side of South Street. NA-C reported the incident to the charge nurse. In a telephone interview on 07/02/2024 at 12:23 PM, NA-D that was scheduled to be working Station 4 on 06/29/2024 confirmed that NA-D was very busy that day and heard that Residents 1 and 2 had gone across the street but was not sure when Resident 1 took Resident 2 across the street. NA-D confirmed that none of the staff realized the residents were gone. NA-D confirmed the staff lets resident 1 and 2 do what they want. NA-D confirmed the nurse lets the staff know who can go out by themselves. NA-D confirmed the staff is unaware of when the residents leave the floor. In an interview on 07/02/2024 at 12:48 PM, Unit Director (UD)-E confirmed UD-E was on call at the time of the incident, but not at the facility. The Social Worker was and reported to UD-E. UD-E confirmed that Resident 2 talked Resident 1 into taking Resident 2 across South Street to Zestos. UD-E confirmed that Resident 1 had a wanderguard bracelet on at the time and was not sure why it did not trigger the alarm system. UD-E confirmed that every nurse's station had a list of residents that wear a wanderguard. UD-E confirmed UD-E tested the wanderguard and it worked, but if the wanderguard bracelets get close to expiration, they get glitchy and don't always read correctly. UD-E confirmed that Resident 1 was younger, ambulates without an assistive device unhindered (without being slowed or more difficult), and talked like the resident knew what the resident was saying. Resident 1 was very deceptive and that may be why the staff allowed the resident to leave the facility. UD-E confirmed that the Director of Nursing (DON) confirmed the DON was working on the investigation and report on 06/29/2024. In an interview on 07/08/2024 at 3:28 PM, Resident 2 confirmed that Resident 2 did not know that Resident 1 had a wanderguard bracelet on or that Resident 1 was not supposed to leave the facility. Resident 2 confirmed that Resident 2 had gone across the street several times before and it was not an issue. Resident 2 confirmed that Resident 2 was in a wheelchair at the time and Resident 1 was nice to push me across the street. Resident confirmed the only place the residents went was to Zesto's to get ice cream. Resident 2 confirmed Resident 2 signed in and out but don't know if Resident 1 did. Resident 2 confirmed 2 staff members from the facility came to Zesto's to tell the residents to go back to the facility. Resident 2 confirmed Resident 2 had not been told they could not go across the street. Resident 2 confirmed the resident has gone across the street several time to the liquor store to get cigarettes, the Mexican restaurant and to Zesto's and has never been told the resident was not supposed to leave the property. In a telephone interview on 07/02/2024 at 11:37 AM, Rec-A confirmed Resident 1 came to the reception desk where Resident 2 withdrew 60 dollars to go across the street to Zesto's to get ice cream. Resident 2 signed self out in the unnamed resident sign-out list dated 06/27/2024 - 06/28/2024 and went outside. Resident 2 then came back in the facility and Resident 1 and Resident 2 got together and were leaving the facility. Rec-A confirmed that another resident with a wanderguard set off the alarm. Rec-A then cleared the alarm and a line of people left the facility that included Resident 1 and Resident 2. Rec-A confirmed that Resident 2 was sitting outside smoking and Resident 1 was also there. Rec-A confirmed that Rec-A thought Resident 1 was just a visitor and did not think anything about it. Later, 2 staff entered the building and told Rec-A that Resident 1 was out and had a wanderguard on. The 2 staff went to get the residents and the residents were at Zesto's. Rec-A confirmed there is a list of residents that says where the resident is allowed to go at the receptionist desk and Resident 1 was not on there yet due to Resident 1 was a new resident. Rec-A again confirmed Rec-A thought Resident 1 was just a visitor pushing Resident 2 around. Rec-A confirmed it can get too busy in the lobby and 1 person cannot watch all the people coming and going. Rec-A confirmed there was a master list of residents with Community Access Passes and where the residents were allowed to go and there was a master list of wanderguards in the computer and that the staff has to pull up the resident's Electronic Medical Record to see a picture of a resident. In an interview on 07/02/2024 at 1:35 PM, the facility's Administrator confirmed the facility has the security video of Residents 1 and 2 leaving the facility and the receptionist knew where the residents were going, so the Administrator confirmed that the facility's management group determined it was not an elopement. The Administrator confirmed that it was not until 10:55 AM that the Administrator was contacted by the facility. The Administrator confirmed that the facility's receptionist was the one that made the determination that it was safe for Resident 1 and Resident 2 to leave the grounds to go across South Street to Zesto's. In an interview on 07/02/2024 at 4:35 PM, the facility's Manager of Operations (MOO) confirmed that when a resident was issued a Community Access Pass, Social Services has a conversation with the UD and the resident's physician to determine the extent to where the resident is allowed to go. The facility's Manager of Operations confirmed that when it was decided that the resident was approved to sit out front only, meant the resident was to stay on the facility grounds. In an interview on 07/02/2024 at 1:42 PM, the DON confirmed the facility's Community Access Pass Master List dated 06/21/2024 revealed Resident 2 was approved to sit out front only. C. Emerald Nursing and Rehab [NAME] was previously cited on 03/28/2024 at the immediate jeopardy level J for an elopement of a resident who walked out the front door and the facility staff were unaware who was at risk for elopements or who wore wanderguards. Abatement Statement was received 07/02/2024 at 9:50 PM. Identified Opportunity for Improvement/Deficient Practice: -Resident 1 currently resides on a locked unit. -Resident 2 is currently hospitalized . Community Pass has been revoked Process/Steps to Identify others having the potential to be impacted by the same deficient practice: -Staff member who shut the Wanderguard system off has been suspended pending investigation related to supporting documentation that (gender) had been educated on facility procedures. -Immediate Education to Receptionist with Competency on 7/2/24. -Community Pass Policy revised as a Best Practice of the facility and not a physician's order. -Current Community Pass residents will be evaluated for prior restrictions to ensure following revised policy by 7/5/24. Measures put into place/systematic changes to ensure the deficient practice does not recur: -Receptionist staff will be re-educated with Competency by the Administrator or designee on resident safety with community passes and wanderguards prior to next immediate shift. -All staff will be re-educated by the Administrator or designee on resident safety with community passes and wanderguards immediately. -Competency will be placed in Orientation for all new hires and agency staff. Plan to monitor performance to ensure solutions are sustained. -Audits to be completed to ensure receptionist are knowledgeable about resident safety with community passes and wanderguards 3 times per week for 1 month and then monthly times 3. -The Plan of correction will be reviewed bu QAPI committee for the next 3 months. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7 Licensure Reference Number 175 NAC 12-006.18B Based on record review and interviews, the facility failed to ensure elopement (unsupervised wandering that leads to the resident leaving the facility without facility staff knowledge) door alarms were functioning, which affected 1 (Resident 3) of 14 sampled residents. The facility failed to ensure all staff were aware of residents who were at risk for elopement which affected 1 (Resident 3) out of 5 sampled residents. This had the potential to affect 14 residents identified at risk for elopement. The facility census was 206. Findings are: A record review of Resident 3's admission Record dated 3/8/2023 revealed that Resident 3 was admitted to the facility on [DATE] with diagnoses of: Ataxia (have problems coordinating how your muscles work, leading to awkward, unwieldy or clumsy movements) following unspecified cardiovascular disease (conditions that affect blood flow and the blood vessels in the brain), Cerebral infarction ( clot blocks a blood vessel that feeds the brain) due to unspecified occlusion of the left cerebellar artery, Attention and concentration deficit (forgetfulness, problems staying on task, easily distracted, easily bored, easily confused and difficulty following instructions), Metabolic Encephalopathy(chemical imbalance in the blood, when the imbalance affects the brain, it can lead to personality changes), Chronic heart failure, Type 2 diabetes, and Urinary Tract Infection. A record review of the Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a residents plan of care) dated 12/ 31/ 2023 revealed Resident 3 had a Brief Interview for Mental Status(BIMS-a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 10 which indicates Resident 3 was moderately cognitively impaired. In Behaviors Section E the question has the resident wandered, was answered no behavior exhibited. In Section GG of the MDS revealed that Resident 3 required some help from another person with all activities of daily living (ADL's). A record review of the Nursing admission Data Collection form dated 12/15/2023 revealed there was no indication or history of exit seeking, wandering away or getting lost and was the resident was determined not to be an elopement risk. A record review of the Social Services admission Data Collection form dated 12/18/2023 revealed that Behavior factors was marked as none above, indicating the resident had no wandering or exit seeking behaviors. A record review of the Comprehensive Care Plan (CCP-written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) dated 12/21/2023 revealed Resident 3 was not an elopement risk. A record review of the Progress Notes dated 3/22/2024 at 2:15 PM revealed Resident 3 had increased confusion and agitation, and was exit seeking. A Wander Guard (A Wander Guard system relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts the caregivers), bracelet had been placed on Resident 3's wrist per the Unit Manager. A record review of the Progress Notes and the Nursing assessment forms revealed no documentation from 3/22/2024 through 3/27/2024 of an Elopement Assessment after placement of the wander guard on Residents 3's wrist. A record review of the Facility Investigation Report dated 3/28/2024 for Resident 3 revealed that on 3/27/2024 at 7:17 PM Resident 3 had left the facility through the front door without staff supervision or knowledge. At 7:37 PM Resident 3 was returned to the facility after a bystander assisted Resident 3 when Resident 3 tipped over in the wheelchair on South Street while Resident 3 was trying to cross South Street. Resident 3 received a skin tear to left elbow and left arm from the fall. Resident 3 was wearing sweat pants and T-shirt when [gender] left the facility. The weather at the time when the resident left the facility was 45 degrees per channel 10/11 news. The front door Wander Guard system failed to alarm when Resident 3 was close to the front door. A record review of the Maintenance log in the Tel's (technology is designed specifically for Senior Living to create safer environments and increase Life Safety compliance. Boost the efficiency of your maintenance teams and gain control over your operations) system for checking the Wander Guard system on the doors revealed that on 2/29/2024 a test of the doors,locks and alarms was documented as completed. The next due date to check functioning of the doors, locks and alarms was scheduled for 3/31/2024. A record review in the Progress Notes dated 3/27/2024 at 7:45 PM revealed Resident 3's Wander Guard bracelet on the resident's wrist was functioning. An interview on 3/28/2024 at 11:30 AM with the Unit Manager (UM) revealed Resident 3 had never been an elopement risk before, and was able to go down to the bistro or activities, and would always come back up to [gender] room. UM confirmed that [gender] received a call on 3/22/2024 regarding Resident 3 exit seeking and increased agitation and informed the staff to put a Wander Guard bracelet on Resident 3. An interview on 3/28/2024 at 3:30 PM with Maintenance Director (MD) confirmed [gender] got a call on 3/27/2024 at 8:00 PM from the facility regarding the malfunction of the Wander Guard door alarm, which was not alarming when a resident with a Wander Guard went through the front door. MD arrived at the facility at 9:00 PM and reset the Wander Guard system. MD confirmed that [gender] did not know why the wander guard system did not alarm. MD also confirmed the wander guard system on the doors are checked monthly. An interview on 3/28/2024 at 4:45 PM with the Electrical contract company (EC) came out to check the Wander Guard system to make sure the system was functioning properly. EC confirmed that [gender] is not sure why the wander guard system malfunctioned. EC checked the timing and wires and verified set up and tested the system and everything was functioning properly. An interview on 3/29/2024 at 11:30 AM with Medication Aide (MA)-A confirmed that [gender] is not aware of how often the Wander Guards are checked on residents who have a bracelet. MA-A confirmed [gender] is not aware of which residents have a Wander Guard on, or the residents who are at risk for elopement. An interview on 3/29/2024 at 11:45 AM with Licensed Practical Nurse (LPN)-G confirmed that the nurses check the function of the Wander Guard bracelets on the residents who are risk for elopement every shift. LPN -G also confirmed that nursing assistants do not necessarily know which residents are at risk for elopement, but the nurses do know. LPN-G confirmed that the wander guard system had this little device that when put up to the wander guard bracelets it would turn green if the wander guard was working and if it turned red the wander guard bracelet would be replaced. LPN-G confirmed that the wander guard bracelets had expiration dates on them. An interview on 3/29/2024 at 2:30 PM with Nursing Assistant (NA)-D, confirmed that Wander Guards are on the resident's wrist, ankle, or wheelchair. NA-D further confirmed [gender] is not aware if there is a list of residents who have Wander Guard on, and is not aware of the residents who are at risk for elopement. NA-D confirmed that the nurses check the Wander Guards with a machine. If the machine turns green, then its working and if it turns red then the wander guard is not working. An interview on 3/29/2024 at 2:45 PM with MA-B confirmed that [gender] is not aware of which residents are at risk for elopement or which residents are wearing a Wander Guard. MA-B does know that the nurses are checking them on the evening shift but not aware of what other shifts do. An interview on 3/1/20204 at 3:30 PM per phone call with Receptionist who monitors the front desk by the front door revealed, that on 3/27/2024 at 7:17 PM, the Receptionist did not notice Resident 3 in the front lobby, nor did [gender] notice that Resident 3 went out the front door. The Receptionist confirmed that Resident 3 may have went out the front door when [gender] went to the bathroom. The Wander Guard system did not alarm when Resident 3 exited through the front door. The Receptionist further confirmed [gender] is not aware of any residents who are at risk for elopement or which residents have a Wander Guard on. The Receptionist also revealed that [gender] is aware of who the smokers are and the residents who have the Resident community access/pass. An interview on 3/28/2024 at 3:30 PM with the Administrator confirmed that Resident 3 was able to leave the unit that Resident 3 lives on to go to the Bistro, or activities provided in other areas of the building. The Administrator confirmed that Resident 3 has the right to go any where in the building. An interview on 3/28/2024 at 12:30 PM with the Director of Nursing (DON) confirmed that on 3/22/2024 an Elopement Assessment was not done for Resident 3 and should have been done. The DON confirmed that the nurses check that the Wander Guard bracelet is functioning every shift, but they do not check the functioning of the Wander Guard system on the doors. The DON confirmed that Resident 3 was able to attend activities and go to the Bistro but that Resident 3 did not leave Unit 4 by self. An interview on 3/28/2024 at 1:30 PM with the Clinical Consultant (CC) confirmed that on 3/22/2024 an Elopement Assessment should of been completed and was not done for Resident 3. The CC confirmed that after the Elopement of Resident 3, during the Risk Management meeting areas of concern were identified. The CC revealed that there was no Policy and Procedure for Wandering/Behavior or Elopement for residents at risk. The CC confirmed that Nursing Assessments are to be done quarterly and that the Nursing Assessments are not being done quarterly. The CC also confirmed that the Nursing Assessments consisted of; elopement/wandering risk, Lifestyle, cognition, communication, hearing, vision and oral, skin conditions, pain, Braden scale, bowel, and bladder, fall risk, hot liquid safety, Safely/Bed enablers/entrapment, mediation use, and Immunization/TB. A record review of the Abatement Statement to remove the immediacy of the situation on 3/28/2024 revealed the following: -Preventative Maintenance checklist will check doors weekly vs monthly due to the malfunction. -Re-education to the DON and Social Worker on the elopement policy by the consultant on 3/28/2024 to include orders, accurate forms, and care plans. -Staff education on 3/28/2024 on residents who are at risk. Provide current list to all stations on residents who are identified at risk. -All new staff will be educated in orientation upon hire. -Agency staff will be educated upon 1st shift in building. -The receptionist in the evening will check the functioning of the wander guard before the end of the shift.