C/O # NJ 182995 Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to provide adequate supervision for a cognitively impaired resident with a known history of aggressive exit seeking which resulted in the resident eloping on 12/12/2024. This deficient practice was identified for 1 of 3 residents reviewed for elopement (Resident #160). Resident #160, who was cognitively impaired with a known history of aggressive exit seeking, eloped from the facility on 12/12/2024. The staff reported last seeing Resident #160 in the dining room between 05:00 PM and 05:30 PM on 12/12/2024. The resident wore a wander guard to their left ankle that the physician ordered to be checked for placement and function every shift, and was last checked on 12/12/2024 at 02:00 PM. On 12/12/2024 at 07:40 PM, the Registered Nurse (RN #1) reported that the resident was not in their room to receive their medication. Between 08:00 PM and 09:00 PM, the Certified Nursing Assistant (CNA #3) could not locate Resident #160, and he observed that the resident did not eat their dinner. At 09:30 PM, CNA #3 searched the building and alerted RN #1 that Resident #160 could not be found. The facility management and staff began a search for the resident both inside and outside the facility and notified the local police. The police, along with a canine (K-9; police dog) blood hound and drone searched for Resident #160, and the police located the resident on the property in the trees on 12/13/2024 at 01:45 AM. Resident #160 was immediately sent to the hospital and the resident was admitted with hypothermia (body temperature lower than 95 degrees Fahrenheit (F), normal temperature 97.7 to 99.5 degrees F) and elevated white blood cells (WBC). The facility's failure to provide adequate supervision to a cognitively impaired resident who was at risk for elopement and eloped posed a likelihood of serious harm, injury, impairment or death. This resulted in an Immediate Jeopardy (IJ) situation which ran from 12/12/2024 at 05:30 PM, when Resident #160 was last seen by staff, until 12/13/2024 at 01:45 AM, when the police located the resident and sent them to the hospital. The IJ was Past Non-Compliance (PNC). The PNC IJ was identified from 12/12/2024 at 05:30 PM, which continued to 12/13/2024 at 01:45 AM, when the resident was found and sent to the hospital for evaluation. The facility was back in compliance when the facility addressed the situation by immediately searching and locating the resident; the resident was sent to the hospital for evaluation; the wander guard system was checked for function; all wander guards were checked; and all staff were inserviced on the facility's elopement protocol. The facility Administration was notified of the PNC IJ on 01/30/2025 at 04:31 PM. The facility submitted an acceptable Removal Plan (RP) on 01/31/2025 at 01:15 PM. The facility team verified the completion of the Removal Plan was 12/30/2024, during the on-site survey on 01/31/2025, and determined the IJ was PNC. The evidence was as follows: A review of a facility policy titled Elopement dated 05/01/2024, revealed under the Intent section; It is the intent of the facility to be aware of its resident's usual habits and locations as reasonably practical. This is with the intent of not invading privacy but to identify a possible missing resident. A review of the electronic Medical Record (EMR) on 01/30/2025 at 02:20 PM, revealed the following: According to the admission Record face sheet (an admission summary) Resident #160 was admitted with diagnoses including but not limited to; unspecified dementia. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 09/26/2024, revealed Resident #160 had a Brief Interview for Mental Status (BIMS) score of 4/14 indicating Resident #160 was severely cognitively impaired. A further review of the MDS indicated the resident was independently ambulatory with no assistive devices and used a wander/elopement alarm daily. A review of Resident #160's individualized comprehensive care plan (ICCP) included a focus area of at risk for wandering/elopement. Goals included that the resident will not leave the facility unattended. Interventions included to: engage resident in purposeful activity initiated on 10/03/2024; provide care in a calm and reassuring manner initiated on 10/03/2024; provide clear simple instructions initiated on 10/03/2024; and wander guard bracelet as ordered to right ankle and left ankle, check placement and function as ordered initiated on 10/03/2024. A review of the Order Summary Report revealed a physician's order dated 06/23/2024, for wander guard on right ankle; to check placement and function every shift. A review of the Medication Administration Record (MAR) dated 12/1/2024-12/31/2024, revealed the physician's order for the wander guard was signed as having been checked for placement and function on 12/12/24 at 06:00 AM and 02:00 PM. A review of an Elopement Evaluation dated 09/26/2024, revealed a score of 5 and that the resident was identified for the following risks; a history of elopement or attempted leaving the facility without informing staff, resident wanders, resident wanders aimlessly or non-goal directed, wander behavior likely to effect the safety or well-being of self/others, and the resident's wandering behavior likely to effect the privacy of others. The evaluation indicated that score of 1 or higher indicated a risk of elopement. A review of the progress notes (PN) dated 11/27/2024 at 11:47 PM, included the resident did not have the wander guard at this time; resident stated that I keep it somewhere. A PN dated 11/28/2024 at 11:10 PM, indicated the resident was calling out hallucinations to oncoming staff; the resident had increased agitation during this shift. A PN dated 11/29/2024 at 11:13 PM, revealed Left ankle wander guard is not functional. Noted resident connected with sharp Nails. ??? [sic] Made aware Nursing Supervisor and shift charge to follow up. A PN dated 11/30/2024 at 12:03 AM, revealed the resident took off their wander guard. A PN dated 11/30/2024 at 05:37 AM, revealed the resident did not have their wander guard on. A PN dated 12/12/2024 at 07:40 PM, indicated the resident was not in their room to receive medication. A PN dated 12/13/2024 at 02:25 AM, revealed the resident was transferred out to the hospital. A review of the facility's Investigation and Summary and Conclusion dated 12/17/2024, revealed the following: under the background section: resident had a history of wandering aimlessly and exit seeking for which interventions have been put into place. Resident wore a wander guard to right ankle. Under the timeline of Events on 12/12/2024, included the following: At approximately (approx) 05:30 PM-06:00 PM, the resident was observed in dining room. At approx 08:00 PM-09:00 PM, CNA #3 went to check on the resident and observed dinner was not touched. At approx 09:30 PM, CNA # 3 initiated a search for the resident. At approx 10:00 PM, management was notified; head count completed; search in the facility and surrounding areas outside of the facility. The outdoor areas were checked by the management team; all doors and wander guard system checked by the Director of Maintenance (DOM) and all wander guards worked properly. At approx 10:15 PM, the family was notified by Director of Nursing (DON). At approx 10:45 PM, the local police department was notified, and the police were on site at approximately 11:00 PM. At approx 11:30 PM, the local police department completed search inside the facility and initiated search outside. The K-9 unit was on-site and not successful. On 12/13/2024: At approx 12:30 AM, the search continued with a different K-9 and drone. From approx 12:30 AM-01:30 AM, the management and corporate team continued with search with address on record and other addresses as recommended by the family. During conversation with family, the [family member redacted] mentioned other locations where the resident could be found. At approx 01:45 AM, the resident was transferred to the hospital for evaluation. At approx 02:00 AM, the Department of Health (DOH) was called to report the event. At approx 10:45 AM, the facility called hospital; the resident was admitted to hospital with elevated WBC. At approx 02:18 PM, the Ombudsman was notified by the LNHA. Under the Interventions in place to prevent future incident included: plan of care reviewed and updated; one-to-one (1:1) supervision; will continue with wander guard; ensure list with at risk for elopement residents placed at front desk; facility wide education completed for elopement protocol; will consider higher level of care for safety-dementia unit; and all wander guards inspected for safety. A review of a handwritten statement signed by the Receptionist on duty on 12/12/2024, revealed the following: I don't know what happened, I do not remember seeing or letting [them] out nor did I hear any alarms going off that night. A review of a handwritten statement signed by the primary nurse (RN #1) dated 12/12/2024, revealed that at 09:30 PM, I was informed that [resident's name] was missing, and cannot find them admitted [to hospital with]: hypothermia and elevated WBC. A handwritten statement signed by the DON indicated that on 12/12/2024 at 10:00 PM, I received a call from the 02:00 PM-10:00 PM supervisor that the resident was missing and could not be located at the facility . A review of a handwritten statement dated 12/13/2024 at 12:12 PM, signed by the DON as having phone conversation with CNA #3, revealed that CNA #3 stated that at approximately 05:00 PM-06:00 PM, he observed the resident in the dining room sitting. At approximately 08:00 PM-09:00 PM, CNA #3 went to check the resident in their room, and he observed the resident's dinner tray was not touched. At 09:30 PM, CNA #3 initiated a search for the resident, and then informed the nurse and the Nursing Supervisor. During an interview with the survey team on 01/30/2025 at 01:17 PM, the Licensed Nursing Home Administrator (LNHA), DON, and the [NAME] President of Clinical Services (VPCS) revealed the following information: The DON confirmed Resident #160 eloped on 12/12/2024, that during the evening shift, the resident was last seen at 05:30 PM in the dining room. The DON stated staff realized between 08:00 PM-09:00 PM, the resident was not in their room, and staff made a facility-wide announcement to alert staff to search the whole facility for Resident #160. The DON confirmed the resident was not found in the facility during the search. The DON confirmed Resident #160 was an elopement risk; their picture was in the lobby; the resident had a wander guard; they were on the risk for elopement list at the front desk; and it was included in their ICCP. The DON stated the facility checked the resident's wander guard every shift for placement and function and that the facility had a wander guard tester that the nurse was responsible for using. The DON acknowledged that the last time the resident's wander guard was checked on 12/12/2024, was at at 06:00 AM. (This contradicted the MAR which was signed as checked on 12/12/2024 at 02:00 PM) The DON stated when the resident was missing, the Nursing Supervisor called the DON who then notified all the department heads and the regional staff. The LNHA stated we (management team) did another sweep of the building and the outside perimeter, and we were unable to locate Resident #160 so we called the police who arrived at the facility and searched both inside and outside. The LNHA continued that the police took a piece of Resident #160's clothing from their room, and had a K-9 smell the clothing for the resident's scent and the K-9 searched outside for the resident. The LNHA stated the DOM went in his car to ask local businesses if they saw Resident #160, and the facility contacted the resident's emergency contact to see if they knew where the resident would go with no success. The LNHA stated the police then called for a blood hound dog and drone, and the drone located the resident on the property in the back left side to the corner of the fence line. The LNHA said that you can not get out of the fence back there; that there were trees and brush/bushes. The LNHA stated that you needed to go into the tree line to actually see the corner of the fence where the resident was located. The LNHA stated that a CNA who was familiar with the resident from a previous facility where Resident #160 had eloped from said the resident was found in the trees and that the facility should check there. The LNHA stated at that time, the facility informed the police of this because the facility was unable to check outside since the police instructed the facility to stay inside so their scents would not interfere with the K-9 search. The LNHA stated that the police located Resident #160 in the trees. The police called the ambulance who transported the resident to the hospital and the resident was admitted for two days for hypothermia and elevated WBC. When questioned how Resident #160 eloped from the building, the LNHA replied that the elevator doors opened if you had a wander guard, but the elevator would not move, it alarmed. The LNHA stated that the facility still did not know how Resident #160 left the second floor nursing unit because when the resident returned from the hospital, their wander guard was functioning. The LNHA stated that only the perimeter doors were alarmed for the wander guard, and the alarm was loud enough to be heard from the elevator at the nurse's station. The VPCS stated at the time of the incident, the nurses were busy administering medication and the CNAs were doing second incontinent care for the residents. The LNHA said We tried to watch the video, hard to see, but [the resident] went out the front door, which did not alarm. The LNHA stated the Receptionist was there until 08:00 PM, and we asked her if she saw Resident #160, but the Receptionist denied it. The LNHA stated they were able to tell on the video the time the resident left the building, but he did not recall the time, and when asked if it was after 08:00 PM, the LNHA could not recall. On 01/30/2025 at 02:23 PM, the surveyor requested to watch the video from 12/12/2024, and the LNHA said it only stores for 72 hours, and we couldn't tell what time [the resident] left. This contradicted the LNHA's previous statement that the facility was able to determine what time the resident eloped from the video, but he could not recall the time. During an interview with the surveyor on 01/30/2025 at 02:28 PM, CNA #2 stated that they cared for Resident #160 frequently, but they were not in the facility on 12/12/2024, when the resident eloped. CNA #2 stated the resident was aggressive regarding exit seeking behaviors and that they often verbalized wanting to leave. CNA #2 stated that Resident #160 felt like they did not belong here, so the resident packed their book bag up and sat at the nurse's station waiting to go home. CNA #2 stated that Resident #160 talked about leaving all the time; that they went on the elevator and the wander guard would go off and staff had to redirect the resident and distract them with things to do. During a telephone interview with Surveyor #5 on 1/30/2025 at 02:00 PM, the Receptionist said she worked at the facility on 12/12/2024, from 04:00 PM-08:00 PM, and she did not know what happened. The Receptionist denied seeing Resident #160 that night; that there were pictures of the residents at risk for elopement. The Receptionist denied hearing an alarm go off at the front door, and stated she was unfamiliar with the wander guard. On 01/30/2025 at 02:30 PM, two surveyors along with VPCS, walked the property to see where Resident #160 was located. The following observations and interviews occurred: The surveyors and VPCS walked left out of the building and toward the rear of the property. Behind the building there was an approx eight feet (8 ft) tall vinyl fence that ran the length of the property, and beyond the vinyl fence were additional grounds that were contained by a chain link fence. That additional area was approx 50 yards (yds) wide with an approx length of 150 yds. The night of the elopement, the VPCS stated that he (the VPCS) walked to the vinyl fence on the rear right side where an 8 ft section of vinyl fence was missing and looked around and stated it was very dark and the VPCS was unable to locate the resident. The VPCS stated there were bushes and small trees that made it harder to see, so he returned to the front of the building where he overheard a police officer say they may have located the resident, and the officers began running behind the building and the VPCS followed them. The VPCS stated it was December and the trees had their leaves and were much bulkier and made it harder to see the area. The resident had gone through the vinyl fence and into the retention basin area that was enclosed within a chain-link fence and was found on the left side of the perimeter against the chain link fence approx halfway down the fence approx 25 yards from the gate. The VPCS stated the administrative team were assuming the resident left the building out the front door, walked around the building to the right to the far-left corner of the property and through the vinyl fence. When the surveyors approached the vinyl fence, they observed that the gate which had a hinge latch that was not closed, and the gate appeared to be stuck open with an approximately one foot wide opening to pass through. At that time, the VPCS attempted to see if the gate would latch and was unable to do so and stated, I could make it close. When asked, the VPCS could not recall if the gate was opened the night the resident eloped. The area behind the gate enclosed in the chain link fence had tall grasses and bushes and trees that sloped down into a valley in the middle similar to a retention basin with black rocks in the middle. The area sloped down sharply toward the middle and was uneven with thorn bushes and brambles. The VPCS stated that he believed the resident was found wearing shoes, gray sweatpants, and a white t-shirt. The VPCS stated the resident was found halfway down the fence line possibly 50 yards beyond the gate entrance along the fence line that was approx 100 ft deep. The VPCS stated the resident was alert and responsive. When asked if the resident had scratches on their skin when found, and the VPCS stated that he did not do a skin assessment at the time because the police were in charge of the situation, and the facility was told to step away. The surveyor observed the closest exit door from the facility to that area was from the First-floor rehabilitation unit that connected to a sidewalk that led to the area the resident was found. The VPCS stated that door was ruled out as where the resident eloped since no one reported hearing an alarm, and the VPCS confirmed if the resident left through the main entrance, the wander guard alarm would have sounded. During a telephone interview with Surveyor #3 on 01/31/2025 at 10:32 AM, RN #1 said that she recalled the incident, but she could not recall the exact dates and times. RN #1 said she believed that she was the supervisor that evening. At that time, the Surveyor confirmed with RN #1 that the Nursing Note was written by her on 12/12/24 at 07:40 PM, that indicated Resident #160 was not in their room to receive medication. RN #1 stated that she covered the medication cart as needed, and when the surveyor questioned what RN #1 did after she identified Resident #160 was not in their room, RN #1 stated she continued to administer medication to other residents. RN #1 stated she recalled seeing Resident #160 at the nurse's station around dinner time at maybe 06:00 PM. RN #1 recalled Resident #160 was pleasant and smiling with no indication they were exit seeking. RN #1 also recalled seeing Resident #160 in the dayroom, but she could not recall the time. RN #1 stated that a CNA (CNA #3) informed her that the resident's dinner plate was untouched as he was collecting trays (unable to recall exact time), and we started searching and I immediately notified the staff and called the DON. RN #1 stated the police were called and the inside and outside of the building was searched. The surveyor asked if RN #1 recalled seeing the resident's meal tray when they attempted to administer medications, and she responded, no, that the resident often refused their meal and would eat it later. Surveyor #3 asked RN #1 if they made additional attempts to administer Resident #160's medications, and the RN stated that typically if a resident was not in their room for medication, she looked for them or she went back to give them medication. RN #1 stated that CNA #3 had alerted her about Resident #160 shortly after. RN #1 confirmed Resident #160 wore a wander guard that was tested daily. During an interview with Surveyor #1 on 01/31/2025 at 11:17 AM, the DOM was asked if the stairways were alarmed, and the DOM confirmed they were alarmed including for a wander guard. The DOM stated that the therapy doors to the outside had a wander guard alarm, magnetic lock and were on a keypad. The DOM said there was no problem with the wander guard system at the time the resident eloped. The acceptable Removal Plan on 01/31/2025 at 01:16 PM, indicated the action the facility took to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: staff initiated the elopement protocol and contacted the police; Resident #160 was located outside the facility, assessed, and transported to the hospital for evaluation; Resident #160's plan of care was updated to include 1:1 supervision; Resident #160's wander guard was checked for function; the facility's wander guard system was checked for function; and all staff were educated on the facility's elopement protocol. The facility self-corrected the deficient practice and it was determined that the IJ was Past Non-Compliance (PNC); that the facility corrected their non-compliance on 12/30/2024. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 01/31/2025. NJAC 8:39-27.1(a)