Based on observations, interviews, record review, and policy review, it was determined that the facility failed to ensure resident safety related to lights over headboard are smoking when turned on for (Resident (R)73 and R51). The lights were found to be smoking by staff on 8/31/2023 and not repaired until 9/28/2023. This failure placed R73 and R51, as well as all residents, at risk of an electrical fire and in an Immediate Jeopardy situation. Additionally, the facility failed to provide a safe smoking environment for 10 residents (Resident (R) 17, R24, R48, R52, R55, R60, R65, R72, R159, and R160) of the facility identified as smokers. The facility's Administrator was informed on 09/28/23 at 6:54 PM that Immediate Jeopardy existed related to the failure to ensure overhead lights were not smoking when turned on for R73 and R51 resulting in the potential for an electrical fire. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 09/30/23 at 9:39 AM. The survey team validated implementation of the removal plan through interviews and record review. Immediate Jeopardy was removed on 09/30/23 at 2:40 PM. After removal of the Immediate Jeopardy, the deficiency remained at a D scope for isolated potential for more than minimal harm. Findings include: 1. Review of the facility policy titled, Maintenance Services, revised 08/01/17, revealed . The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . Maintaining the building free from hazards .Maintaining all mechanical, electrical, and patient care equipment in safe operating condition .The Director of Maintenance is responsible for maintaining the following records/reports: .work order requests . a. Review of R73's admission Record located in the paper chart, indicated she was originally admitted to the facility with a primary diagnosis of pulmonary embolism (blood clot in the lung). Review of R73's Orders, located in the electronic medical record (EMR) under the Orders tab, included Hoyer lift with transfers dated 08/11/23. Review of R73's Care Plan, located in the EMR under the Care Plan tab and revised on 06/15/23, included assistance with transfers and use of mechanical aid such as Hoyer lift. Review of R73's admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 05/16/23, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating she was cognitively intact. R73 required extensive, two-person assistance with bed mobility and transfers. 2. Review of R51's admission Record, located in the EMR under the Profile tab, indicated she was originally admitted to the facility with a primary diagnosis of primary hyperparathyroidism. Review of R51's Care Plan located in the EMR under the Care Plan tab, revised 08/07/23, did not include ambulation/bed mobility status. Review of R51's annual MDS with an ARD of 07/28/23, located in the EMR under the MDS tab revealed a BIMS score of 14 out of 15, indicating she was cognitively intact. R51 required limited assistance with one-person physical assist for bed mobility and transfers. During an interview on 09/27/23 at 5:58 PM, R51 stated she forgot to mention to the surveyor during the initial interview that the light above her roommate's bed [R73] did not work and that it had exploded when somebody turned it on and that now there was a sign on it to not touch the light. An observation on 09/26/23 at 12:07 PM, revealed a sign above R73's bed stating, 08/25/23 Do not turn bed light on. During an interview on 09/26/23 at 12:07 PM, R73 confirmed that she required full assistance from staff with all transfers and that staff use a Hoyer lift to get her out of bed. During an observation on 09/28/23 at 12:25 PM, a sheet of notebook paper above R73's bed, taped to the wall below the malfunctioning light revealed, 08/25/23 Do not turn bed light on. Review of a work order dated 08/31/23 at 3:05 AM, provided by the facility revealed, lights over headboard are smoking when turned on in room for R73. During an interview on 09/28/23 at 11:51 AM, Certified Nursing Assistant (CNA)2 confirmed that R73's light over her bed was not working and that when they tried to use it the light smoked and that it had been that way for about a month. CNA2 confirmed that R73 required full assistance with transfers and a mechanical lift. During an interview on 09/28/23 at 12:11 PM, CNA1 confirmed that R73's light over her bed was not working and that she had heard from other staff that it had previously sparked so she did not turn it on. Additionally, CNA1 confirmed there was a sign above R73's bed stating to not use the light. Additionally, CNA1 stated that R73 required full assistance with bed transfers and a mechanical lift. During an interview on 09/28/23 at 12:25 PM, R51 and R73 stated that about three weeks ago one of the CNAs turned on the light and she got shocked. The Maintenance Director had come to check the light the following week and told them he would be back but had not returned. The residents stated due to the light not working above the bed for R73, staff and residents were having to use the overhead light to the room, or the light above the bed for R51. During an interview on 09/28/23 at 12:51 PM, Registered Nurse (RN)1 confirmed that R79 was bedbound and required two-person assist with all transfers and repositioning. Additionally, she was aware of the light not working above R73's bed, but she did not know why. During an interview and observation on 09/28/23 at 2:49 PM, the surveyor asked the Maintenance Director if he had followed up on the light in R73's room. Initially the Maintenance Director did not know what room the surveyor was referring to so the surveyor and Maintenance walked to the room together. R73 was in bed and we announced that we were in the room to check on the light and the heat. Once the Maintenance Director entered the room, he recalled the malfunctioning light. R73 stated It doesn't work [referring to the light]. The Maintenance Director went over to the light and picked up the top metal covering over the light fixture and then the light illuminated. During an interview on 09/28/23 at 3:08 PM, the Maintenance Director stated he was aware that staff reported the light sparking that was located over R73's bed on 08/31/23, via the online TELS program (maintenance requests). Four surveyors were present for his statement. When asked what precautions had been put in place, he stated there was a hand-written sign hanging above the bed stating to not use the light and that he had disconnected the light from the circuit on 08/31/23. He was not able to explain how he disconnected the light or electricity going to the light fixture, and did not have any documentation to reflect he had disconnected the electricity going to the light. He then went on to say that when he pulled the light string on 09/28/23 at 2:49 PM he saw a spark come out near the location of the string coming out of the light unit. When asked if a replacement light had been ordered, he was unable to locate the order, and stated he was in the process of ordering a new light fixture. He stated that he was currently in the process of disconnecting the circuit from the light and that every Monday he chooses a hall to check the lights. He confirmed he had not checked the light unit above bed for R73 since 08/31/23. Additionally, the Maintenance Director acknowledged that an unknown person had put in a bulb on an unknown date, and he didn't understand why. On 09/29/23 at 9:30 AM the Maintenance Director notified the survey team that an electrician made a visit on 09/28/23 around 9:30 PM and noted two separate ballasts for the light fixture above the bed (for R73). One ballast had a frayed wire, and the other ballast was fine. The electrician provided a written statement to the facility verifying that the power going to the light fixture was disconnected when he made the visit on evening of 09/28/23. During an interview on 09/28/23 at 5:55 PM, R73 stated on 08/25/23 she saw the light spark, and R51 stated she smelled something burning but could not tell where the smell was coming from due to the privacy curtain being pulled for privacy of R73 and that this occurred on the evening shift and that staff put up the sign stating to not use the light. R51 stated she was afraid of the light fixture causing an electrical fire. During an interview on 09/28/23 at 6:18 PM the Administrator stated he was not aware of the malfunctioning light above R73's bed until the surveyors notified him. Review of the facility's Smoking Policy, dated 07/23, revealed It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and nonsmoking residents. The policy explanation and compliance guidelines included provision of ashtrays made of noncombustible material and safe design; accessible metal containers with self-closing covers into which ashtrays can be emptied; residents who smoke will be further assessed to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all; any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan; smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. The facility identified 10 residents who smoked (R17, R24, R48, R52, R55, R60, R65, R72, R159, and R160). All 10 residents smoked on the outdoor smoking patio. a. Review of R17's quarterly Minimum Data Set (MDS), located under the MDS tab in the electronic medical record (EMR) with an assessment reference date (ARD) of 08/11/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R17 was cognitively intact. Review of R17's smoking assessment, located under the assessment tab with an ARD of 06/14/23, revealed R17 required no supervision for smoking. b. Review of R24's quarterly MDS, located under the MDS tab in the EMR with an ARD of 07/10/23, revealed a BIMS score of 12 out of 15, indicating R24 was moderately cognitively impaired. Review of R24's smoking assessment, located under the assessment tab with an ARD of 09/13/23, revealed R24 required no supervision for smoking. c. Review of R48's admission MDS, located under the MDS tab in the EMR with an ARD of 09/21/23, revealed a BIMS score of 14 out of 15, indicating R48 was cognitively intact. Review of R48's smoking assessment, located under the assessment tab with an ARD of 09/14/23, revealed R48 required no supervision for smoking. d. Review of R52's admission MDS, located under the MDS tab in the EMR with an ARD of 09/08/23, revealed a BIMS score of 15 out of 15, indicating R52 was cognitively intact. Review of R52's smoking assessment, located under the assessment tab with an ARD of 08/08/23, revealed R52 required no supervision for smoking. e. Review of R55's quarterly MDS, located under the MDS tab in the EMR with an ARD of 08/12/23, revealed a BIMS score of 13 out of 15, indicating R55 was cognitively intact. Review of R55's smoking assessment, located under the assessment tab with an ARD of 09/13/23, revealed R55 required no supervision for smoking. f. Review of R60's annual MDS, located under the MDS tab in the EMR with an ARD of 08/17/23, revealed a BIMS score of 15 out of 15, indicating R60 was cognitively intact. Review of R60's smoking assessment, located under the assessment tab with an ARD of 02/19/23, revealed R60 was a safe smoker. g. Review of R65's admission MDS, located under the MDS tab in the EMR with an ARD of 08/10/23, revealed a BIMS score of 15 out of 15, indicating R65 was cognitively intact. Review of R65's smoking assessment, located under the assessment tab with an ARD of 08/10/23, revealed R65 required no supervision for smoking. h. Review of R72's admission MDS, located under the MDS tab in the EMR with an ARD of 07/05/23, revealed a BIMS score of 15 out of 15, indicating R72 was cognitively intact. Review of R72's smoking assessment, located under the assessment tab with an ARD of 06/28/23, revealed R72 required no supervision for smoking. i. Review of R159's admission MDS, located under the MDS tab in the EMR with an ARD of 09/25/23, revealed a BIMS score of 15 out of 15, indicating R159 was cognitively intact. Review of R159's smoking assessment, located under the assessment tab with an ARD of 09/18/23, revealed R159 required no supervision for smoking. j. Review of R160's admission MDS, located under the MDS tab in the EMR with an ARD of 09/18/23, revealed a BIMS score of 12 out of 15, indicating R160 was moderately impaired cognitively. Review of R160's smoking assessment, located under the assessment tab with an ARD of 09/11/23, revealed R160 required no supervision for smoking. Observation on 09/28/23 at 1:10 PM, of the designated smoking area revealed the area was an outside covered patio which contained three self-extinguishing tower ashtrays; one open ashtray with a trash can, lined with a plastic trash bag, underneath; a smoking blanket; a fire extinguisher; and a large open trash can, lined with a plastic bag. Ten residents were waiting in a lounge for the staff member, assigned to monitor the smoking time. When the staff member, Licensed Practical Nurse (LPN)3, arrived, she said no one goes out without a smoking apron on. When smoking, the 10 residents said they put their cigarette butts in the open ashtray, when it gets full, we dump it in the bottom trashcan. The ashtray and trashcan were noted to be metal. Observation on 09/29/23 at 9:10 AM, of the designated smoking area revealed the open ashtray with cigarette butts inside and the plastic bag lined trashcan underneath. Nine residents were outside smoking. LPN3 and the residents were asked how they were able to get back into the building as there was no keypad on the inside of the door to get outside. R55 said we're supposed to push the doorbell, but it's broken, you just have to knock really loud. On 09/29/23 at 10:47 AM, the surveyor, Administrator, Maintenance Director (MD), and Director of Housekeeping (DH) observed the open trashcan on the smoking patio. The DH lifted the plastic bag out of the trashcan. The bag contained approximately five inches of cigarette butts in the bottom. As the DH lifted the bag completely out of the trashcan, the bag ripped as it was burned/melted on the bottom. The DH said he would remove the trashcan and they can use the other one, which was an actual trashcan with a plastic liner. The Administrator said he would find a more permanent/safe solution. Observation on 09/29/23 at 6:20 PM revealed the open ashtray and trash can had been removed, however the large open trashcan with a plastic liner remained on the smoking patio. During an interview on 09/29/23 at 6:22 PM, LPN3 revealed she did not like that they could not open the door to get back into the building if needed for a medical concern. NJAC 8:39-4.1(a)11 NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint Intake #NJ161004 and NJ160982 Based on interviews, record review, facility policy review, and video surveillance review, the facility failed to provide supervision for 1 (Resident #5) of 8 residents reviewed for wandering/elopement. The facility failed to identify and implement interventions to prevent elopement for Resident #5 who had a documented history of elopement attempts, was cognitively impaired, and was unable to walk safely. On 12/15/2022, Resident #5 left the facility without staff knowledge. A staff member leaving the facility found the resident in the rain by a busy four-lane highway by the facility and assisted the resident back to the facility. Resident #5 was outside unsupervised without staff knowledge for approximately nine minutes. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 11/30/2022 when Resident #5 was expressing the desire to leave the facility by calling a ride-hailing service. The Nursing Home Administrator (NHA) and Regional Director of Operations (RDO) were notified of the IJ on 02/19/2023 at 3:40 PM and provided the IJ template at that time. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency (SSA) on 02/24/2023 at 1:03 PM. The IJ was removed on 02/24/2022 at 6:30 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity that was not immediate jeopardy for F689. Findings included: Review of the facility policy titled, Wandering and Elopements, revised March 2019, indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as at risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the charge nurse of director of nursing services that a resident is attempting to leave or has left the premises. 4. When the resident returns to the facility, the director of nursing services or charge nurse shall: a. examine the resident for injuries; e. complete and file an incident report; and f. document relevant information in the resident's medical record. During an interview on 02/24/2023 at 5:32 PM, the Director of Nursing (DON) stated elopement and other assessments were done upon admission, quarterly, and with any changes. The DON stated nursing staff completed the admission assessments, and the quarterly assessments were completed by the nurse manager. A review of the admission Record Report indicated the facility admitted Resident #5 on 11/25/2022 with diagnoses that included COVID-19, muscle weakness, arteriosclerotic health disease, and cognitive communication deficit. A family member, Family Member #1 was listed as the first emergency contact for Resident #5. Further review of the admission Record Report revealed Resident #5 experienced a hospital stay from 12/09/2022 to 12/15/2022, and the resident's current admission date was 12/15/2022. Review of the pre-admission hospital record revealed a physician history and physical note, dated 11/18/2022, indicating Resident #5 had a history of leaving healthcare facilities against medical advice (AMA). The hospital provider indicated the resident left AMA on a prior admission several days ago. Review of an Admission/re-admission Evaluation dated 11/25/2022, revealed Resident #5 had no history or presence of wandering, history of exit seeking, nor verbalizing a desire to exit. Review of Resident #5's care plan, dated 11/25/2022, revealed resident showed potential for discharge and the patient and relative expressed a wish for discharge. Interventions included discussing the discharge process, investigating needs for special equipment and referrals, and reviewing progress toward discharge during scheduled meetings. Review of nursing Progress Notes dated 12/01/2022 at 11:31 PM, revealed Resident #5 was alert but confused. Review of Resident #5's Progress Notes, dated 12/01/2022 at 4:08 PM, revealed the resident had weakness, moderate cognitive impairment on the Brief Interview for Mental Status (BIMS) assessment, and limited safety awareness. The admission Minimum Data Set (MDS), dated [DATE], revealed Resident #5 had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had not exhibited wandering behavior nor behavioral symptoms during the previous seven days. The MDS indicated Resident #5 required extensive staff assistance for bed mobility, transfers, toileting, and hygiene. The MDS indicated the resident did not walk in the resident's room or in the corridor. According to the MDS, Resident #5 was unsteady and utilized a wheelchair for mobility. Further review of Resident #5's care plan, dated 12/05/2022, revealed the resident was at risk for complications related to cognitive impairment due to the resident's desire to participate in outdoor hot/cold weather activities. The facility developed interventions that included avoiding extended amounts of time outdoors, observing for signs and symptoms of over exposure, and offering and assisting with protective garb such as gloves, hat, and coat. There was no documented evidence the facility addressed the resident's supervision needs while outdoors. Review of Progress Notes revealed on 11/30/2022 at 1:55 PM, the Infection Preventionist (IP Nurse) documented Resident #5 was slightly agitated about being here and stated the resident would catch a uber to come pick me up. The note indicated the IP Nurse attempted to redirect Resident #5, but the resident became angry and said, I'm getting out of here. The note revealed the IP nurse called the family who stated the resident had been confused since being in the hospital and indicated the resident, could not leave. The IP Nurse notified the nurse practitioner of the incident. The Progress Notes further indicated the nurse practitioner saw the resident on 11/30/2022 at 3:24 PM and indicated the resident wanted to leave the facility. Review of Progress Notes, dated 12/05/2022 at 12:09 PM, revealed Resident #5 was delirious, and very short tempered with family and staff. The note further indicated the resident believed the resident could go home alone and did not need assistance. However, the provider had discussed this with occupational therapy (OT) and OT stated the resident was unsafe to return home alone and needed 24-hour care. The note further indicated the resident had poor judgement and insight. According to the Progress Notes, Resident #5 had a diagnosis of vascular dementia with delirium. Review of Progress Notes, dated 12/09/2022 at 11:43 AM, revealed Registered Nurse (RN) #9 documented Resident #5 was propelling himself/herself in and out of other residents' rooms and the resident was unable to be redirected. The resident would become agitated and try to walk unsteadily in the hallway. The Progress Notes further indicated at 2:24 PM on 12/09/2022, Resident #5 was caught opening the window in the resident's room. The note indicated the resident stated, I want to jump out of this window, I'm tired of this place and the physician was notified immediately. The Progress Notes indicated at 4:13 PM on 12/09/2022, the physician saw the resident and was argumentative and insisting on going home. There was no documented evidence the facility reassessed the resident for elopement or identified Resident #5 as at risk for wandering, elopement, or other safety issues. A review of Progress Notes, dated 12/09/2022 at 4:45 PM, revealed Resident #2 was very agitated. The resident was Demanding to go home. Attempting to leave [the] facility to catch a bus. Unable to be redirected. The note indicated the resident's family was notified and gave permission to transfer the resident. Emergency Medical Services (EMS) was notified, and the resident willingly left with EMS. A review of an Acute Care Transfer-V2 form dated 12/09/2022, revealed Resident #5 had At Risk Alerts that included being a wanderer and being at risk for falls. A review of the hospital history and physical, dated 12/09/2022 at 8:45 PM, revealed Resident #5 presented to the emergency department (ED) with altered mental status. The resident was delirious and not offering any subjective history. The resident became aggressive toward other residents and became agitated which prompted the facility to send the resident to the ED. The resident was found to have a urinary tract infection and delirium for which the resident was being admitted . A review of a hospital physician Progress Note, dated 12/13/2022, revealed while at the hospital, Resident #5 tried to leave, and the hospital had a one-to-one sitter with the resident. The note revealed the resident had delirium that had been improving. A review of a hospital physician's progress note, dated 12/14/2022 at 10:36 AM, revealed Resident #5 had no focal deficit (a focal neurological deficit is a problem with nerve, spinal cord, or brain function). The physician indicated the resident was alert but disoriented. Review of the resident's acute care hospital stay record, which was part of Resident #5's facility readmission packet on 12/15/2022, revealed a progress note from a hospital nurse dated 12/13/2022 at 4:45 AM, that indicated Patient got restless and combative after using the restroom at 4:45 AM. The note indicated Resident #5 gathered [his/her] belongs (keys and bag) and said [he/she] was leaving. The resident was immediately placed on one-to-one monitoring with nursing staff helping. However, the resident got out of [his/her] room and begun to walk out of the building AMA. Security was called; however, before security could reach Resident #5, the resident unexpectantly hit the nurse in the chest with a fist blow. Upon arrival, security escorted the resident to the resident's room and one on one supervision continued. A review of a Fast Track form, dated 12/15/2022, revealed Resident #2 was readmitted to the facility on [DATE] at 11:30 AM. Review of Resident #5's MDS assessments revealed the facility completed an entry MDS on 12/15/2022, following the acute care hospital stay and submitted the MDS on 12/19/2022. A review of an Admission/re-admission Evaluation-V7, with an admission date of 12/15/2022 but signed by the nurse on 11/25/2022, submitted by the facility following the survey exit date, indicated the resident had no behavioral symptoms. There was no documented evidence that the facility identified the resident was at risk of elopement nor developed interventions to address the resident's risk. A review of a Witness Statement revealed Certified Nurse Aide (CNA) #3 provided a statement to the facility regarding an incident with Resident #5 on 12/15/2022 at 3:42 PM. According to the statement, CNA #3 was in her car going home when she saw Resident #5 walking in the rain. The CNA parked her car and walked with the resident back inside the facility. The statement indicated CNA #3 told the nurse who was responsible for Resident #5's care about the incident and the nurse told the CNA to be quiet. A review of Resident #5's electronic medical record revealed the surveyor was unable to determine what transpired with Resident #5 from readmission to the facility on [DATE] at 11:30 AM until a staff member found the resident outside unsupervised by a four-lane highway near the facility at approximately 3:05 PM. A review of the weather history for the area on 12/15/2022 at 2:54 PM and 3:19 PM, obtained from www.wunderdground.com, revealed the temperature was 43 degrees Fahrenheit and it was raining. On 02/17/2023 at 1:32 PM, CNA #3 was interviewed. CNA #3 stated she primarily worked on the 7:00 AM to 3:00 PM shift at the facility. CNA #3 stated when she was leaving work on 12/15/2022, she was driving out of the facility parking lot when she observed Resident #5 standing outside in the rain. It was approximately 3:05 PM. Resident #5 was close to the busy, four-lane highway, by the facility's monument sign. The CNA indicated she parked her car and walked up to Resident #5 to see if the resident was okay. The resident told CNA #3 that the resident was waiting for the bus. CNA #3 stated she was able to coax the wet resident back into the facility. CNA #3 stated Resident #5 had just returned to the facility from a hospital stay at approximately 1:00 PM. CNA #3 stated when she assisted Resident #5 back to the North Unit, CNA #3 reported the resident's elopement to the Charge Nurse, Registered Nurse (RN) #15. RN #15 responded to CNA #3 by making a Shhh sign, by using her index finger over her mouth. CNA #3 stated she was always taught to report things such as an elopement and she did not appreciate being told to shhh when this was important, and the resident's safety was at risk. CNA #3 stated, They like to sweep things under the rug around here. CNA #3 further stated the facility had video surveillance and the Director or Maintenance (DOM) had access to the footage. Further interview with CNA #3 revealed the CNA wrote a statement about Resident #5's elopement and gave it to Licensed Practical Nurse (LPN) #16. On 02/17/2023 at 2:50 PM, the DOM was interviewed in the maintenance office that housed the video surveillance equipment. While the DOM was retrieving the video, he stated that Resident #5 could be seen walking right out the front door. He continued by stating the camera on the front of the building was not very clear, but Resident #5 could be seen standing at the edge of the property by the monument sign. The DOM revealed that the Nursing Home Administrator (NHA) reviewed the video the day the resident eloped. The DOM stated that while he did not have a lot of information about the elopement, he knew no one in the facility was aware that Resident #5 had walked out the front of the facility and the police were never called. The DOM revealed the facility would routinely follow up with in-service training after an event such as an elopement, but nothing was done following the elopement with Resident #5. Observation of the facility's video surveillance footage with the DOM revealed on 12/15/2022 at 3:06 PM there were approximately five people standing around the front lobby reception desk. Per the video, Resident #5 walked around the people at the desk and proceeded to walk out the front door. The front entry to the facility had two sets of doors. Resident #5 first walked out the door into a vestibule area and then out the second door to the outside. An observation of the video footage revealed that no one acknowledged Resident #5 leaving the facility. The camera located on the front of the building showed Resident #5 walking towards the four-lane highway. At 3:15 PM on 12/15/2022, Resident #5 was seen walking back toward the facility, escorted by CNA #3. Resident #5 returned to the front lobby at 3:30 PM. On 02/20/2023 at 10:03 AM, Receptionist #20 was interviewed. Receptionist #20 stated that unless the resident had a WanderGuard bracelet (a device that alerts staff when a resident gets near an exit door equipped with a WanderGuard system), she would not necessarily realize if a resident went out the front door. She stated she never saw Resident #5 walk out. Receptionist #20 stated the day Resident #5 walked out there were about four or five people standing around the reception desk, and it wasn't until I saw CNA #3 bring Resident #5 back in that I found out the resident had walked out. She revealed the facility had a notebook at the front desk with a list of residents who wandered, but the same residents also had a WanderGuard bracelet. If one of those residents came near the front door, the door would lock, and an alarm would sound. Resident #5 did not have WanderGuard bracelets. On 02/18/2023 at 10:18 AM, RN #15 was interviewed regarding elopements. RN #15 stated that when a resident wandered out of the facility they called a code, they notified the DON and/or the nursing supervisor, and if the resident could not be found, the police were also notified. RN #15 stated her definition of elopement was anyone who left the facility without staff letting them out. RN #15 stated she did not recall any recent elopements. When asked specifically about the day Resident #5 eloped on 12/15/2022, RN #15's response was, Now you did it. RN #15 followed up and stated she did not remember a resident with Resident #5's name. RN #15 stated if any resident left the building, it should be considered an elopement and should always be reported. A follow-up interview with RN #15 on 02/18/2023 at 11:25 AM, revealed RN #15 had no recollection of CNA #3 reporting that a resident had eloped. RN #15 stated if she was giving report, then she had no memory of CNA #3 reporting an elopement. On 02/18/2023 at 11:41 AM, LPN #16 was interviewed. LPN #16 defined elopement as a time when a resident walked out the door unsupervised. LPN #16 stated the procedure following an elopement was to report the incident and place a WanderGuard on the resident. LPN #16 indicated Resident #5 walked out the front door because the resident did not want to be at the facility. During the previous admission, LPN #16 stated Resident #5 was always looking for his/her purse so the resident could go home. According to LPN #16, Resident #5 had not previously wandered off the unit, but would wander into other resident rooms. LPN #16 stated one of the CNAs (CNA #3) found Resident #5 outside when she was leaving for the day. LPN #16 indicated CNA #3 wrote out a statement about the elopement, and LPN #16 gave the statement to the NHA to use for reporting the incident. On 02/18/2023 at 4:35 PM, LPN #18 was interviewed via the telephone. LPN #18 defined elopement as when a resident steps outside that front door. He stated if a resident was trying to leave, a WanderGuard would be placed on the resident, and the DON, physician, and family would be notified. LPN #18 did not recall ever working with Resident #5 and did not recall being notified of an elopement. On 02/20/2023 at 10:33 AM, LPN #2 was interviewed. LPN #2 stated a resident needed to be supervised if they were going out the front door. LPN #2 recalled Resident #5 and remembered the resident was transferred to the hospital. LPN #2 stated she received a report from the hospital about 30 minutes prior to Resident #5 returning to the facility on [DATE]. However, LPN #2 stated she never saw Resident #5 when the resident returned and was never told that the resident was discharged against medical advice (AMA) the same day. LPN #2 stated when a resident was re-admitted , the nurse was expected to take vital signs right away. She stated it would be unusual for a resident to refuse vital signs. LPN #2 also stated that as a nurse, You don't forget when you hear about an elopement. LPN #2 stated it was a huge concern if an elopement happened during a shift change, and both nurses did not remember the incident. LPN #2 followed up by stating, I have been told by leadership to not discuss some situations. On 02/18/2023 at 1:05 PM, the NHA was interviewed. The NHA defined elopement as someone who left a secured area without people knowing they were gone and without having eyes on the resident. She stated a WanderGuard bracelet would be placed on a resident who had eloped. The NHA stated she did not view the instance when Resident #5 left the facility as an elopement. The NHA stated when Resident #5 returned from the hospital stay, the resident indicated a desire to go home and was not going to stay at the facility. According to the NHA, if assessments were not completed when the resident came back from the hospital on [DATE], she did not consider the resident as having been readmitted to the facility. After learning that an entry MDS had been completed and submitted for Resident #5, the NHA then stated that she would have to agree that Resident #5 was re-admitted , if there was an MDS done. The NHA stated she had reviewed the incident with Regional Director of Operation (RDO) #17, who agreed that it was not a reportable occurrence. On 02/19/2023 at 1:11 PM, RDO #17 was interviewed via the telephone. Initially during the interview, RDO #17 stated he understood the facts to be that Resident #5 was a new admission and did not want to stay. He stated it was his understanding that there was no consent to treat, no assessments had been completed, and the family picked up the resident. The RDO acknowledged he told the staff Resident #5 did not elope if the resident was never admitted . He stated, I thought we were fine with this, and I thought it wasn't an issue. RDO #17 revealed he did not know Resident #5 was a readmission to the facility. He stated the NHA had not made him aware of this information. RDO #17 stated the staff should have kept Resident #5 safe. On 02/18/2023 at 1:57 PM, the Regional Director of Clinical Services (RDCS) was interviewed. The RDCS stated her definition of an elopement was when a resident exited the building without the staff being aware. Regarding Resident #5, the RDCS stated if none of the staff knew the resident had gone outside, then it was an elopement. The RDCS stated if the resident had not allowed the staff to complete the admission assessment because the resident wanted to go home, then the facility would have to call the hospital to get the resident somewhere safe. The RDCS stated if those assessments did not occur, then the resident would not be considered admitted . The RDCS continued by stating the facility was responsible for Resident #5 as long as the resident was in the facility. However, the RDCSF stated she would need more information about what happened from the time Resident #5 returned to the facility to when Resident #5 left to determine if there was an elopement. Removal Plan: 1. Resident #5 no longer resides at the center. All residents who are at risk for elopement were reviewed by licensed nursing staff on 02/19/2023 using the new elopement risk assessment. It includes ambulation status, predisposing diseases, mental status, cognitive processes, days of residence, history of elopement episodes for the last three months, is there a transient medical cause contributing to increasing confusion, and is there a transient cause contributing to increased confusion. The assessment is currently on paper. The licensed nurses observed the wander guards in place on the six residents that were previously identified as being at risk for elopement. The nursing staff checked the wander guards for functioning. All wander guards functioned appropriately. All six residents had a care plan in place for elopement risk. All facility residents were reviewed by licensed nurses using the elopement risk assessment. There is an elopement risk list at the reception desk. This list has been there since prior ownership. When a resident exhibits a change that indicates they could be at risk for elopement, an elopement assessment will be completed by a licensed nurse. Changes that may indicate a resident is at risk for elopement may include exit seeking behaviors, which could include verbalization of wanting to leave the facility. 2. All nursing supervisors, nurses, nurse's aides, and staff in all departments were in-serviced on 02/23/2023 by the NHA/DON/Designee on elopement assessments, elopement care planning, and elopement interventions. Staff who work per diem or who are on time off will be in-serviced at the beginning of their next shift. 3. A new elopement risk evaluation will be completed by licensed nurses on all residents upon admission, re-admission, quarterly, and with any changes. When a resident exhibits signs that they have had a change that indicates they could be at risk for elopement, an elopement assessment will be completed by licensed nurses. Residents identified as being at risk for elopement will have a wander guard placed by licensed nurses as well as a care plan for being at risk for elopement. The provider and resident responsible party are also notified. 4. The NHA/DON/Designee will review admissions and if a resident triggers for being at risk for elopement based on the elopement risk assessment, the DON/NHA/Designee will confirm placement of the wander guard and confirm care planning for risk for elopement is in place. The NHA/DON/Designee will review residents that have been identified as being at risk for elopement after admission for placement of the wander guard and a care plan for risk for elopement. These audits will be conducted weekly x [for] 4 weeks, then every other week for 4 weeks, and then monthly x [for] three months. All findings will be reviewed at the quarterly quality assurance meetings. 5. All corrections were completed on 02/23/2023. 6. The immediacy of the IJ was removed on 02/23/2023. Onsite Verification of Removal Plan: The survey team conducted an onsite verification that the Removal Plan had been implemented on 02/24/2023. The IJ was removed on 02/24/2023 at 6:30 PM. The survey team verified the use of a new elopement risk assessment and verified that the facility completed elopement risk assessments on all residents in the facility. The survey team verified that the residents identified at risk for elopement had a care plan in place and were identified on a list kept at the reception desk. The survey team verified educational sign-in sheets for staff education regarding elopement were completed. All staff members were identified by the facility as having received the education and signed the in-service sheets. This was verified by interviews on 02/24/2023 with two staff from housekeeping, three staff from therapy, two dietary staff, an activity assistant, four CNAs, one LPN, one RN, the MDS coordinator, the DON, and the Administrator. Interviews with these staff revealed education had been provided regarding when elopement risk assessments would be completed, what to do if a resident exhibited exit seeking behaviors, interventions to prevent an elopement, and notifying responsible parties and providers of elopement attempts. The survey team verified new residents admitted to the facility had an elopement assessment completed upon admission. The survey team verified the facility had completed an initial audit to identify residents at risk for elopement and interviews with the DON and Administrator verified that these audits would be completed weekly on Mondays. New Jersey Administrative Code § 8:39-27.1(a)