**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical and facility record review, video footage, and staff interview during a recertification and abbreviated survey (Case # NY00287505) the facility failed to provide adequate supervision for one (Resident #216) of 8 residents reviewed for accidents. Specifically, on 12/3/21 at 11:30 AM the facility failed to provide Resident #216, who was severely cognitively impaired, with supervision. Subsequently, Resident #216 was able to exit the building through a coded/locked door off the unit and 2 sets of alarmed doors exiting the facility for over two hours. Both alarmed doors were disabled by facility staff. Facility video footage revealed resident exited the facility at 11:30AM and facility staff did not discover the resident missing until lunch time at 12:15PM. In addition, facility staff did not follow their process for elopement when the facility staff member that exited through the coded/locked door did not observe and ensure the door closed and locked behind them; did not perform a headcount when the interior alarmed door sounded and the source of the alarm was not identified and the facility staff deactivated the alarmed door that exited to the outside and did not call a Code 1, when an alarmed perimeter door is breached, a Code 1 would be announced. This resulted in no actual harm with the likelihood for more than minimal harm that is Immediate Jeopardy and substandard quality of care/past noncompliance to resident health and safety. The Immediate Jeopardy was lifted on 12/15/2020. This was evidenced by: The facility's policy and procedure dated 6/2017 titled Resident (Missing) Code 1 Alarm, Doctor Yellow, Door Alarm (Interior) documented that when an interior door alarm sounds, staff would immediately respond to the alarm and if unable to determine the reason for the alarm, a head count would be performed on that unit and if a resident was missing, the staff would follow a Dr Yellow - potential missing resident alert. Additionally, it documented when an alarmed perimeter door was breached, a Code 1 would be announced, the staff in the immediate location must proceed to the door and determine the cause. If the cause is undetermined, search procedures will begin. A resident head count would be completed. Resident #216: Resident #216 was admitted to the facility with the diagnoses of dementia, adjustment disorder with anxiety, and hypertension. The Minimum Data Set (an assessment tool) dated 11/28/2021 documented Resident #216 was able to understand others, was able to make self-understood, and had severe cognitive impairment. Resident #216 was able to walk with supervision only. The Comprehensive Care Plan (CCP) dated as initiated on 1/18/2021 and revised on 8/24/2021, documented the resident was at risk for wandering related to disorientation to place, and impaired safety awareness. The CCP documented the resident was non exit seeking and the goal documented that the resident would not leave the facility unattended through 2/22/2022. Interventions included; provide structured activities, walking inside and outside, and re-orientation strategies. It documented to re-evaluate the resident's risk for wandering quarterly and as needed. The Behavior assessment dated [DATE] documented that Resident #216 had the behavior of unsafe wandering without regard to physical safety by ambulating or self-propelling their wheelchair, may attempt to open doors, enter unsafe areas, or follow others through exit doors but is not seeking to leave and does not verbalize the desire to leave. The assessment did not document that Resident #216 was a risk for elopement. Observation of video footage provided by the facility showed that the resident exited the facility on 12/3/2021 at 11:30 AM. Facility staff did not discover the resident missing until 12:15 PM. The Director of Information Technology verified the date and time of the video footage as above. The facility's Incident Report dated 12/3/2021 documented the resident was an elopement risk. The incident Report documented the date the resident was last seen before elopement was 12/3/2021, the time last seen before the elopement was 11:30 AM, and the time missing was 12:15 PM. The Incident Report documented the system to prevent elopement functioned properly. -The description section of the Incident Report documented; on 12/03/2021 at 12:40 pm, staff could not find Resident #216 in the dining room for lunch and proceeded to search the immediate areas with no results. A code Yellow (Missing resident) was called at 01:00 pm and a facility wide search began. -Resident #216 was seen and assessed by a Registered Nurse (RN), Physician and Nurse Practitioner (NP). Resident #216 had no evidence of distress, their skin was a bit warm and dry, no visible injuries were noted and appeared not to have had any psychological negative effect from the incident. -The investigation findings documented on 12/03/2021: 11:25 AM - Resident #216 left the unit through the west kitchen door after Certified Nurses Aide (CNA) #5 punched in the security code and left the unit for his lunch break. Resident #216 was following CNA #5 who was also Resident #216's caregiver for the day, by quickly grabbing the door and exiting taking a left turn, while CNA #5 proceeded straight ahead to the elevator: 11:30 am - Resident #216 proceeded to push and walk through a security door (Elevator E- Double-Door) while the alarm was sounding. The Director of Housekeeping (DOH) who had just come into the Carmel Garden core area from Carmel Gardens [NAME] heard the alarm, looked around in the core area, looked up the ambulance entrance hallway and did not see or hear anything unusual and reset the alarm. 11:35 am - Resident #216 was observed on video exiting the ambulance entrance (exterior door), walked to the left and got into an unlocked employee car (silver car) which was parked about 300 ft on a paved parking lot; 01:45 pm - Social Worker (SW) #1 found Resident #216 sitting alone in the back seat of the silver car after SW #1 approached the left back door and noticed the resident. SW #1 knocked on the window and Resident #216 responded by opening the door. SW #1 asked for the name and Resident #216 responded I'm cold. It's freezing out here. SW #1 gave Resident #216 their jacket and brought Resident #216 back into facility. 02:00 pm - Director of Nursing (DON) performed an RN assessment on Resident #216 after returning to the facility. Resident #216 showed signs of apprehension when approached, pulling away and folding arms. After about three minutes the resident was smiling and was offered something to eat and drink. Color was pale, skin warm and dry. No flush to face, arms warm. Resident #216 had socks and shoes on with a shirt and sweater. No bruises or redness observed to body. Resident #216 was able to ambulate without difficulty, was not able to relate how they got out of building, refused a BP and has a BIMS of 03. The Medical Director, Physician and NP were made aware. Resident #216's niece and responsible party were notified. The nursing progress note dated 12/3/2021 at 3:01 PM, documented at around 11:55 AM Resident #216 was seen on the cameras following staff. The staff member had entered the code to the exit door and Resident #216 was seen following right after the staff member out the locked unit. Code yellow initiated, Resident #216 found and redirected back to the unit without incident. Resident #216 was assessed by the Nurse Practitioner (NP) and MD #1 and no issues found. Medical Director notified. POA (power of attorney) notified. Roam alert (a system to provide protection to wandering-prone residents by controlling exit doors) placed on right wrists for Resident 216's safety. The nursing progress note dated 12/3/2021 at 4:31 PM documented Resident #216 was assessed by this writer after they were returned to facility, showed signs of apprehension when approached pulling away and folding arms. After about three minutes was smiling and was offered something to eat and drink. Color was pale, skin warm and dry. No flush to face, arms warm. Resident #216 had socks and shoes on with shirt and sweater. No bruises or redness observed to body. Resident #216 was able to ambulate without difficulty. Resident #216 was not able to relate how they got out of the building, had a BIMS of 3 and had diagnosis of Alzheimer/Dementia. Medical Director, MD #1, and NP was made aware. Family, niece made aware. Labs were ordered, Roam alert was applied to the resident's right wrist. Behavior assessment done. Care Plan and Care Card updated. During an interview on 12/21/2021 at 12:21 PM, the Director of Life Enrichment (DOLE) stated the west kitchen door was only used by staff. On the day of the elopement CNA #5 did not see Resident #216 come out of the door (west kitchen door) behind them. The second door (security door-Elevator E- Double-Door) was a push and go door, people did it all the time. It would alarm and could just be egressed (exited), staff would have to come to the door and reset the code, it was typical that someone would reset code after looking. During an interview on 12/21/2021 at 12:21 PM, the Registered Nurse Manager (RNM) of the secured memory unit stated, staff were expected to ensure all coded doors closed and locked prior to them leaving the area to ensure a resident did not exit the unit undetected. Resident #216 was not at risk for elopement and did not have exit seeking behavior. Before, the resident never demonstrated they wanted to leave the unit, they wandered throughout the unit and lacked safety awareness, liked to pick up residents' things and look into rooms and things would catch the resident's attention. All people are responsible for identifying compliance, if someone put in a code and came through the door it would stop the alarm for 20 seconds. The west kitchen door alarm did not go off that we know of. The second door (security door-Elevator E- Double-Door) alarm would go off a lot, the code had to be entered physically at the door. During an interview on 12/22/2021 at 9:20 AM the Director of Environmental Services (DES) stated they heard the alarm while on a resident unit. DES approached the alarming door (security door-Elevator E- Double-Door), was unable to identify the cause of the alarm and entered a code to silence the alarm. A resident head count was not completed. The alarm goes off a lot and staff became complacent about responding to the alarm. During an interview on 12/22/2021 at 09:44 AM the Assistant Director of Maintenance stated the double doors (security door-Elevator E- Double-Door) was, push and open doors that had a local alarm, that would sound only in the area of the door and on both units on that same floor. The alarm would go off when the doors were held open a little too long. That alarm was not considered a Code 1 alarm, when the alarm goes off staff needed to search the immediate area, a head count should have been initiated and was not done. The back door (ambulance entrance-exterior double door), the right-side door had no code but was alarmed and had a crash bar. The left side door had a Mag lock (automatic releasing mechanism) and delayed egress. Both doors would have alarmed at the front reception desk. During an interview on 12/22/2021 at 12:26 PM, the Director of Plant Management (DPM) stated staff became desensitized to the interior door (security door-Elevator E- Double-Door) alarm as the alarm sounded five to six times per day from staff members holding the door open too long. After the cause of the alarm going off was unable to be identified, staff did not implement a resident head count, and they should have. Then, when the resident exited the back door (ambulance entrance-exterior double door) the alarm was activated at the front reception desk and a Code 1 should have been called by the receptionist and was not called. It was more than an hour later that a staff member called the receptionist and had them announce a Code Yellow for a Missing Resident. After the incident a Mag Alarm was added for extra protection. The staff are educated frequently for responding to the alarms no matter how often they go off. The DPM stated there was no camera at the double doors in the vestibule, and cameras were placed after the incident. During an interview on 12/22/2021 at 12:45 PM the Director of IT and a member of their alarm company stated, they confirmed the alarm was activated when the resident exited the facility (as confirmed by video and an alarm log reviewed by the facility). A Code 1 was not called, a resident head count was not completed and a Dr Yellow - missing resident search was not initiated. During an interview on 12/22/2021 at 1:40 PM the Front Lobby Receptionist stated they took their lunch break every day at 12:00 PM until 12:30 PM. From the timeframe of 11:00 AM until 12:00 PM no alarms for the exit doors had gone off, the alarms are so loud that anyone in the surrounding area would have heard them. The Receptionist would have looked at the panel that would display which door was alarming, and the computer screen at the reception desk showed every exit door in real time, then the button to turn off the alarm would have to be pushed to disarm the alarm once it was determined there was no problem. During an interview on 12/22/2021 at 5:18 PM, the Administrator (ADM) stated the double doors in the vestibule (security door-Elevator E- Double-Door) needed to have a code put in and then you could go through, it had a 15 second delay, then the alarms would start sounding. The ADM was not aware that staff were not compliant with the door alarm. If there is an alarm going off staff must respond to it. If ADM had been aware that staff were desensitized to the alarm, the ADM would have rolled out an education right then and there. The alarm is part of an elopement protocol. There is always someone at the reception desk. After the incident when the alarm did not sound at the reception desk, we did a sweep of all the egress doors. The ADM stated they knew the receptionist denied an alarm had gone off, and that all receptionists have been re-inserviced on the alarms. On the Memory Care Unit, they have individualized dining, there was no set time for a resident to have lunch, Resident #216 was always on the go. Immediately following the event, a Mag Alarm was placed on the security door-Elevator E- Double-Door that eliminated the 15 second delay and cameras were also installed in that area. In the future Administrative staff will receive text messages when the exit doors are breached. The ADM assessed the search for Resident #216 in order to improve upon the protocol. Improved pictures of all residents have been placed at the front reception desk. 10NYCRR483.25(d)(1)(2) Based on the following corrective actions, the facility corrected the non- compliance as of 12/15/2021. The facility reached past noncompliance by taking sufficient corrective actions prior to the recertification and abbreviated survey to both remove the immediate jeopardy and fully correct the noncompliance before the start of the survey. The facility's corrective actions included the following effective 12/15/21: - 95% of staff have been reeducated on elopement. The education provided included: unsafe wandering/elopement in-service that includes if the reason for an alarmed door cannot be determined a headcount is performed, and elopement prevention policy and procedure with emphasis on making sure there are no residents behind staff when going through any door on the secured unit and ensure the door has closed and was locked before leaving the area. -A delayed egress with Westminster Chimes feature was added to the right interior door on 12/14/2021 (the left door opens from the other direction). When the crash bar is depressed, within 5 seconds, this door alarms locally and via the nurse call system; the Westminster chimes alarm throughout the unit. The door releases 30-seconds after the delayed egress feature is activated. The keypad bypasses the delayed egress feature and all alarms. -A delayed egress with a local alarm feature was added to the right leaf of the exterior doors on 12/13/2021. The left leaf had been delayed egress. When the crash bar is depressed, within 5 seconds, either door will alarm locally and at the Reception Desk. The keypad bypasses both local alarm and reception alarm. Surveillance staff from the Capital District Regional Office remained onsite to complete the recertification survey.