**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview, review of the facility's investigation, review of the witness statements, review of the facilities self-reported incidents (SRIs), review of an emergency medical services (EMS) report, review of hospital records, review of emergency room (ER) notes, review of the local weather report, and review of a facility policy, the facility failed to provide adequate supervision and implement timely interventions for exit-seeking behaviors for Resident #39, who was cognitively impaired, had a history of recent exit-seeking behaviors, and who resided in a secured unit, to prevent his elopement from the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #39 broke the window in his room using a fire extinguisher and later returned to the room and exited the secured building by jumping out of the second story window, approximately 13 feet from the ground level. Resident #39 was missing from the facility for approximately 12 hours before staff found the resident being cared for by police and EMS six miles from the facility. This affected one (#39) of three residents reviewed for elopement risk. The facility identified twenty-seven residents (#01, #03, #04, #05, #08, #09, #10, #11, #12, #14, #15, #16, #18, #24, #25, #27, #33, #34, #36, #38, #40, #43, #44, #44, #45, #46, and #47) at risk for elopement on the secured unit. The facility census was 47. On [DATE] at 3:46 P.M., the Administrator, the Director of Nursing (DON), Regional Director of Clinical Services (RDCS) #314, and Regional Director of Operations (RDO) #315, were notified Immediate Jeopardy began on [DATE] at 6:30 A.M., when Resident #39 eloped from the facility, without staff knowledge due to the failure of the facility to provide adequate supervision. On [DATE] at 6:30 A.M., State Tested Nursing Assistant (STNA) #300 discovered Resident #39 had broken out his room window with a fire extinguisher and reported it to Licensed Practical Nurse (LPN) #220. Staff then moved Resident #39 from his room to the common area. LPN #220 who was assigned to monitor Resident #39, allowed the resident to return to the room with the broken window and then left the resident's room to check on another resident. LPN #220 was aware the resident broke his window and had STNAs take him and roommate to the dining room. At 6:45 A.M., in an interview with LPN #220, she stated she observed the resident returning to his room and he refused to leave the room. LPN #220 was observing him from the door when she left to care for another resident leaving the resident unsupervised and by himself in his room. On [DATE] at 7:30 A.M., STNA # 265 could not locate Resident #39. Staff looked out Resident #39's broken window and saw the following items on the ground below: a pillow, unused gloves, wipes, a flat sheet, and a bedspread. On [DATE] at approximately 7:40 P.M., STNA #265 was off duty and observed Resident #39 with the police and EMS personnel in a heavily trafficked area approximately six miles away from the facility. Resident #39 was taken to the hospital for evaluation. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 6:30 A.M., LPN #220 was informed the window in Resident #39's room was broken. At 7:00 A.M., LPN #220 was stationed outside the resident's room to supervise and ensure the safety of Resident #39 and to prevent re-entrance and access to the resident's room. At 7:25 A.M., LPN #220 stationed outside of the resident's room responded to another resident screaming and went to check on the resident. • On [DATE] At 7:30 A.M., STNA #265 checked the resident's room for the resident and noted him missing. Resident #39 was believed to have exited through the broken second floor window and landed 13 feet below on the exterior ground which consisted of grass and concrete and was unsecured. On the ground there was a pillow, unused gloves, wipes, a flat bed sheet and a bed spread. A head count was conducted immediately and there was a total of 45 residents present in-house out of a census of 47 (there was one resident on a Leave of Absence (LOA) with family and Resident #39 was unaccounted for). • On [DATE] at 7:30 A.M., upon discovering the Resident #39 could not be located, STNAs #218, #217, #312, #265 and LPN # 251 began searching the facility. • On [DATE] at 7:30 A.M., all other windows were checked by STNAs #216 and #312 and validated as being secured, and all exits/entrances were validated as being secured by STNA # 218. • On [DATE] at 7:45 A.M., STNAs #218 and #312 searched the perimeter of the facility until 8:10 A.M. • On [DATE] at approximately 8:00 A.M., LPN #293 notified the local Police Department Resident #39 was missing. Resident #39's Guardian, Psychiatric (Psych) Physician #316 and Medical Director (MD) #317 were notified by LPN #251. • On [DATE] at 8:00 A.M., Maintenance Technician (MT) #318 arrived at the facility. • On [DATE] at 8:10 A.M., the DON and Administrator were notified that Resident #39 could not be located. LPN #293 was placed on door watch outside of Resident #39's room to ensure the resident's room was not entered due to the broken window where she remained until the window was fixed around 10:12 A.M. by MT #318. • On [DATE] at approximately 9:00 A.M., the DON, Business Office Manager (BOM) #207, Therapy Manager #258, Activities Director (AD) #305, MT #318, Administrator, RDO #315, Minimum Data Set (MDS) Coordinator #256 and Social Services Designee (SSD) #271 arrived at the facility and conducted an additional neighboring community search to locate the missing resident. • On [DATE] at 9:30 A.M., calls were made to all local hospitals by SSD #271 and Resident #39 was not located. • On [DATE] at approximately 10:12 A.M., the Administrator conducted a second audit of all door alarms and the elevator keypads to check for proper function and locking mechanism. No concerns were identified. • On [DATE] at approximately 10:15 A.M., MT #318 conducted a second window audit to ensure all windows were secured and in proper function. There were no concerns identified. • On [DATE] at 12:00 P.M., the DON and RDO #315 reviewed/completed wandering observation tools for each resident. No new residents were identified as an elopement risk. • On [DATE] at 12:30 P.M., MDS Coordinator #256 reviewed/updated all care plans to identify residents who were at risk for wandering and elopement. No new residents identified. • On [DATE] at approximately 1:00 P.M., the DON reviewed the elopement binder, the elopement policy, pictures, and face sheets of all at risk residents and no corrections were needed. • On [DATE] at 2:30 P.M., the search for Resident #39 was concluded by the facility staff. • On [DATE] at 3:00 P.M., the DON and Administrator initiated education on elopement management with all facility staff. There were 108 educated out of 108 total staff and completed by 9:00 P.M. and the facility utilized no agency staff. All 108 staff were educated electronically and any staff member not present was instructed to sign off on the education prior to the next scheduled shift. • On [DATE] at approximately 3:30 P.M., education was provided to the Administrator by RDO #315 on elopement management and elopement prevention. • On [DATE] at approximately 3:30 P.M., education was provided to the Administrator and DON by RDO #315 on management of potential risks and hazards to prevent accidents that include but not limited to safeguarding identified risks/hazards to avoid exposure to residents. • On [DATE] at approximately 3:30 P.M., education was provided to the Administrator and DON by RDO #315 on supervision of residents when known risks or hazards are identified that include but not limited to one-on-one (1:1) supervision. • On [DATE] at approximately 7:40 P.M., Resident #39 was located in a neighboring community six miles away by STNA #265 who was heading home and familiar with the area. STNA #265 observed the resident with the police and EMS. STNA #265 notified the DON Resident #39 had been located. • On [DATE] at 7:55 P.M., RDO #315 was notified by the Administrator that Resident #39 had been located by STNA #265. • On [DATE] at 8:08 P.M., an unknown Dispatcher at the local Police Department (PD) called the Administrator to provide an update on the status of Resident #39. The PD Dispatcher was instructed to have EMS transport Resident #39 to the local hospital for a psychological evaluation. • On [DATE] at 8:12 P.M., Resident's #39's Guardian was notified by the DON and Administrator Resident #39 had been located and was being transported to the local hospital for a medical and psychological evaluation. • On [DATE] at approximately 8:14 P.M., Psych Physician #316 was updated by the Administrator and DON on the status of the resident being transitioned to the hospital's Psychiatric Unit. Psych Physician #316 reported the hospital would evaluate the resident and determine if he was appropriate for a 72-hour hold (psychiatric admission). • On [DATE] at 8:25 P.M., an unknown ER Nurse at the local hospital called and spoke with the Administrator and DON and informed them Resident #39 would be assessed psychologically and medically. • On [DATE] at 8:59 P.M., Medical Director #317 was updated on Resident #39's status by the Administrator. • On [DATE] at 9:00 A.M., the DON and Administrator reported to the Quality Assurance Performance Improvement (QAPI) committee the findings related to compliance. The QAPI committee consists of the Administrator, DON, SSD #271, RD #252, BOM #207, MDS Coordinator #256, RDO #315, Therapy Manager #258, and MD #317 (via telephone). • On [DATE] at approximately 3:15 P.M., the DON called the local hospital for an update on Resident #39. The hospital noted Resident #39 was assessed, and no new discoveries or diagnoses were determined, thus the resident was set for discharge back to the facility at 5:00 P.M. • On [DATE] at 5:32 P.M., an elopement drill was conducted by the DON and Administrator. No issues were identified. • On [DATE] at 6:02 P.M., Resident #39 returned to the facility. The resident's Guardian and MD #317 were notified of the resident's return with no new orders given. • On [DATE] at 6:02 P.M., Resident #39 was immediately placed on 1:1 observation and will remain until determined by the Interdisciplinary Team (IDT) and MD #317 that 1:1 observation was no longer required. All staff were educated on expectations of the resident being on 1:1 observation by the DON and Administrator. • On [DATE] at 6:29 P.M., an admission assessment was completed (including skin, pain, and a Braden Scale) on Resident #39. A care conference with the facility's IDT and Resident #39's Guardian/mother was scheduled for [DATE] at 12:45 P.M. • Beginning [DATE], to monitor for ongoing compliance, elopement drills will be completed twice weekly for four weeks, then monthly. The drills will be conducted by the DON or Administrator on day shifts and night shifts. • On [DATE] at 12:45 P.M., A 72-hour care conference was held with the facility's IDT which included SSD #271, DON, Administrator, Therapy Manager #258, MD #317, RDO #315, Registered Dietitian (RD) #252, BOM #275 and Resident #39's Guardian/mother. The Guardian was okay with the new interventions of a room move, 1:1 observation, and a psychiatric consultation. A Brief Interview Mental Status (BIMS) assessment was completed on Resident #39 and noted to be a 12 which indicated the resident was cognitively intact. Resident #39's care plan was updated to show the resident eloped and new interventions include 1:1 observation, educate the resident to speak with staff if he would like to take a walk outside, provide diversionary activities, notify the physician of behavior changes, and offer additional snacks and hydration. • On [DATE] 3:30 P.M., Resident #39's room change was conducted. Resident remains on 1:1 observation close to the nurse's station. • On [DATE], the surveyor completed review of the medical records for residents (#03, #09, #24, and #38) identified as elopement risks and revealed no concerns related to actual elopement from the facility, elopement risk assessments were current and accurate, and care plans were initiated and updated with appropriate interventions to prevent elopement. • On [DATE] from 11:00 A.M. to 12:30 P.M. and on [DATE] from 12:00 P.M. to 3:36 P.M., interviews with STNAs #216, #265, #218, Registered Nurse (RN) #210, LPNs #220 and #293, Central Supply (CS) #282, AD #215, and Activities Assistant (AA) #321, revealed all staff were educated and verbalized knowledge of the facility's elopement policies and procedures and guidelines for monitoring residents who have been placed on 1:1 supervision. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #39 revealed an admission date of [DATE] with diagnoses including schizoaffective disorder, Tourette's disorder, schizophrenia, dementia, bipolar disorder, seizures, suicidality, myocardial infarction, attention deficit hyperactivity disorder (ADHD) combined type, and history of falling. Review of a Guardianship Order dated [DATE] for Resident #39 revealed the resident was assigned a guardianship due to being incompetent, and a mental disability related to schizoaffective disorder and schizophrenia. Review of the physician's order dated [DATE] for Resident #39 revealed the resident was ordered to be admitted to a secured unit. Review of a Wandering Tool Evaluation dated [DATE] for Resident #39 revealed the resident had a past history of wandering, elopement attempts, had expressed anxiety/apprehension to leave the facility, the family/responsible party voiced concerns that would indicate the resident may have wandering tendencies or try to leave, and the resident wandered without sense of purpose, i.e., confused, may enter others rooms and explore belongings. The assessment identified Resident #39 as being at risk for elopement or unsafe wandering. A follow- up evaluation was completed on [DATE] which revealed Resident #39 remained at risk for elopement and unsafe wandering. Review of the care plan dated [DATE] and revised on [DATE] for Resident #39, revealed the resident resided on a secured unit related to elopement risk, and poor cognition. Interventions included educate the resident/resident's representative of the need for a secured unit to maintain the resident's safety, notify the medical provider/resident's representative of any behavior changes, provide diversionary activities as needed and redirect when appropriate. Review of a progress note dated [DATE] at 1:04 P.M. for Resident #39, revealed the resident was seen by laundry staff trying to remove the ceiling tiles as an escape route. The resident was redirected and accompanied to the dining room for lunch. The vital signs were within normal limits, the resident denied pain, the skin was intact, and the resident was calm. Fifteen (15)-minute checks were initiated, and Resident #39 remained on 15-minute checks from [DATE] until [DATE]. Review of the quarterly MDS assessment dated [DATE] for Resident #39 revealed the resident was cognitively impaired and required supervision for activities of daily living (ADLs). Resident #39 was assessed to have the presence of wandering behaviors. Review of a progress note dated [DATE] at 8:45 A.M. for Resident #39 revealed at approximately 7:30 A.M., Resident #39 was noted to not be in his room. The Physician, DON, the resident's Guardian, and the local police were notified. Review of the EMS run report dated [DATE] revealed EMS was dispatched at 7:37 P.M. for unknown problem/person down. The report indicated the patient (Resident #39) broke out of a long care facility this morning. He has a history of mental health. There are no medical issues that he was complaining of and needs transportation back to the facility. Cincinnati Police Department (CPD) notified and responded to transport patient. The patient was turned over to law enforcement. Review of a progress note dated [DATE] at 9:00 P.M. for Resident #39 revealed the resident was located by a staff member (identified as STNA #265) earlier this evening. The police responded and EMS. The resident was transported to a psychiatric hospital for a psychological and medical evaluation. The resident was placed on 72-hour hold and the resident's Guardian was notified. The Facility Psychiatrist #316, Medical Director #317, the RDCO# 314, and RDO #315 were notified. The residents room change will be initiated prior to returning to the facility. Review of the hospital ER notes dated [DATE] at 9:40 P.M. for Resident #39 revealed the resident presented to the ER for foot pain after going missing from a nursing home. The notes revealed the nursing home found evidence that the resident had broken a window out and jumped out of the second story window around 7:30 A.M. The resident was reported to have a shuffled gait; however, refused to participate in the medical care team's examination. The resident did not express discomfort with palpation of the extremities or examination of the spine and due to history, imagining was ordered to rule out trauma. The resident had various imaging studies which were all negative for any acute fractures or abnormalities. Resident #39 was medically cleared, diagnosed with fall, schizophrenia with acute exacerbation, discharged from the ER on [DATE] at 6:08 A.M. and immediately re-admitted to psychiatry unit at the same hospital. The psychiatry notes indicated the resident was well known to the psychiatry team and the resident was originally placed in a Skilled Nursing Facility (SNF) due to injuries he sustained after breaking out a window at home and jumping. The resident received comprehensive psychiatric evaluation and therapeutic management in accordance Psychiatric Emergency Services (PES) guidelines for dangerous behavior while he was at his SNF. Resident #39 was monitored for 10 hours and discharged back to the SNF at 5:32 P.M. with no new orders. Review of STNA #306's written statement dated [DATE], revealed she had clocked out and was about to leave when someone said they couldn't find Resident #39 for his breakfast tray. They started looking for the resident and she stayed and waited. Review of LPN #220's undated written statement revealed the resident was walking around and acting usual. The resident didn't say or do anything unusual. Review of STNA #300's undated written statement revealed the resident was pacing until about 4:00 A.M. The resident went to his room and STNA #300 saw the window was broken and told the nurse. They checked it out and told the DON. STNA #300 helped clean up the glass. Review of SSD #271's written statement dated [DATE], revealed she called area hospitals searching for the resident and the resident was not located. SSD #271 drove around with BOM #275, and the resident was not located. Review of STNA #265's written statement dated [DATE] revealed when she arrived at work at 7:02 A.M., she was informed Resident #39 was on 15-minute checks. STNA #265 went into the resident's room at 7:15 A.M. to check on the resident and the resident was lying in bed and when she went back to check on the resident, the resident was not in the room. They all went out to check. Review of STNA #265's additional written statement dated [DATE], revealed she was heading home after work when she was driving and saw EMS who was with Resident #39. STNA #265 pulled over to let them know that Resident #39 had escaped from the facility where she worked at. STNA #265 called the DON to let her know the resident was found. Review of STNA #208's written statement dated [DATE], revealed she worked on [DATE] and noticed the window was broken along with STNA #300. During rounds, she took Resident #39 and his roommate to the dining room at 6:30 A.M. and when she left at 7:00 A.M., they were still there. Interview with the DON on [DATE] at 10:00 A.M., revealed the resident was originally admitted to the facility on [DATE] post hospitalization related to the resident jumping out of an apartment building window and fracturing both feet. The DON verified the resident was observed trying to remove ceiling tiles on [DATE] as an escape attempt and the resident was placed on fifteen-minute checks. Interview with STNA #208 on [DATE] at 1:05 P.M., revealed she was assigned to care for Resident #39 on [DATE] during the night shift (7:00 P.M. to 7:00 A.M.). STNA #208 stated during her rounds at 6:30 A.M., she discovered the window in the resident's room was broken and she reported it to LPN # 220. STNA #208 stated she did not hear glass breaking during her shift and could not be certain when the window was broken. STNA #208 stated she was instructed by the LPN #220 to remove the resident and his roommate from the room, so she placed Resident #39 and his roommate in the dining room and sat with the residents until the end of her shift at 7:00 A.M. STNA #208 stated LPN #220 was standing in the hallway near Resident #39's room to make sure no other residents entered the room as she took the residents to the dining room. Interview with LPN #220 on [DATE] at 1:32 P.M., revealed she was assigned as Resident #39's nurse on [DATE] during the night shift and into the morning of [DATE]. LPN #220 stated she was informed by STNA #208 of the broken glass in the resident's room and instructed the STNA to move the resident and his roommate to the dining room and stay with them. LPN #220 stated she did not hear breaking of any glass in the resident's room during the shift and could not be certain when the glass was broken. LPN #220 stated STNA #300 assisted her with cleaning up the glass and she remained in the hallway near Resident #39's room. LPN #220 stated at approximately 6:45 A.M. she saw Resident #39 return to his room and the resident refused to leave his room. LPN #220 stated she left the facility at approximately 7:15 A.M. when the day shift nurse, LPN #293, arrived. Interview with STNA #265 on [DATE] at 1:37 P.M., revealed she was assigned to care for Resident #39 on [DATE] during the day shift (7:00 A.M. to 7:00 P.M.). STNA #265 stated Resident #39 was on 15-minute checks and she was informed the resident's room window was broken earlier in the morning but never informed the resident was not supposed to be in his room or be on 1:1 observation. STNA #265 stated she checked on the resident at 7:15 A.M. and he was lying in his bed, and she did not want to disturb him and when she checked on him again at 7:30 A.M. the resident was not in his room. STNA #265 stated she looked out the resident's window and saw a pillow and some bed linens lying on the ground and the gate was open. STNA #265 stated she immediately informed LPN #293 and all staff started searching for the resident. STNA #265 stated after her shift at 7:00 P.M., she decided to search the neighboring community because she had heard the resident talk about the area. STNA #265 stated at approximately 7:40 P.M. she located Resident #39 with EMS and notified the Administrator. STNA #265 stated the resident was dressed in hoodie, jeans, and tennis shoes. STNA #265 left when the resident was transported to the hospital. Interview with LPN #293 on [DATE] at 1:44 P.M., revealed she was assigned to care for Resident #39 on [DATE] during the day shift. LPN #293 stated she was informed by LPN #220 that Resident #39's room window had been broken out. LPN # 293 stated she was getting report from the previous shift and did not see the resident and at 7:30 A.M., STNA #265 informed her the resident was not in his room and when she looked out the window, she saw a pillow and blankets and assumed the resident had eloped through the broken window. LPN #293 stated she initiated a head count which ended at approximately 8:15 A.M. and Resident #39 was not in the facility. LPN #293 stated she closed the door to the resident's room and stayed by the door from 8:15 A.M. until 10:12 A.M. when MT #318 repaired the window. Observation of Resident #39 on [DATE] at 1:57 P.M., revealed the resident was on a 1:1 observation by RN #210. Interview with Resident #39 at the same time, revealed the resident reported he couldn't remember what happened on [DATE] but stated he wanted to leave the facility. Telephone interview with the Administrator on [DATE] at 3:33 P.M., revealed on [DATE] at 8:00 A.M., LPN #293 notified the local police Resident #39 was missing and the police put out a statewide be on the lookout ([NAME]). The Administrator stated she was contacted by the local police on [DATE] at 8:08 P.M., that the resident had been found and asked if she wanted him held at the police station or returned to the facility. The Administrator instructed the police to take him to the hospital for a psychiatric and medical evaluation. The Administrator stated a fire extinguisher was found on the floor of the resident's room and the facility had determined he used the fire extinguisher to break the window. The Administrator stated after the resident returned to the facility on [DATE], she interviewed the resident and he stated he used the fire extinguisher to break the window and jumped out of the window because he wanted to go home. Review of the online weather report at the website https://www.wunderground.com/history/daily/us/oh/cincinnati/KCVG/date/2024-4-21 revealed the air temperature on [DATE] at 7:52 A.M. was 39 degrees Fahrenheit, there was no precipitation, and the wind speed was approximately twelve miles per hour. Review of the facility's undated policy titled, Elopement Management revealed failure to provide adequate supervision for cognitively impaired residents who leave the facility or safe area and are unaccounted for is considered an elopement. This deficiency represents non-compliance investigated under Complaint Number OH00153232.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview, review of the facilities investigation, review of the facilities self-reported incidents (SRIs), review of guardianship documents, review of a police report, and review of a facility policy, the facility failed to provide adequate supervision to prevent the elopement of Resident #100, who had impaired cognition, assessed with exit seeking behaviors and resided in a secured behavioral building. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #100 eloped from the facility without staff knowledge. The lack of adequate supervision and timely response to interventions resulted in Resident #100 exiting the secured building at an unknown time. Resident #100 was discovered missing from the facility at 6:30 P.M. during nursing rounds and Resident #100 was discovered by fire department personnel at 7:10 P.M. when the resident walked into an apparatus bay of the local fire department which was 1.1 miles from the facility and located in a congested, highly trafficked area. This affected one resident (#100) of three residents assessed at risk for elopement in the facility. The facility census was 46. On [DATE] at 1:36 P.M., the Administrator, Regional Director of Clinical Operations (RDCO) #801, and Licensed Practical Nurse (LPN) #17 were notified Immediate Jeopardy began on [DATE] at 6:30 P.M., when Resident #100 was not provided adequate supervision and eloped from the facility, without staff knowledge. On [DATE] at 7:10 P.M., the resident was found by the fire department personnel when the resident walked into an apparatus bay of the local fire department which was 1.1 miles away and located in a congested, highly trafficked area. The fire department personnel called the local police department who responded to the fire department and transported Resident #100 back to the facility at 7:15 P.M. Observation of the facility's front door on [DATE] at 2:22 P.M. with the Administrator, revealed the front door was left unalarmed and was able to be opened with no delayed egress while there were no staff present in the area watching the door. The Administrator stated she was not aware the door was left unalarmed and verified the door was able to open without the delayed egress. The Administrator was observed to ask the nurse at the nurse's desk if she had been watching the door and the nurse stated she had no knowledge that the door was unlocked, and it was not alarmed. No other staff were in the vicinity and no staff members identified themselves as watching the door as the Administrator was attempting to find out who was watching the door while maintenance staff had the front door alarm and delayed egress turned off and were not in the vicinity of the door. Interview with the Administrator at the same time verified the front door was left unalarmed and was able to open with no delayed egress. The Administrator also verified the door was not being watched by staff and maintenance staff were not present at the door. The Immediate Jeopardy was removed [DATE] when the facility implemented the following corrective actions: • On [DATE] at 6:30 P.M., LPN #17 ensured all residents were accounted for. • On [DATE] at 6:45 P.M., LPN #17 completed an audit to ensure all windows and doors were secured and functioning properly. • On [DATE] at 7:15 P.M., Resident #100 was returned to the facility and immediately had a head-to-toe assessment, a pain assessment, and a wandering assessment completed by former Director of Nursing (DON) #800. • On [DATE] at 7:15 P.M., Resident #100 was placed on one-on-one (1:1) supervision for 24 hours. • On [DATE] at 7:25 P.M., LPN #17 notified Physician #200 and new orders were written for Tylenol (over the counter pain) and Aloe Vera lotion. • On [DATE] at 7:52 P.M., LPN #17 notified Resident #100's guardian. • On [DATE] at 9:00 P.M., Former DON #800 and LPN #17 completed wandering and elopement assessments on all residents and no new residents were identified with elopement risks. • On [DATE] at 9:00 P.M., two-hour safety checks were initiated for all residents and continued until [DATE]. • On [DATE] at 9:00 P.M., RDCO #810 educated the Executive Director regarding elopement risks, secure access monitoring upon exit and entrance, and elopement prevention. • On [DATE] at 9:09 P.M., Executive Director initiated education for all staff including Bridgeway (agency staff) on elopement risks, secure access monitoring upon exit and entrance, and elopement prevention. This education was completed on [DATE] at 9:00 A.M. • On [DATE] at 9:30 P.M., LPN #17 reviewed and updated Resident #100's care plan to include wandering interventions to provide activities, asses for hunger, thirst and toileting needs when wondering. • On [DATE], former DON #800/Designee initiated elopement drills twice weekly for two weeks, then weekly for two weeks. • On [DATE] at 10:53 A.M., LPN #09 completed pain and Braden Scale skin assessments for Resident #100. • On [DATE] at 11:00 A.M., the Executive Director removed the high back chairs from the front door area as an extra security measure due to Resident #100 sitting in the chairs. • On [DATE] at 2:03 P.M., Therapy Manager #812 completed a Brief Interview for Mental Status (BIMS) assessment on Resident #100. • On [DATE] at 5:30 P.M., Maintenance Technician #814 changed all door and elevator codes. • On [DATE] at 11:00 A.M., Former DON #800 reported to the Quality Assurance and Performance Improvement (QAPI) committee the findings related to compliance. The QAPI committee consisted of former Administrator #817, Registered Dietitian (RD) #816, Licensed Social Worker (LSW) #812, Social Services Designee #818, Physician #200, and Registered Nurse (RN) #808. • On [DATE] between 4:30 A.M. and 2:25 P.M., LPN #17, RN #809, STNAs #01, #02, #04, and #08 verified they were educated on resident elopement and wandering as well as responding to resident alarms. All staff members interviewed were knowledgeable of the content of each education provided by the facility. • On [DATE] at 2:45 P.M., LPN #17 ensured all residents were accounted for. • On [DATE] at 3:00 P.M., LPN #17 and RDCO #801 educated all staff on ensuring exit doors were closed and secured prior to walking away and that secured doors required monitoring by staff if the door was not able to be secured. • On [DATE] at 3:10 P.M., Facilities Manager #809 and Maintenance Director #810 fixed the front door and ensured it was in good working order. • On [DATE] at 3:30 P.M. and [DATE] at 1:00 P.M., LPN #17 and RDCO #801 completed an audit to ensure all windows and doors were secured and functioning properly. • On [DATE] at 9:00 A.M., LPN #17 and RDCO #801 completed an audit of all residents at risk for elopement, reviewed the facility elopement binder for accuracy and all resident's care plans were reviewed. • On [DATE] at 10:00 AM., Administrator in Training (AIT) #815 reported to the Ad hoc QAPI committee the findings related to compliance audits. • On [DATE], surveyor completed review of the medical records for residents (#01, #11 and #20) identified as elopement risks and revealed no concerns related to actual elopement from the facility, elopement risk assessments were current and accurate, and care plans were initiated and updated with appropriate interventions to prevent elopement. • On [DATE], to monitor ongoing compliance, Executive Director/designee will complete elopement drills twice weekly for two weeks, then once per week for two weeks. • On [DATE], to monitor ongoing compliance, Maintenance Director #810 will complete an audit to ensure all windows and doors are locked and secured. Audits will be completed five times per week for two weeks, then three times per week for two weeks, then weekly for two weeks. • On [DATE], Maintenance Director #810/Designee will change the door codes and elevator codes every 30 days. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #100, revealed an admission date of [DATE] with diagnoses including dementia, mild intellectual disabilities (ID), schizoaffective disorder bipolar type, chronic obstructive pulmonary disease (COPD), epilepsy, and major depressive disorder. Resident #100 was discharged to another skilled nursing facility on [DATE]. Review of a guardianship order dated [DATE] for Resident #100, revealed the resident was assigned a guardianship due to mental disability related to dementia and schizoaffective disorder. Review of the physician's order dated [DATE] for Resident #100, revealed the resident was ordered to be admitted to a secured unit. Review of the progress note dated [DATE] for Resident #100, revealed Emergency Medical Services (EMS) called the facility asking about Resident #100 and stated the resident had called 911 and EMS was on their way to check out the resident. EMS was told that Resident #100 was fine, and the nurse saw him about 10 minutes ago. The nurse went to check on the resident and the resident was noted walking out of his room. The resident was asked if he called EMS and he stated yeah, I am getting out of here. Resident #100 denied any concerns and no distress was noted. Resident stated I want a pop. I know I am not supposed to call 911 but I want a coke. The last time the officer told me I could go to jail for calling too much. The nurse reminded Resident #100 that 911 was for emergencies. Review of the secured unit care plan dated [DATE] for Resident #100, revealed the resident required a secured unit for behaviors and poor cognition. Interventions included evaluate the need for a secured unit, obtain consent for the resident from resident representative, obtain a medical provider order to include the diagnosis and exhibited behaviors, notify the medical provider and resident representative of behavioral changes, provide diversionary activities as needed and redirect resident when appropriate. Review of the wandering observation tool dated [DATE] for Resident #100, revealed the resident had a history of wandering. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #100, revealed the resident was moderately cognitively impaired, and Resident #100 required limited assistance with transfers, and toileting. Resident #100 required supervision with bed mobility, dressing, eating, and personal hygiene. Review of the secured unit follow up review assessment dated [DATE] for Resident #100, revealed the resident was agitated at times and wanted to leave and would tell staff he wanted to leave. Resident #100 also called 911 occasionally and was anxious at times. Review of the progress note dated [DATE] at 7:52 P.M. for Resident #100, revealed the resident's guardian and brother were made aware of Resident #100's unauthorized leave of absence and Resident #100's return to the facility. Review of the progress note dated [DATE] at 7:52 P.M. for Resident #100, revealed the resident left on an unauthorized leave of absence and was found at the fire station without concern. Policy and procedure were followed. Review of the police report dated [DATE], revealed the police were dispatched to the facility on [DATE] at 6:42 P.M. and arrived at the facility at 6:48 P.M. to take a report for a missing resident. Upon arrival, police met with an employee (unknown) that was waiting outside for police. After speaking with the employee, it was determined that the individual was missing from the secured part of the facility. Staff told police he was last seen at 1:30 P.M. Police gathered all the information to be able to enter him as an endangered missing person and left the scene to look for the individual. As police were entering the individual as a missing person, the fire station called at approximately 7:10 P.M. to report that a person walked into their fire house and stated he was from the facility's address. Police responded and it was the missing individual. The firehouse was a little over a mile away from the facility. Police returned the resident to the facility and to the care of the nurses. Review of the wandering observation tool dated [DATE] for Resident #100, revealed the resident had a history of wandering, had not accepted current living arrangements, the resident had expressed anxiety and apprehension to leave the facility, the resident had a history of elopement, the resident wandered without a sense of purpose and the resident had psychiatric issues. Review of LPN #802's written statement dated [DATE], revealed she last saw Resident #100 in the hall during lunch by his room around 12:30 P.M. Review of LPN #17's written statement dated [DATE], revealed she sat outside with the residents during a smoke break at 11:15 A.M. Review of STNA #803's written statement dated [DATE], revealed the last time she saw Resident #100 was in his room at 4:30 P.M. or 5:00 P.M. when the nurse administered his medications. Review of LPN #804's undated written statement, revealed she came to work on [DATE] at 2:15 P.M. She started her medication pass around 4:15 P.M. Resident #100 received medication around 4:30 P.M and she finished her medication pass around 6:15 P.M. LPN #804 got prepared for her report for the next shift and making eye contact with all of the residents when she noticed Resident #100 was missing. She contacted nursing staff and they immediately started looking for the resident. She called Resident #100's guardian and his brother, and they looked for the resident inside and outside of the building. Review of STNA #805's written statement dated [DATE], revealed she saw Resident #100 at about 4:45 P.M. in his room in his bed. Review of STNA #01's written statement dated [DATE], revealed she saw Resident #100 around 1:30 P.M. Review of STNA #11's written statement dated [DATE], revealed she saw Resident #100 at dinner time when she was passing the trays and he was laying in his bed at 5:30 P.M. Review of STNA #806's written statement dated [DATE], revealed she last saw Resident #100 at 3:15 P.M. Review of LPN #17's undated written statement revealed the temperature was 78 degrees Fahrenheit outside on [DATE] and it was somewhat cloudy due to overcast. It was not raining. Resident #100 was wearing jeans, a black T-shirt, socks, and shoes. He was dressed appropriately. Review of the facility's in-service dated [DATE], revealed staff were educated on elopement, ensuring all doors close and lock when exiting and no one follows. Staff were also educated on ensuring the elevator door closes completely when exiting. Division of Facilities Manager #809 was not listed as being educated on [DATE] and Maintenance Director #810 was not employed by the facility on [DATE]. No maintenance staff were listed as being educated on elopements. Review of the facilities SRIs from [DATE] to [DATE], revealed there were no SRIs filed in regard to any elopements from the facility. Review of the progress note dated [DATE] for Resident #100, revealed the resident discharged to another skilled nursing facility. Review of Maintenance Director #810's employment orientation education dated [DATE], revealed Maintenance Director #810 was educated that staff must ensure that all exit doors are completely closed, and the lock is engaged prior to exiting the facility and when entering the facility. Interview on [DATE] at 4:21 A.M. with STNA #02, revealed he was not present on the date of Resident #100's elopement but stated Resident #100 would make comments that he wanted to leave and go home prior to the elopement incident. Telephone interview on [DATE] at 8:43 A.M. with Resident #100's guardian, revealed Resident #100 was never authorized to go out of the facility unsupervised as he has poor safety awareness and the intellectual ability of an eight- to ten-year-old. Resident #100's guardian stated that Resident #100 eloped from the facility a few weeks ago and was found by the police at the fire department. Resident #100's guardian stated the facility notified her in the late afternoon that Resident #100 was missing from the facility, and they stated they did not know how long he had been gone. Resident #100's guardian stated the facility also notified Resident #100's brother prior to calling her and the facility did not know how he got out of the facility. Resident #100's guardian reported the facility reported that Resident #100 had a history of sitting by the door and watching the door and he likely got out from watching the doors. Resident #100's guardian stated Resident #100 had a history of attempting to leave the facility and had previously eloped from prior facilities. Resident #100's guardian reported the facility was aware of Resident #100's elopement history. Telephone interview on [DATE] at 9:52 A.M. with Police Officer #807, revealed he got a call on [DATE] at 6:42 P.M. from the facility and he responded to the call. Police Officer #807 stated staff were outside looking for Resident #100 when he arrived at the facility, and he went inside to the nurse's station. Police Officer #807 reported staff were not able to tell him when he was last seen but one staff member reported Resident #100 was last seen at 1:30 P.M. Police Officer #807 stated he asked facility staff members questions related to when Resident #100 was last seen and information about him and how he eloped several times and the responses were not consistent. Police Officer #807 reported he left and went to the shopping center across the street from the facility to search for the resident and then went back to the police department to enter Resident #100's information into their missing person systems. Police Officer #807 stated the fire department called him at 7:10 PM. and reported they had a person there that said he walked away from a nursing home. The fire house was located at 7050 Blue Ash Road Cincinnati OH 45236 which was over a mile away from the facility. Police Officer #807 stated he could not remember exactly what Resident #100 was wearing and he took Resident #100 back to the facility at 7:15 P.M. Interview on [DATE] at 10:37 A.M. with STNA #01, revealed the STNA worked on the day Resident #100 eloped from the facility, but she could not remember the time or the details. STNA #01 stated that someone told her Resident #100 eloped from the facility but could not remember who told her or what time it was but stated it might have been around dinner time. STNA #01 stated staff started looking for Resident #100 and she was not sure how he got back at the facility or what time he arrived back at the facility. Telephone interview on [DATE] at 12:48 P.M. with STNA #11, revealed the facility noticed Resident #100 was missing but she was not sure who noticed that Resident #100 was missing. STNA #11 stated she was told by another staff member that Resident #100 was missing, and they started searching the resident rooms and looking outside for Resident #100. STNA #11 stated she was not sure who called the police, when Resident #100 returned to the facility or where Resident #100 was found. Telephone interview on [DATE] at 1:13 P.M. with RN #808, revealed she did not know what time Resident #100 was last seen or when he went missing. RN #808 stated she could not remember any details of the event. RN #808 then called back on [DATE] at 1:20 P.M. and stated staff noticed Resident #100 missing at an unknown time and a head count was completed. RN #808 stated the physician and guardian were notified and Resident #100 returned to the facility at 7:15 P.M. and was not too far from the facility. Interview on [DATE] at 1:47 P.M. with the Administrator, revealed the Administrator was not the acting Administrator at the time when Resident #100 eloped from the facility on [DATE]. The Administrator stated Resident #100 was last seen at 5:30 P.M. by STNA #11 and LPN #804 noticed Resident #100 missing at 6:30 P.M. The Administrator reported staff searched all the resident rooms twice and then they went outside and checked the neighboring facility and the perimeter of the building. The Administrator stated the police were also called and the former Administrator and former DON #800 were notified. The Administrator reported the police came and the resident was assisted back to the facility by police approximately 45 minutes after he was found. The Administrator stated she was not sure where he was found as she was not working at the facility at the time of the incident but later reported he was found at the fire department. The Administrator reported the resident was wearing jeans, a black T-shirt, socks, and shoes and it was 78-degree Fahrenheit outside on [DATE]. The Administrator stated Resident #100 had a guardian and it was an unauthorized leave of absence. The Administrator stated the facility was not sure how Resident #100 got out of the facility but stated he could have followed a family member out of the building. The Administrator stated Resident #100 did not have any injuries and staff started doing resident checks every two hours, and elopement drills on [DATE]. The Administrator reported the doors and windows were checked on [DATE] and were functioning properly and the door codes were changed on [DATE]. The Administrator stated the door codes are now changed every thirty days and family are not given the codes. Observation of the facility's front door alarm on [DATE] at 1:59 P.M. with the Administrator, revealed the door was not alarming and would not open. Interview with the Administrator at the same time verified the front door was not alarming and would not open. Administrator stated she would call maintenance. Observation of the facility's front door on [DATE] at 2:22 P.M. with the Administrator, revealed the front door was left unalarmed and was able to be opened with no delayed egress while there were no staff present in the area watching the door. The Administrator stated she was not aware the door was left unalarmed and verified the door was able to open without the delayed egress. The Administrator was observed to ask the nurse at the nurse's desk if she had been watching the door and the nurse stated she had no knowledge that the door was unlocked, and it was not alarmed. No other staff were in the vicinity and no staff members identified themselves as watching the door as the Administrator was attempting to find out who was watching the door while maintenance staff had the front door alarm and delayed egress turned off and were not in the vicinity of the door. Interview with the Administrator at the same time verified the front door was left unalarmed and was able to open with no delayed egress. The Administrator also verified the door was not being watched by staff and maintenance staff were not present at the door. Telephone interview on [DATE] at 2:25 P.M. with Former DON #800, revealed she no longer worked at the facility but was in meetings at the neighboring skilled nursing facility on [DATE] when Resident #100 eloped from the facility. Former DON #800 stated that she walked over to get her stuff to go home, and the staff told her that they could not find Resident #100. Former DON #800 stated she was not sure what time it was, but staff searched the facility, and the Administrator was notified. The police were called but she was not sure who called the police and Resident #100 was later found at the fire department. Former DON #800 stated that she was not sure when Resident #100 was last seen, and stated staff recollections of events were very inconsistent. Review of LPN #17's undated witness statement, revealed the front door was fixed and was fully functioning on [DATE] at 3:10 P.M. Review of Division of Facilities Manager #809's education dated [DATE], revealed Division of Facilities Manager #809 was educated to ensure all exit doors are closed and secured prior to walking away and all exit doors require monitoring if not secured. Review of Maintenance Director #810's education dated [DATE], revealed Maintenance Director #810 was educated to ensure all exit doors are closed and secured prior to walking away and all exit doors require monitoring if not secured. Telephone interview on [DATE] at 8:58 A.M. with Firefighter/Emergency Medical Technician (EMT) #811, revealed he was working at the fire department on [DATE] when Resident #100 walked into the bay and asked if anyone was looking for him. Firefighter/EMT #811 stated that Resident #100 was wearing a black shirt, jeans, and shoes and that he was familiar with Resident #100 and knew he resided at the facility and had a history of dementia or cognitive impairment. Firefighter/EMT #811 stated the police were contacted by the fire department. Telephone interview on [DATE] at 12:53 P.M with LPN #804, revealed she was not sure when Resident #100 went missing but thought it was around 4:00 P.M. LPN #804 stated she was not sure how long Resident #100 was gone but thought it was a couple of hours. LPN #804 stated she did not know when she last saw Resident #100. LPN #804 stated she was not sure who noticed Resident #100 missing but staff started to search for him once they noticed he was missing. LPN #804 stated she was not sure who called the police. Telephone interview on [DATE] at 1:00 P.M. with LPN #802, revealed she was working at the facility on [DATE] when Resident #100 eloped from the facility. LPN #802 reported she was not sure what time she last saw Resident #100 but reported he went missing around 6:00 P.M. LPN #802 stated they checked all the rooms and then walked to the facility next door (a sister facility on the same campus) to search there. LPN #802 stated she was not sure who contacted the police and stated the police brought Resident #100 back to the facility around 7:30 P.M. and reported that Resident #100 was found at the fire station. LPN #802 stated Resident #100 was wearing a jacket with a shirt under it and long pants, but she could not recall if he was wearing shoes. LPN #802 reported she was not sure how long Resident #100 was gone or how he got out of the facility. Interview on [DATE] at 1:10 P.M. with LPN #17, revealed the front door was fixed on [DATE] at 3:10 P.M. LPN #17 stated she was in her office and watched Division of Facilities Manager #809 and Maintenance Director #810 leave the small hallway where the front door was located and walk down the hallway, but they never told her they were leaving the door unalarmed and unlocked without a delayed egress. LPN #17 stated Division of Facilities Manager #809 and Maintenance Director #810 were educated on leaving doors unalarmed and without a delayed egress without telling staff on [DATE]. Interview on [DATE] at 1:12 P.M with Division of Facilities Manager #809 and Maintenance Director #810, revealed the facility's front door was not functioning properly on [DATE] due to a sensor contact issue. Division of Facilities Manager #809 stated he and Maintenance Director #810 were working on the door on [DATE] and they left to go get tools. Division of Facilities Manager #809 reported they told LPN #17 to watch the door. Interview on [DATE] at 1:21 P.M. with LPN #17, revealed she was working in the skilled nursing facility next door on [DATE] when former DON #800 notified her that Resident #100 was missing. LPN #17 stated staff could not find Resident #100 and stated she was not sure what time it was but thought it was around 6:30 P.M. LPN #17 stated she met former DON #800 outside, and they notified the physician, guardian and Resident #100's brother. LPN #17 stated she was not sure who contacted the police and stated they continued searching for Resident #100 as staff had already done a head count of all residents. LPN #17 reported they continued to search for the resident and the police brought him back, but she was not sure where Resident #100 was located. Interview on [DATE] at 2:53 P.M. with the Administrator and LPN #17, verified Division of Facilities Manager #809 was not educated on elopements until [DATE] and Maintenance Director #810 was educated on elopements upon hire on [DATE] and on [DATE]. Email correspondence on [DATE] at 3:46 P.M. with LPN #17, verified Division of Facilities Manager #809 was covering the maintenance needs at the facility from [DATE] until [DATE] after Maintenance Technician #814 left the faciity on [DATE] and prior to Maintenance Director #810's employment at the facility. Review of the facility's undated elopement management policy revealed an elopement is defined as when a resident leaves the premises or a safe area without authorization or the necessary supervision. The facility is to immediately initiate procedures to locate any resident or patient that is unaccounted for. Notification of appropriate parties will comply with state and federal regulations. Following the location of the involved resident, the facility leadership will review prevention systems to identify performance opportunities. Failure to provide adequate supervision for cognitively impaired residents who leave the facility or safe areas and are unaccounted for is considered an elopement. Review of the facility's undated abuse, neglect and misappropriation policy revealed alleged violations of neglect, exploitation, misappropriation of resident property or mistreatment that do not result in serious bodily injury must be reported no later than 24 hours. The self-report will be made to the state survey agency if appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00144202.