**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interviews, review of a facility investigation, and review of facility policy, the facility failed to ensure staff provided adequate supervision and intervention to prevent Resident #01, who had impaired cognition, was at risk for elopement, was housed on a secured memory care unit and who had a history of eloping from his bedroom window, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (#01) was placed at potential risk for serious life-threatening harm and/or injury when the resident was displaying a change of condition and was observed pacing near the nurse's station and the resident was noted to be observing Licensed Practical Nurse (LPN) #110 closely. Resident #01 eloped from his bedroom window without staff knowledge and was found 2.3 miles from the facility, leaving a Dollar General store in a very busy area of town. This affected one (#01) of six residents reviewed for risk for elopement. The facility census was 71. On 06/12/24 at 3:03 P.M., the Administrator, Director of Nursing (DON), Regional Quality Assurance Nurse (RQAN) #403, Director of Clinical Services #401, Regional Director of Operations (RDO) #402 and Assistant Director of Nursing (ADON) #405 were notified that Immediate Jeopardy began on 06/09/24 at an unknown time, when Resident #01 exited the facility without staff knowledge. Resident #01 was seen pacing near the nurse's station on 06/09/24 at approximately 4:00 A.M. when LPN #110 provided the resident with water in the common area of the memory care unit. LPN #110 reported Resident #01 was observing her closely. State Tested Nursing Assistant (STNA) #76 reports seeing Resident #01 on 06/09/24 at 5:00 A.M. when he asks her for a cup of ice water. On 06/09/24 at 5:50 A.M., LPN #110 went to Resident #01's room to administer his morning medication, when she noticed the resident was not in his room and noticed the bedroom window was partially raised with the screen removed and it was lying on the ground outside. The staff immediately conducted a head count which revealed Resident #01 was missing. The staff initiated their elopement plan and all staff started searching for Resident #01. The Police Department was contacted on 06/09/24 at 6:13 A.M. to help with the search. On 06/09/24 at 11:47 A.M., Director of Rehabilitation (DOR) #85 located Resident #01 leaving the Dollar General store approximately 2.3 miles from the facility and in a very busy area. Resident #01 continued to walk down the street and cross the middle of the street until he reached the Sunoco Gas Station which was 2.4 miles from the facility. On 06/09/24 at 12:03 P.M., nine-one-one (911) was called to assess Resident #01 and the resident refused care. On 06/09/24 at 12:20 P.M., Resident #01 was returned to the facility by emergency medical services (EMS). A head-to-toe assessment was completed and found Resident #01 to be free of any pain or distress. Resident #01 did have abrasions on both knees. Resident #01 had a previous elopement in May 2023 from the same room where he eloped from his bedroom window. The Immediate Jeopardy was removed on 06/09/24 when the facility implemented the following corrective actions: • On 06/09/24 at approximately 5:45 A.M., LPN #110 identified Resident #01 was not in his room and the facility began searching for the resident. • On 06/09/24 at 11:41 A.M., DOR #85 located Resident #01 at a Dollar General Store and the facility was notified. • On 06/09/24 at 12:20 P.M., Resident #01 was returned to the facility by [NAME] EMS, accompanied by the [NAME] Police Department. ADON #405 initiated one to one safety supervision for Resident #01. At 12:30 P.M., Registered Nurse (RN) #109 completed a head-to-toe assessment on Resident #01 and the resident was free from any pain or psychosocial distress related to the incident. Resident #01 did have an abrasion noted to his bilateral knees. • On 06/09/24, RQAN #403 reviewed progress notes for the last 30 days for all current facility residents for any like behaviors and no other concerns were identified. • On 06/09/24, the Administrator installed metal L Brackets and additional upgraded hardware to prevent Resident #01's window from opening more than six inches or wide enough to prevent the resident from exiting the window. • On 06/09/24, the Administrator audited all resident accessible windows and upgraded securement hardware throughout the facility. All windows were noted to be secured without any identified concerns. • On 06/09/24, Unit Manager (UM) #134 completed elopement risk assessments for all current facility residents. There were no identified concerns from prior elopement assessments. • On 06/09/24, Clinical Operations Specialist (COS) #121 completed wander risk assessments for all current facility residents. There were no identified concerns noted from the prior assessments. • On 06/09/24, the Administrator audited all egress doors, alarm panels and the facility wander guard system to ensure proper alarm and functioning. There were no identified concerns noted. • On 06/09/24, COS #121 audited all current facility residents with physician orders for wander guards. All wander guards were placed properly, functioning and within required expiration. No identified concerns were noted. • On 06/09/24, UM #134 audited all current facility residents at risk of elopement, to ensure all those at risk have a care plan with appropriate interventions in place. There were no identified concerns in the audit. • On 06/09/24, COS #121 audited to ensure all current facility residents with a wander guard were appropriately assessed for placement as ordered, had a physicians order and had a care plan in place. There were no identified concerns noted. • On 06/09/24, UM #122, Dietary Manager #400, DOR #85, Environmental Services Director #450 and Nursing Administrative Assistant #79 began educating all current facility staff in person, on the missing resident procedure and the facility Abuse/Neglect policy and all remaining staff via phone. The education was completed on 06/09/24. • On 06/09/24, the Administrator held an elopement drill in person with staff on dayshift and night shift. Staff response was immediate and appropriate. There were no identified concerns noted. • On 06/09/24, the facility held a Quality Assessment and Performance Improvement (QAPI) meeting with the Administrator, RQAN #403, ADON #405, UM #134, UM #122, COS #121, RDO #402 and Medical Director #501. Resident #01's elopement and the facilities corrective action plan was discussed. The facilities corrective action plan was approved by the QAPI committee. • Maintenance Director #130 or designee will conduct elopement drills on each shift, twice weekly for a period of four weeks to ensure staff respond accordingly with the first elopement drill being conducted on 06/09/24. All variances will be corrected upon discovery and additional education/follow-up will be provided as deemed necessary. All findings will be reported to the facility's QAPI committee. • Maintenance Director #130 or designee will conduct checks of exit doors/wander guard system once weekly, for a period of four weeks to ensure proper functioning with the first one being conducted on 06/09/24. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary. Ongoing compliance will be further maintained through audits as dictated by the facility's QAPI committee. • The DON or designee will complete elopement risk and wandering risk assessments on current residents weekly for a period of four weeks, to ensure no changes in behavior patterns are present, placing residents at risk for elopement and ensuring that appropriate and effective interventions are in place with the first one being conducted on 06/09/24. All variances will be corrected upon discovery and additional education/follow-up will be provided as deemed necessary. • The DON or designee will review current resident progress notes in the clinical operations meeting five times weekly for a period of four weeks to monitor acute changes in behavior patterns that require further intervention with the first one being conducted on 06/09/24. All variances will be corrected upon discovery and additional education and follow-up will be provided as deemed necessary. • The DON or designee will audit all current facility residents with physician's order for wander guard five times a week, for a period of four weeks to ensure proper functioning, placement and devices within stated expiration with the first one being conducted on 06/09/24. All variances will be corrected upon discovery and additional education/follow-up will be provided as deemed necessary. All findings will be reported to the facility's QAPI committee. • The Administrator or designee will conduct checks of window securement hardware, three times a week for a period of four weeks to ensure windows are secure and safety latches remain intact with the first one being conducted on 06/09/24. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary. Further continued ongoing compliance will be further maintained through audits as dictated by the facility quality assurance committee. • RDO #402 will review all audits weekly for a period of four weeks to ensure completion and compliance. All variances will be corrected immediately upon discovery and additional follow-up and education will be provided as deemed necessary. • The DON or designee will educate new hires and/or agency staff working in the facility prior to working their shift on the Wandering elopement procedure and Abuse/Neglect policy for four weeks. All variances will be corrected upon discovery and additional education and follow-up will be provided as deemed necessary. Although the Immediate Jeopardy was removed on 06/09/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimum 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 Resident #01's medical record revealed he was admitted to the facility on [DATE]. Diagnoses include hyperlipidemia, tinnitus, major depressive disorder, essential primary hypertension, vascular dementia, and encephalopathy. Review of Resident #01's care plan dated 03/31/23, revealed the resident was at risk of elopement related to cognitive dysfunction, lack of capacity, poor judgment and decision making. Further review of the care plan revealed Resident #01 was at a moderate risk for wandering. Review of Resident #01's care plan revealed there was no specific care planned interventions addressing the resident's previous elopement from his window on 05/21/23. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/28/24, revealed Resident #01 had a brief interview for mental status (BIMS) score of 10 out of 15 indicating the resident had moderate cognitive impairment. Resident #01 was dependent on staff for medication administration and set up assistance with eating, dressing, oral hygiene, and putting on or taking off shoes. Resident #01 required supervision from staff with toileting, showering, and personal hygiene. Review of Resident #01's nursing progress notes revealed on 05/22/23 (late entry for 05/21/23) the resident's window was observed to be broken and the screen out in the courtyard. Resident #01 exited the facility through his window. Resident #01 was documented to be returned to the facility by the staff. Review of Resident #01's assessment titled, Wandering Assessment, dated 05/24/24, revealed the resident was determined to be a moderate risk for elopement. Review of Resident #01's assessment titled, Elopement Risk, dated 05/24/24, revealed the resident was capable of leaving the facility and had a history of elopement. Resident #01 resides on a locked unit with alarms. Review of Resident #01's progress notes revealed a late entry note, dated 06/09/24 at 12:20 P.M., which documented the resident exited the facility from his room after breaking and opening the window. Resident #01 returned to the facility accompanied by EMS and facility staff. The progress note documented Resident #01 was free of pain and distress and placed on a one-on-one supervision. On 06/10/24 at 2:50 P.M., the progress notes identified Resident #01 had abrasions on both knees. Interview on 06/12/24 at 8:12 A.M. with STNA #76 revealed she was pulled from the memory care unit on 06/08/24 at approximately 11:00 P.M. and worked on another unit. STNA #76 stated this left one nurse (LPN #110) and one STNA (#78) to work the floor with a total of twenty-three memory care residents. STNA #76 confirmed one other STNA (#129) was assigned to work on the memory care unit on a one-on-one with Resident #20. STNA #76 confirmed the memory care unit is hard to work when it is only one nurse and one aide assigned to the unit. STNA #76 stated there are times that several residents are exit seeking and pushing on the doors. During an interview on 06/12/24 at 8:23 A.M. with LPN #110, who was the nurse for Resident #01 on the day of the elopement from the facility on 06/09/24, she stated she started her shift at 7:00 P.M. on 06/08/24 on another hallway. LPN #110 stated after competing her assignment, she took over the assignment on the memory care unit. LPN #110 stated she began her shift with two STNA's assigned to the memory care unit to work with her (STNA #76 and STNA #78). LPN #110 explained another STNA #129 was assigned to the memory care unit; however, she was assigned to provide one-on-one care for Resident #20 because this resident had eloped from the facility on 06/08/24. LPN #110 stated STNA #76 was pulled from the memory care unit to work on another hallway for the rest of the shift. LPN #110 confirmed this left one STNA (#78) providing care along with herself (LPN #110) for a total of twenty-three memory care residents. LPN #110 stated on 06/09/24 at 4:00 A.M. Resident #01 asked her for a drink of water. LPN #110 stated it was not unusual for Resident #01 to be up at 4:00 A.M. LPN #110 further stated looking back on the incident, Resident #01 was observed to be pacing back and forth by the nurse's station and he was keeping a close eye on her. LPN #110 stated she began her medication pass on 06/09/24 at 5:00 A.M. and arrived at Resident #01's room on 06/09/24 at approximately 5:50 A.M. when she identified Resident #01 was not in his room and the window was open wide. LPN #110 stated she did not notice it at first but later identified a piece of wood on the floor along with a metal screw which were a part of the window. LPN #110 stated she immediately began a headcount and Resident #01 was the only resident not accounted for. LPN #110 stated she contacted the management team on 06/09/24 at 5:55 P.M. LPN #110 confirmed STNA #129 remained on her one-on-one assignment for Resident #20, and STNA #78 was providing care to another resident down the hallway. Interview on 06/12/24 at 11:51 A.M. with DOR #85 stated he was assisting with searching for Resident #01 after his elopement on 06/09/24. DOR #85 stated he was driving down the streets and searching for Resident #01 and thought he may have passed Resident #01, but he was not sure. DOR #85 stated he observed Resident #01 enter a nearby store and DOR #85 parked his car and walked into the store. DOR #85 confirmed he saw who he thought was Resident #01 and asked what his name was. DOR #85 asks the cashier to contact the police as DOR #85 followed Resident #01 out the door of the store. DOR #85 confirmed he was unable to redirect Resident #01, so he followed him. DOR #85 confirmed Resident #01 crossed a busy road and did not use the crosswalk and walked into a gas station. DOR #85 stated the police arrived with other staff members and later the squad arrived and took Resident #01 back to the facility. DOR #85 could not say for sure but thought this was around noon on 06/09/24. Interview on 06/12/24 at 12:23 P.M. with the Administrator revealed he stated he was not aware of Resident #01's previous elopement in May 2023 and could not provide any information related to that elopement. Interview on 06/12/24 at 2:32 P.M. with STNA #78 revealed two aides were assigned to work on the memory care unit on 06/08/24 until they pulled STNA #76 to work on another unit. STNA #78 stated it was not unusual for a STNA to be pulled from the memory care unit. STNA #78 confirmed it was herself and LPN #110 to provide care for twenty-three memory care residents. STNA #78 confirmed STNA #129 was assigned to provide one-on-one care supervision to Resident #20 because the resident eloped from the facility on 06/08/24. STNA #78 stated management was at the facility late on 06/08/24 and completed an elopement drill and education because Resident #20 had exited one of the memory care doors. STNA #78 confirmed she saw Resident #01 on 06/09/24 at 5:00 A.M. when he asked her for a cup of ice water. STNA #78 thought she must have woken Resident #01 when she turned on the light to provide care to his roommate. STNA #78 stated on 06/09/24 at around 5:30 A.M. LPN #110 told her that she could not find Resident #01. STNA #78 told LPN #110 she would help search for Resident #01 after she completed personal care on another resident. STNA #78 stated LPN #110 noticed the window in Resident #01's room was open wide, and Resident #01 was missing. A subsequent interview and observation on 06/13/24 at 12:30 P.M. with the Administrator confirmed the type of stop previously located in Resident #01's room was similar to the one in the conference room. The Administrator pointed at a small block of wood about two inches long with a metal screw on the face inside of the conference room window frame. The Administrator stated he replaced the pieces of wood and screws on Resident #01's window with metal L shaped brackets. Review of the facility policy titled, Wandering and Elopements, dated March 2019, revealed the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining a least restrictive life. Further review of the policy revealed the facility will provide strategies and interventions to maintain resident's safety. This deficiency represents non-compliance investigated under Complaint Number OH00154691.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, resident interview, staff interview, review of the facility's Self-Reported Incident (SRI) and investigation, review the National Weather Forecast, and review of facility policy, the facility failed to provide adequate supervision to ensure a cognitively impaired resident, assessed to be at moderate risk for elopement from the facility and had previous attempts to elope, did not elope from the facility. This resulted in Immediate Jeopardy when Resident #26 was placed at risk for potential serious harm and/or injury when the resident eloped from the facility without staff knowledge and exited through the front door. The resident was missing for approximately six hours before being found approximately 3.9 miles from the facility, after accepting a ride from a neighbor of the facility, riding public transportation, accessing funds from the bank, and located walking along a main downtown street with variances of two to four lanes. This affected one (#26) of six residents (#26, #45, #66, #84, #91 and #96) reviewed for elopement. The facility identified four residents (#26, #45, #84, and #91) to be at risk for elopement. The facility census was 71. On 11/08/23 at 3:34 P.M., the Administrator was notified Immediate Jeopardy began on 10/20/23 at 7:00 A.M. when State Tested Nurse Aide (STNA) #556, assigned to provide one-to-one supervision for Resident #26, left at the end of her shift without ensuring another staff member assumed supervision of the resident. Subsequently, Resident #26 cut off his wander guard bracelet from his left ankle with a pair of nail clippers and exited from the facility through the front door without staff knowledge. Resident #26 was located approximately six hours later by facility staff as the resident was walking down a main downtown street, approximately 3.9 miles away from the facility. The ambient air temperature outside on 10/20/23 was a low of 50 degrees Fahrenheit (F) to a high of 54 F. Resident #26 was placed at potential risk of being hit by a car while walking through areas that had two to four lane roads of traffic, traveled by city bus, procured a ride from a facility neighbor, withdrew funds from the bank, and gave money to a friend. At the time of discovery, Resident #26 was transported to the hospital for evaluation and found to have no injuries. The Immediate Jeopardy was removed, and the deficient practice corrected on 10/21/23 when the facility implemented the following corrective actions: · On 10/20/23 at approximately 8:10 A.M., Registered Nurse (RN) #521 discovered Resident #26 was not in his room and initiated a head count of facility residents. All residents were accounted for, except Resident #26. · On 10/20/23 at 8:26 A.M., Unit Manager (UM) #643 called a code and alerted all available staff to conduct a thorough search inside the facility and assigned additional staff to search immediately outside of the facility. · On 10/20/23, Regional Quality Assurance Nurse (RQAN) #651 notified the assisted living facility on campus to conduct a thorough search of their facility and grounds. · On 10/20/23 at 8:30 A.M., the Administrator began organizing a search team to conduct a thorough search of external facility grounds and adjacent areas outside the facility. The search team disseminated photographs and physical description of Resident #26 and conducted an on-going search for Resident #26. · On 10/20/23 at 8:41 A.M., the Administrator notified the police department Resident #26 exited the facility unsupervised and was unable to be located. · On 10/20/23 at 8:47 A.M., RQAN #651 notified the Medical Director and Social Service Designee (SSD) #510 notified the emergency contact of Resident #26's elopement from the facility. · On 10/20/23 from 10:20 A.M. to 10:50 A.M., Regional Clinical Resource Specialist (RCRS) #654 assessed all facility residents with physician orders for wander guards to ensure they were properly placed, functioning, and within expiration dates. Additionally, all residents with a wander guard were assessed to ensure use was appropriate and care plans were in place related to the use of a wander guard. · On 10/20/23 between 10:25 A.M. and 10:50 A.M., RCRS #654 and Director of Clinical Reimbursement (DCR) #650 searched the rooms for all residents currently ordered a wander guard for objects that could potentially impair the integrity of a wander guard strap. No concerns were identified. · On 10/20/23 between 10:45 A.M. and 11:00 A.M., RCRS #654 audited to ensure all current facility residents identified at risk for elopement had a care plan with appropriate interventions in place. There were no variances identified in the audit. · On 10/20/23 between 10:45 A.M. and 12:40 P.M., Minimum Data Set (MDS) Nurse #538 assessed all current facility residents for elopement risk. There were no variances noted from prior assessment. · On 10/20/23 between 10:50 A.M. and 2:30 P.M., UM #525 assessed all facility residents for risk of wandering. There were no variances noted from prior assessment. · On 10/20/23 between 10:51 A.M. and 11:00 P.M., the Administrator educated Assistant Director of Nursing (ADON) #619, DCR #650, Medicaid Specialist (MS) #551, Medical Records Coordinator (MRC) #642, and Director of Rehabilitation (DR) #540 on the missing resident/Wandering and Elopement Procedure, expectations of one-to-one safety supervision, ensuring residents with wander guards did not have sharp objects in room, and the facility Abuse/Neglect policy. · On 10/20/23 from 11:00 A.M. to 8:40 P.M., ADON #619, DCR #650, MS #551, MRC #642, and DR #540 educated all working agency staff and current facility staff in person on the missing resident/Wandering and Elopement procedure, expectations of one-to-one safety supervision, ensuring residents who had wander guards did not have sharp objects in room and the facility Abuse/Neglect policy. Staff not working were educated by phone. One hundred percent of facility staff were educated by 8:40 P.M. · On 10/20/23 at 1:51 P.M., Resident #26 was located approximately 3.9 miles away from the facility, walking down the street, by UM #643. The resident was free of any injury, pain, or indicators of psychosocial distress. UM #643 called 911 and Emergency Medical Services (EMS) transported Resident #26 to the hospital to be assessed as a precaution. · On 10/20/23 between 2:25 P.M. and 8:40 P.M., Senior Administrator (SA) #653 held an elopement drill with in-person staff on day shift. Staff response was immediate and appropriate. · On 10/20/23 between 2:40 P.M. and 5:00 P.M., SA #653, Director of Business Development (DBD) #554, Director of Clinical Services (DCS) #550, and RCRS #654 reviewed progress notes for the past 90 days for all facility residents for any like behaviors without any variances identified. · On 10/20/23 between 3:52 P.M. and 3:59 P.M., [NAME] President of Operation (VPO) #555 and RQAN #651 interviewed STNA #556 via phone. STNA #556 verified leaving her one-to-one safety assignment with Resident #26 without handing-off supervision to another responsible person at 7:00 A.M. STNA #556 was suspended and removed from the nursing schedule. · Beginning on 10/20/23, the Director of Nursing (DON) or designee completed elopement and wandering risk assessments on current residents five times weekly for two weeks, then three times weekly for two weeks to ensure no changes in behavior patterns were present placing residents at risk for elopement and ensuring that appropriate and effective interventions were in place. Evidence was received verifying monitoring was completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. · Beginning on 10/20/23, the DON or designee audited the resident activities room five times weekly for four weeks to ensure residents did not have unsupervised access to sharp objects, such as scissors. Any variances were corrected upon discovery and additional education and follow-up provided as deemed necessary. Evidence was provided verifying monitoring was completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. · Beginning on 10/20/23, the DON or designee verified each shift for four weeks that one-on-one supervision was provided for Resident #26 and staff had full understanding of the requirement for providing one-on-one supervision. Evidence was provided verifying this was completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. · Beginning on 10/20/23, the DON or designee reviewed current residents' progress notes in the clinical record five times weekly for four weeks to monitor for acute changes in behavior patterns that required further intervention. Evidence was provided verifying this was completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. · Beginning on 10/20/23, the DON or designee audited all current facility residents with physician order for wander guards five times weekly for four weeks to ensure proper functioning, placement and devices were within the stated expiration date. Evidence was provided to verify audits were completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. · Beginning on 10/20/23, the DON or designee interviewed five staff members five times weekly for four weeks to ensure understanding of one-to-one education provided on supervision and elopement and one-to-one supervision was to continue for Resident #26, without exception, until it is discontinued. Evidence was provided to verify this was completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. · Beginning on 10/20/23, the Administrator or designee audited, via observation, each resident room with a physician order for a wander guard to ensure the room was free from sharp items that may impair the integrity of a wander guard strap five times weekly for four weeks. Evidence was provided verifying this was completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. · Beginning on 10/20/23, MD #622 or designee conducted elopement drills on two shifts five times a week for two weeks, then three times a week for two weeks to ensure staff respond accordingly. Evidence was provided to verify elopement drills were completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. · Beginning on 10/20/23, MD #622 or designee conducted checks on exit doors/wander guard system five times a week for four weeks to ensure proper functioning. Evidence was provided to verify the checks were completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. · On 10/20/23 at 8:42 P.M., an ad hoc (unplanned) Quality Assurance and Performance Improvement (QAPI) meeting was held to review the corrective action plan. The plan was approved by the committee, including ongoing monitoring to ensure compliance. · On 10/20/23 at approximately 10:00 P.M., Resident #26 returned to the facility via EMS transport. A wander guard was placed to the resident's right ankle by UM #643. Resident #26 was free of any injury or complaints. STNA #656 was assigned to provide one-to-one safety supervision for Resident #26. · On 10/23/23, STNA #556 was terminated for failing to provide one-to-one as required and leaving the premises without supervisor's permission or knowledge. · On 11/01/23, the physician completed a competency evaluation and the facility submitted to probate court to obtain a legal guardian for Resident #26. · On 11/06/23 at 3:42 P.M., observation of exit doors revealed all doors functioned properly and staff responded to alarms. · On 11/06/23, 11/07/23, 11/08/23 and 11/13/23, observations throughout the day of Resident #26 confirmed one-to-one safety supervision was in place. · On 11/08/23, interviews with MRC #642, Accounts Manager (AM) #655, MDS Nurse #538, and Activities Assistant (AA) #548 verified they were educated on elopement, Abuse, and one-to-one supervision on 10/20/23. All verified they have participated in elopement drills. · Review of five (#45, #66, #84, #91, #96) additional open resident records, reviewed for elopement, revealed no concerns. Findings include: Review of medical record for Resident #26 revealed an admission date of 08/23/23. Diagnoses included, but not limited to, sepsis, type II diabetes, pseudocyst of pancreas, alcohol dependence, bipolar II disorder, schizoaffective disorder, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had moderately impaired cognition for daily decision making, inattention and disorganized thinking, and required extensive assistance of one for Activities of Daily Living (ADL's). Review of the plan of care dated 10/02/23 revealed Resident #26 was at risk for elopement/wandering related to impaired cognition and unaware of safety needs. Interventions included one-to-one supervision as needed, orient to new surroundings, psychoactive medication as ordered, remind resident not to leave facility without notifying staff, wander guard to left ankle, check placement and function every shift, assess for risk factors per facility procedures, follow facility elopement procedures, monitor/report changes in behavior (restlessness and pacing), monitor medication side effects, provide diversional activities of interest as needed, and redirect as needed. Review of a Wandering Risk assessment dated [DATE] revealed Resident #26 was disoriented, combative/severely agitated, did not understand surroundings, disturbed by environmental noise levels, loss of self-control, and experienced of anger/fear of abandonment. Resident #26 was independent for mobility and was taking antipsychotics. Resident #26 scored 09 on the assessment, indicating a moderate risk for wandering. Review of a Social Service Note dated 10/17/23 at 11:50 A.M. revealed Resident #26 attempted to exit the facility, accompanied by staff. The resident's emergency contact and physician were notified. The wander guard was replaced to the resident's ankle and Resident #26 was placed on one-to-one safety supervision. Review of a statement dated 10/17/23, from UM #643, revealed Resident #26 was noted to have removed his wander guard and attempted to leave the facility through the front door. Staff were present at the time the resident attempted to leave the facility and followed immediately behind resident, walking beside him while he exited the facility. The resident was redirected into the facility without difficulty. Review of a Health Status Update Note dated 10/18/23 at 11:18 A.M. revealed Interdisciplinary Team (IDT) spoke with Resident #26's emergency contact in regard to having an apartment in the community. Emergency contact was unaware of the whereabouts of an apartment in the community, stating Resident #26 was homeless prior to arriving. The physician was notified to schedule a competency evaluation as the resident did not have a responsible party and the emergency contact did not wish to make decisions for Resident #26. Review of the Health Status Update Note dated 10/20/23 at 8:10 A.M. revealed Resident #26 exited the facility unsupervised by staff. Wander guard and nail clippers observed on bedside table. The note did not indicate what time the resident exited the facility. Review of the facility's Self-Reported Incident (SRI) dated 10/20/23 revealed STNA #556 had knowledge Resident #26 required one-to-one assistance to ensure his safety and well-being. STNA #556, on her own accord, chose to leave her safety assignment with Resident #26 without securing one-to-one supervision. STNA #556 left Resident #26, absent of the necessary supervision to ensure his safety, had the appropriate knowledge in respect of the need for continued one-to-one supervision for Resident #26, and chose to leave him unattended and left the facility without any staff having knowledge of her doing so. The facility substantiated STNA #556's neglect of Resident #26. The facility understands the potential severity of such instances and implemented extensive staff education and monitoring to ensure the safety of all residents as it relates to exiting the facility unsafely. STNA #556's employment was terminated. Resident #26 continues to reside within the facility absent of any indicators of psychosocial and physical distress. Resident #26's plan of care will be updated as necessary to reflect his highest practicable psychosocial/physical well-being and safety. Resident #26 reports he will not be exiting the facility again, however, continues to remain on one-to-one supervision at this time. Review of a statement dated 10/20/23 at 8:39 A.M. from the former Administrator revealed the facility was notified by a vendor that at approximately 8:10 A.M. to 8:15 A.M., Resident #26 was standing outside in front of the facility wearing a black hoodie (sweatshirt) and blue sweatpants. Review of a statement from STNA #556, dated 10/20/23 at 3:52 P.M., obtained by VPO #555 and RQAN #651, revealed STNA #556 reported leaving her one-on-one safety assignment with Resident #26 without handing-off to another responsible person at 7:00 A.M. Interview on 11/08/23 at 10:50 A.M. with Resident #26 revealed on 10/20/23 a neighbor of the facility gave him a ride to a local fast-food restaurant and then he walked to the bank. From the bank, Resident #26 stated he went to a local grocery store and caught the city bus to go to a restaurant downtown. Resident #26 confirmed he removed his wander guard before leaving the facility and was eventually located by facility staff while walking in the downtown area. Interview on 11/08/23 at 12:00 P.M. with DCS #550 revealed upon admission, Resident #26 had encephalopathy and was confused. On 10/17/23, Resident #26 cut off his wander guard and attempted to leave the facility and one-to-one supervision was initiated as an intervention. Following that incident, the facility requested the physician complete a competency evaluation for guardianship as there was no responsible party willing to make decisions for the resident. DCS #550 stated one-to-one supervision would continue until a court appointed guardian was in place. Telephone interview on 11/15/23 at 2:50 P.M. with the DON and DCS #550 verified on 10/20/23, STNA #556 left her assignment of one-to-one supervision for Resident #26 without handing-off responsibility for supervision and without notifying any facility staff she was leaving, which the DON and DCS #550 confirmed should have occurred. Subsequently, Resident #26 was left without the supervision level identified by the facility to ensure his safety, resulting in the resident leaving the facility unsupervised. The DON and DCS #550 verified Resident #26 was missing from the facility for approximately six hours before being located by facility staff. DCS #550 verified, based on physician evaluation, Resident #26 was not capable of making safe decisions for himself due to mental illness. Review of AccuWeather data, located at https://www.accuweather.com, for 10/20/23 revealed the ambient air temperatures were a low of 50 degrees Fahrenheit (F) and a high temperature of 54 F. Review of facility policy titled Wandering and Elopements, revised March 2019, revealed the facility will identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Additionally, 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. This deficiency represents non-compliance investigated under Complaint Number OH00147915 and Complaint Number OH00147452.