**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of a facility self-reported incident (SRI) investigation, review of police reports, review of the Emergency Medical Services (EMS) run report, review of hospital documentation, review of facility policy, and interviews, the facility failed to provide adequate supervision to prevent Resident #16, who was cognitively impaired, aphasic and at risk for elopement (with use of a WanderGuard device) from eloping. This resulted in Immediate Jeopardy and the potential for Actual Harm, serious physical injury or death on [DATE] when 911 dispatch for the local police department received a 911 call from a passerby in the community with concerns for an unattended individual. The individual, identified to be Resident #16 was found by the police, coming out of the woods and falling into a ditch in a residential area that was 0.6 miles from the facility. The resident was noted to be confused and wearing a monitor device on his ankle which prompted the police to check with the facility to see if they had a missing resident, as the resident could give no details and had no identification on him. Resident #16 was subsequently transferred from the scene to a local hospital for treatment of hypotension (low blood pressure) and was stabilized after resuscitation with intravenous fluids. Resident #16 returned to the facility on [DATE] and his WanderGuard remained in place. On [DATE] during the onsite investigation it was identified the facility WanderGaurd system was not functioning properly because an unknown person was entering a master override code into the system that was disarming the WanderGaurd system which placed Resident #16 and other residents at risk of accidents/hazards pertaining to elopement. The facility identified five residents (#4, #13, #16, #22, and #26) as at risk for elopement. The facility census was 32. On [DATE] at 3:34 P.M. the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #349 were notified Immediate Jeopardy began on [DATE] when Resident #16, exited the facility without staff knowledge and was found 0.6 miles away from the facility in a ditch by the police department. The facility was not aware Resident #16 was missing from the building until the police arrived at the facility for identification of Resident #16. Resident #16 was subsequently transported to the emergency room by Emergency Medical Services (EMS) who arrived at the scene, received testing and treatment with intravenous (IV) fluid and then returned to the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action. On [DATE] at approximately 5:50 P.M. Regional Director of Clinical Services (RDCS) #349 completed an elopement assessment on Resident #16 and reviewed the resident's elopement risk care plan. On [DATE] Resident #16 returned to the facility from the hospital. Pain assessment, skin assessment, neurological checks through [DATE] were initiated and charted in the resident record. On [DATE] the ADON and SSD reviewed elopement assessments on 32/32 residents to ensure all current residents had elopement assessments in the last quarter. One new Resident (#13) identified at risk for elopement and wander guard placed and resident added to elopement binder. On [DATE] an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, Nurse Practitioner (NP) #351 and the DON to discuss the elopement incident, interventions initiated and plan of care. On [DATE] the Administrator and Maintenance Director completed an elopement drill on first shift. On [DATE] the Ohio Department of Health surveyor and Maintenance Director identified the wander guard system was not functioning as designed. At 4:15 P.M. the DON was notified and placed staff for door supervision. Secure Care company was notified at 5:00 P.M. by the Administrator. On [DATE] at approximately 10:00 A.M. Secure Care company arrived to inspect the wander guard system and determined a universal code, which was a separate code from the new code was being entered by unidentified staff that was overriding the system which caused the wander guard system to not alarm. On [DATE] the Administrator and RDCS #349 determined the root cause of the elopement was a universal over-ride code was being used by staff instead of the new door code that was changed on [DATE]. The universal override code, when entered into the keypad to open the secured doors, would disable the wander guard system. On [DATE] all facility door codes were changed including a change of the master override code by Administrator. The master override code would be privy to only the Administrator and Maintenance Director. On [DATE] facility staff completed a headcount to ensure all 32/32 residents were accounted for. On [DATE] 42/43 staff (2/2 Activities Staff, 14/15 Certified Nursing Assistants (CNAs), 8/8 Dietary Staff, 6/6 Housekeeping Staff, 3/3 Licensed Practical Nurses (LPNs), 2 Registered Nurses (RNs), and 7 administrative staff including the DON, ADON, Administrator, Human Resources, Social Services and Medical Records) were educated on the new facility door code, the elopement policy, and the abuse/neglect policy. One CNA was not able to be educated due to leave of absence and would receive education by the DON/designee upon return to work. Two agency staff were also provided with education, and all agency staff would receive education by the DON/designee prior to working in the facility. All new hires would be educated by the Maintenance Director during orientation process. On [DATE] a repeat door audit was completed by the Administrator to ensure all doors and alarms were functioning. On [DATE] at approximately 6:30 P.M. the ADON completed a wander guard audit on five of five residents with wander guards. On [DATE] the ADON and DON reviewed 32/32 residents elopement risk scores for accuracy. On [DATE] at approximately 7:00 P.M. the facility interdisciplinary team completed an elopement drill. On [DATE] at approximately 7:30 P.M. the SSD completed review of the elopement book to ensure all residents at risk were in binder. On [DATE] at 6:45 P.M. an Ad Hoc Quality Assessment and Performance Improvement (QAPI) meeting was held via phone with the Medical Director, DON, ADON, RDCS #349, the Administrator, Human Resources, Maintenance Director, Social Services Director and Medical Records to review steps taken for the facility removal plan. On [DATE] auditing was initiated to include the DON/Designee to complete audits on all residents with wander guards daily for two weeks then weekly for two weeks to ensure proper placement and functioning. Maintenance Director/Designee to complete door alarm audit with emphasis on secure care alarms to ensure appropriate functioning daily for one week then five times per week for three weeks. One-to-one staff monitoring of the doors would be implemented if the alarms would be identified as not working as should. Beginning on [DATE] audits would be conducted daily for one week then five times a week for four weeks to ensure no behaviors related to wandering or elopement have occurred. Findings would be addressed if indicated. Beginning on [DATE] elopement drills would be conducted one each shift by the Administrator, Maintenance Director or designee and then weekly for four weeks. Results of facility audits would be forwarded to the QAPI committee for review and recommendations. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained 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 were monitoring to ensure on going compliance. Findings include:Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, aphasia, cardiac arrhythmia, muscle weakness, lack of coordination, hypertension, dementia with behavior disturbance, difficulty walking, need for assistance with personal care, bilateral cataract, and schizoaffective disorder.Review of the comprehensive care plan, date initiated [DATE], revealed Resident #16 was at risk for falls due to multiple sclerosis and at risk for elopement/wandering related to dementia and impaired cognition. Interventions for falls included to keep a clear pathway and keep a call light in reach. Interventions for risk for elopement included to include family conference to discuss resident's attempts to leave, involve Resident #16 in activities of choice, orient Resident #16 to new surroundings and provide psychoactive medication as ordered, WanderGuard, allow one-on-one to vent feelings, assess risk factors according to facility procedures, attempt to involve Resident #16 in decision making, follow facility elopement procedures, monitor and report changes in behavior such as restlessness and pacing, monitor for medication side effects, provide diversional activities and redirect as needed. The resident was to reside on a secured unit for safety. The care plan was last reviewed on [DATE] and there were no dates of revision listed on the care plan for elopement risk since initiated on [DATE].Review of the facility document titled Weekly Risk Meeting, dated [DATE], revealed the facility had concerns regarding Resident #16's decreased cognition. The facility moved Resident #16's room and asked the physician for a WanderGuard (a technology designed to prevent residents at risk of wandering from leaving secured areas using an audible alarm when a resident approached an area equip with the WanderGuard system).Review of physician's orders dated [DATE] revealed an order for Resident #16 to have a WanderGuard to left ankle, check placement, skin and function every shift.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #16 had adequate hearing, unclear speech/mumbling or slurred words, was sometimes able to express himself and understand others, impaired vision requiring large print, used corrective lenses and was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 01 (out of 15). The assessment revealed Resident #16 had no behaviors and did not wander.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16's cognition was moderately impaired. A Brief Interview of Mental Status (BIMS) score was not available. The assessment revealed wandering behavior was not exhibited. Resident #16 did not need a mobility device such as a cane, walker, or wheelchair. Resident #16 was independent to walk 150 feet in a corridor or similar space.Review of the facility documents titled Elopement Risk Screen, dated [DATE] and [DATE], revealed Resident #16 was disoriented, independent for mobility, had not attempted to leave the facility and was not at risk for elopement.Review of Resident #16's Treatment Administration Records (TARs) dated [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE] and [DATE] to [DATE] revealed a physician order dated [DATE] for WanderGuard to left ankle, check placement and function each shift twice a day. Resident #16's Wanderguard was checked during the morning and evening shifts on 27 of 30 days in [DATE] of 31 days in [DATE] of 31 days in [DATE] and 26 of 29 days in [DATE].Review of a nursing note dated [DATE] at 4:50 P.M. authored by RN #335, revealed the facility was informed by local police department (name provided) that Resident #16 was found on Wick Street and transported to local hospital (name provided) emergency room for evaluation. Resident #16 had unknown pain or injuries known at that time. Awaiting lab results and electrocardiogram (EKG) results. Physician #350 was aware, and all responsible parties were aware.Review of the facility document titled Elopement Risk Screen, dated [DATE], revealed Resident #16 was disoriented, independent for mobility, wanders throughout facility or prior residence but does not leave interior setting, had a prior history of elopement and was at risk for elopement.Review of a local police department report incident number 25-19485 dated [DATE] revealed local dispatch received a wireless 911 call at 4:33 P.M. that a man fell in a ditch, came out of the woods and required an officer to come out. The address was 2615 Wick Street, [NAME], Ohio 44484. The caller stated they did not know the man. Police officer #353 was dispatched to the scene at 4:43 P.M. and arrived at 4:50 P.M. Emergency Medical Services (EMS) were dispatched at 4:53 P.M. and arrived on scene at 5:03 P.M. At 5:10 P.M. Police Officer #353 indicated to dispatch that the man may have wandered over here from [NAME] Oak off of Ridge/heading over there to see if I can ID (identify) him. At 5:17 P.M. Police Officer #353 identified Resident #16 by name and date of birth . EMS had taken Resident #16 to the local hospital for an evaluation.Review of Google Maps indicated the distance between the facility and the location where Resident #16 was found on [DATE] at 4:33 P.M. was 0.6 miles from the facility.Review of the weather conditions on [DATE] via wunderground.com (a historical archive of weather conditions) between 4:00 P.M. to 5:00 P.M. the environmental temperature ranged between 85 to 87 degrees Fahrenheit (F) and was mostly cloudy with no precipitation.Review of the EMS Run Report (Number 25-75669) dated [DATE] revealed a call was received at 4:54 P.M. for an immediate response fall victim. EMS arrived at the scene at 5:00 P.M. and left the scene at 5:10 P.M. Scene information included Resident #16 went missing from nursing home, unknown to nursing home staff. Last seen by staff before 2:30 P.M. Resident #16 was found by passerby in a vehicle who called 911. [NAME] Police was on the scene also. Chief complaint was altered mental status. EMS noted Resident #16 had an ankle monitor in place on the left ankle. Local police were to contact the facility of a possible missing resident as patient had no identification. Resident #16 was transported to local hospital emergency room.Review of the hospital emergency room (ER) documentation dated [DATE] at 5:28 P.M. revealed Resident #16 presented to the emergency department for evaluation of altered mental status. Resident escaped from [NAME] Oak Manor and was found in a ditch with altered mental status. History of present illness revealed Resident #16 presented for evaluation after he skipped from the nursing home and was found laying down in a ditch by emergency medical system. With Resident #16's mental status and aphasia (non-speaking) the resident was unable to communicate what happened. emergency room course of stay revealed Resident #16 was resuscitated with intravenous fluids. Resident #16's troponin (a specific blood protein to determine if your heart muscle has been damaged) was trended up, likely demand ischemia (a condition where the heart muscle does not receive enough oxygen to meet its increased demand) . Since Resident #16 was initially hypotensive and after resuscitation (with intravenous fluids) had stabilized. Resident #16 was discharged back to the nursing home for further care and evaluation. Review of a nursing note dated [DATE] at 12:40 A.M. written by LPN #341 revealed Resident #16 returned to the facility by EMS and two attendants. Resident #16 was alert to self. Cognition was at baseline. Resident #16 was noted to be incontinent with bowel and bladder with staff total assist. The note included Resident #16's condition was stable.Review of the facility documented titled Elopement Risk Screen, dated [DATE] revealed Resident #16 was disoriented, independent for mobility, wanders throughout facility or prior residence but does not leave interior setting, had a prior history of elopement and had a wander guard was in place.Review of the facility staffing schedule for nursing services dated [DATE] revealed the following direct care nursing staff were working in the facility at the time of the elopement: CNA #324, CNA #327, RN #335, CNA #340 and CNA #348.Review of a facility Self-Reported Incident (SRI) dated [DATE] at 9:06 P.M. revealed Resident #16 was last seen in the building (on [DATE]) at 4:00 P.M. by a Certified Nursing Assistant (not identified by name). The SRI included Resident #16 was outside of the facility within close proximity of facility property at approximately 4:33 P.M Resident without injury and safe. No witnesses were identified by name in the SRI. The facility concluded that neglect did not occur and unsubstantiated the SRI. The investigators were listed at the Administrator and the Assistant Director of Nursing. The SRI stated the facility implemented Quality Assurance Performance Improvement (QAPI) measures including head count of all residents, statements from all staff working at the time of the incident, all WanderGuards were checked for placement and function, elopement assessments reviewed and updated, completion of an incident report, elopement risk care plan review, audit of all door alarms, elopement binder review, completion of elopement drills, staff education on elopement policy, completion of skin assessment, initial audit of residents with Wander guards to ensure functioning, elopement assessments for at risk residents reviewed and updated as needed, review of progress notes for last 72 hours to check for any exit seeking behaviors, all facility door codes changed on [DATE], all residents educated on [DATE] that they were not allowed to give out door codes, and all staff education on the change of door codes on [DATE]. There was no root cause analysis identified in the SRI to explain how Resident #16 exited the facility.Review of the SRI facility investigation, dated [DATE], revealed a witness statement from RN #335 which revealed the police arrived around 4:50 P.M. The police gave a description of Resident #16. The police stated Resident #16 was found on Wick Street in a ditch and taken to the hospital (hospital name provided). The statement included Resident #16 was last seen at 2:30 P.M. sitting in the dining room with another resident. Resident #16 was wearing a WanderGuard.Review of a witness statement from CNA #340, dated [DATE], revealed CNA #340 did not interact with Resident #16 because CNA #340 worked another unit. The statement then included CNA #340 stated Resident #16 was seen on his unit walking around 4:00 P.M.Review of a witness statement from CNA #327, dated [DATE], revealed the last time CNA #327 saw Resident #16 was around 4:15 P.M. sitting in the dining room.Review of a witness statement from Activity Assistant (AA) #334, dated [DATE] revealed the last time AA #334 saw Resident #16 was when AA #334 came back in from smoke break and witnessed Resident #16 standing by the elevator.Review of the witness statement from Social Services (SS) #318, dated [DATE], revealed SS #318 last saw Resident #16 at 3:30 P.M. in the 300-wing dining room when SS #318 accompanied the ADON to let a visitor out.Review of the witness statement from CNA #324, dated [DATE], revealed CNA #324 saw Resident #16 was around 4:00 P.M. on the 100-station.On [DATE] at 5:50 P.M. Resident #16 was observed in the facility. Attempts to interview the resident at the time of the observation revealed Resident #16 was not oriented to person, place, time or situation. Resident #16 was not able to answer yes/no questions or state what door he walked out of during the incident on [DATE]. Resident #16 was observed to walk with a slow shuffle and had a WanderGuard on his ankle.Observation on [DATE] at 10:10 A.M. with the Maintenance Director #346 revealed a code was needed to open the rear foyer door in order for the door to open. Maintenance Director #346 punched a code in the module by the rear foyer door the door opened. A new WanderGuard was placed by the rear door and there was no alarm notification. Maintenance Director #346 walked out the rear foyer door with the new Wanderguard that did not properly function and stated these boxes are old. The WanderGuard alarm was attempted three times with no results of an alarm. Maintenance Director #346 verified the findings at the time of the observations.Observation on [DATE] at 4:30 P.M. with the DON and ADON #344 revealed Resident #16 had a WanderGuard on his left ankle. The DON placed a code in the box by the rear foyer door, Resident #16 walked close to the rear foyer door and out to the rear foyer door and no alarm sounded (the alarm should have sounded at that time). The DON attempted a new WanderGuard not attached to a resident and the alarm did not sound when a code was punched into the box and the WanderGuard was near the door and outside the door. The DON stated it must not be working.Interview on [DATE] at 5:05 P.M. with RN #335 revealed she did not know how Resident #16 got out of the facility (on [DATE]) and she did not know Resident #16 was missing until the police came to the facility to ask if the facility was missing a resident. The police gave the description of the person they found, and it was the description of Resident #16. The RN revealed Resident #16 was found a block away from the facility. RN #335 stated the last time she saw Resident #16 was 2:30 P.M. when Resident #16 was sitting in the facility dining room.Interview on [DATE] at 5:12 P.M. with Business Office Manager ( BOM) #336 revealed she stayed late on [DATE] for dinner service. BOM #336 revealed the facility did not know Resident #16 was missing until the police came to the facility for a missing person identification. Interview on [DATE] at 5:30 P.M. with CNA #340 revealed Resident #16 wandered from his unit on the 300 hall to the 100 hall , which was unusual for him on [DATE]. Resident #16 went missing around dinner time on [DATE]. CNA #340 did not know Resident #16 was missing until the police arrived at the facility. The CNA stated the last time he saw Resident #16 was one hour before dinner time, approximately 3:45 P.M., as dinner arrived at 4:45 P.M.Interview on [DATE] at 8:33 A.M. with the Administrator revealed the foyer doors have a WanderGuard alarm and the side doors have an egress alarm. The Administrator stated no alarms went off on [DATE] (related to Resident #16's elopement). CNA #340 was the last staff member to see Resident #16 around 4:00 P.M. The police found Resident #16 on Wick street.Interview on [DATE] at 8:45 A.M. with Regional Director of Clinical Services (RDCS) #349 revealed the facility was in the process of fixing the rear foyer door alarm at this time.Interview on [DATE] at 9:08 A.M. with the DON revealed on [DATE] Resident #16 was picked up in a ditch by the EMS and taken straight to the hospital. The police came to the facility to ask if they were missing a resident. The facility was not able to see the condition of Resident #16 when he was found. The DON stated Resident #16's cognition had declined. The facility performed a risk assessment on Resident #16 because he was walking up hallways and going to exit doors and wandering alone.Interview on [DATE] at 9:31 A.M. with Certified Nurse Practitioner (CNP) #351 revealed Resident #16 was too confused to be wandering by himself outside, as he had poor safety awareness. CNP #351 verified Resident #16 had a WanderGuard and required a secured environment.Interview on [DATE] at 11:06 A.M. with the Administrator revealed the alarm company looked at the rear foyer door WanderGuard system and determined if the master code was used to exit the building the sensors would not sound if a Wanderguard passed by the sensors. Additional interview revealed the resident was found a street over from the facility in a ditch and when the resident's ankle monitor was noticed the police officer assumed Resident #16 may be from this facility.Observation on [DATE] at 5:45 P.M. revealed the route from the facility to 2615 Wick Street per odometer reading was 0.6 miles away from the facility. Observation of 2615 Wick Street consisted of a neighborhood road that had active car traffic at the time of the observation. The wooded area had multiple dead trees, and a three-foot ditch separated the woods from the street.Interview was conducted on [DATE] at 2:21 P.M. with RDCS #349 who verified the facility did not know the root cause of how Resident #16 left the faciity on [DATE]. RDCS #349 confirmed it was discovered on [DATE] after the start of the Ohio Department of Health survey that someone was entering a master override code that disabled the WanderGaurd system.Interview on [DATE] at 8:30 A.M. with RDCS #349 verified Resident #16's care plan was not reflective of updates/revisions by date in accordance with subsequent resident assessments leading up to the actual elopement on [DATE] and verified Resident #16 had a WanderGuard ordered since [DATE] due to risk of elopement.Observation on [DATE] at 10:42 A.M. at the police station with Sergeant #354 revealed a body camera footage from [DATE] involving Resident #16 and the local police officers who were called to the scene. The footage revealed a bystander approached police officer #353 and stated his son saw a suspicious man walking on the street in the neighborhood. The bystander stated when he found Resident #16 he was in a ditch on all fours. Resident #16 was observed to be sitting in the bystander's car drinking water the bystander stated he gave Resident #16. Resident #16 was observed to have a t-shirt on, jogging pants on and socks and shoes. Police officer #352 asked Resident #16 for identification and Resident #16 handed Police Officer #353 a hairbrush. Observation of the wooded area and ditch was seen in the camera footage. The bystander stated Resident #16 told him someone pushed me in the ditch, it hurts. When the EMS arrived , Resident #16 was not able to stand on his own and needed an assistance of one person to walk from the car to the gurney. Resident #16 was observed to be pale, confused and muttering while on the gurney.Observation on [DATE] at 11:00 A.M. at the police station with Sergeant #354 revealed a second body camera footage on [DATE] at 5:11 P.M when Police Officer #353 arrived at the facility. CNA #340 verified the identity of Resident #16 and verified Resident #16 wore an ankle bracelet. It was observed Police Officer #353 told RN #335 Resident #16 was found in a ditch on Wick Street. At 5:18 P.M. ADON #344 approached the police officer and was told Resident #16 was found in a ditch on the corner of Wick Street and [NAME] Avenue. Observation at time stamp 5:20 P.M. revealed the police exited the facility, residents were eating dinner in the dining room and staff was huddled on the 100 hall.Review of facility policy titled Elopements and Wandering Residents, revision date [DATE], revealed elopement occurred when a resident leaves the premises without authorization or necessary supervision to do so. The facility was to be equipped with door locks and alarms to help avoid elopements, and alarms were not a replacement for necessary supervision. Staff was to be vigilant with response to alarms. The procedure for locating a missing person consisted of alerting staff with CODE UNIT. If the resident was not located on the grounds the administrator would notify the police and corporate office and appropriate reporting requirements to the State Survey agency would be conducted. Post elopement procedure consisted of a physical assessment, documentation and report findings to physician. Social services would reassess if counseling was needed. Staff was to be educated for elopement.This deficiency represents non-compliance investigated under Complaint Number 2599954