**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An IJ was identified from 11/17/24 through 11/21/24. The deficient practice remained at isolated level of a potential for harm. On 11/21/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to to provide adequate supervision to prevent elopement for a resident with severe cognitive impairment and elopement seeking behaviors, and to educate staff on how to identify residents at risk for elopement. On 11/17/24, Resident #1 was reported missing from the facility and found one block away from a driver passing by. Resident #1 stepped off the curb and fell to their knees and was transported to the ER. This resulted in Resident #1 acquiring a closed head injury, laceration of the face requiring sutures, and an abrasion of the knee. On 11/21/24 at 2:45 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 11/21/24 at 2:51 p.m., the administrator and DON were notified of the IJ situation and the IJ template was provided. On 11/21/24 at 4:51 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal documented the total number of residents at risk for the same deficient practice was three. It documented the actions to remove the immediacy of the alleged deficient practice were the following: a. on 11/17/24, Resident #1 was placed on one on one supervision when they returned to the facility, b. on 11/18/24, a care plan meeting was scheduled with Resident #1's family to discuss a safer and more appropriate setting such as an Alzheimer unit and information was provided on facilities with locked units, c. after the care plan meeting, Resident #1's family made the decision to discharge the resident home on [DATE] to seek a locked unit, d. on 11/18/24, all residents were educated to not let other residents out of the doors without consulting a nurse, e. signage was placed on exits and entry doors informing visitors, staff, and residents to be aware and not allow residents to exit the facility, f. an elopement risk manual was implemented that contained all residents that were elopement risk, g. on 11/21/24 at 2:56 p.m., all 54 staff were inserviced in person and by phone on the location of the manual and to check it prior to starting their shift each day to determine who was at risk for elopement, and h. all residents deemed an elopement risk, assessments were updated and the form with the residents picture was placed in the manual. It documented action taken to prevent recurrence of the alleged deficient practice were the following: a. the administrator or DON will monitor 3-5 employees weekly for 30 days to ensure they are proficient in where to locate the elopement risk manual and monitoring would continue until all employees could voice proficiency, b. all new staff will be educated upon hire to the location of the elopement risk manual and sign acknowledgment, and c. any new resident identified with exit seeking behavior will have a new elopement risk assessment completed with care plan and the elopement identification form will be placed in the elopement risk manual. The IJ was lifted, effective 11/21/24 at 4:52 p.m., when all components of the plan of removal had been verified as completed. The deficient practice remained isolated with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent elopement for a resident with severe cognitive impairment and elopement seeking behaviors and to educate staff on how to identify residents at risk for elopement for one (#1) of three sampled residents reviewed for elopement. The DON identified 46 residents resided in the facility and two residents were at risk for elopement. Findings: The facility's Elopements policy, revised 12/2007, read in part, staff shall promptly report and resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. Resident #1 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder and dementia. Resident #1's Elopement Risk Evaluation, dated 11/13/24, did not document any wandering behaviors or exit seeking behaviors. Resident #1's Care Plan, revised 11/13/24, read in part, [name withheld] could be at risk for Elopement as [they] voices [they] want to go home. It documented the following interventions: a. clearly identify resident's room and bathroom, b. identify if there is a certain time of day wandering/ elopement attempts occur, c. provide care in a calm and reassuring manner, e. provide clear, simple instructions, and f. provide reorientation to surroundings, environment. The care plan did not document wandering, exit seeking behaviors, or visual checks. An Administration Note, dated 11/15/24 at 7:58 p.m., documented Resident #1 was upset, pacing the halls, cursing, and attempting to exit the doors. It documented Resident #1 was angry when redirected. A Behavior Note, dated 11/16/24 at 12:30 p.m., documented Resident #1 was carrying laundry hampers, pacing hallways, going door to door, and wanting to go home. It documented the resident was showing signs of agitation. An initial State Reportable Incident, dated 11/17/24, documented Resident #1 was reported missing to the administrator at 10:07 a.m. during a visual check. It was documented Resident #1 was found one block away by a driver passing by. It documented Resident #1 stepped off the curb and fell to their knees and was transported to the emergency room arriving at 10:08 a.m Resident #1's [Name withheld] ER, report, dated 11/17/24, documented Resident #1 was treated for a CHI (closed head injury), complex laceration of the face requiring non-dissolvable sutures, and an abrasion of the knee. Resident #1's discharge assessment, dated 11/18/24, documented the resident's cognition was significantly impaired. It documented the resident exhibited the behavior of wandering for 1-3 days. On 11/21/24 at 8:47 a.m., the DON stated Resident #1 was placed on Q15 minutes visual checks on 11/15/24 after elopement seeking behavior ,but they did not care plan the Q15 minute checks or reassess Resident #1 for elopement risk. The DON stated it was Friday night when they observed the resident with exit seeking behaviors when they were leaving for the day. On 11/21/24 at 9:52 a.m., CNA # 2 was asked how they identified which residents were at risk for elopement. CNA #2 stated there was a list of residents at risk for elopement at the nurses station. On 11/21/24 at 9:56 a.m., CNA #3 was asked how they identified which residents were at risk for elopement. CNA #3 stated there was a list of residents at risk for elopement at the nurses station. On 11/21/24 at 10:00 a.m., CNA #4 was asked how they identified which residents were at risk for elopement. CNA #4 stated some residents wore red bracelets and the care plan was used to identify residents at risk for elopement. There was no observation of a list of at risk residents for elopement and residents were not observed wearing red bracelets. On 11/21/24 at 1:08 p.m., the administrator was asked about the list of residents at risk for elopement and the red bracelets. The administrator stated there was not a process in place to identify residents at risk for elopement and there was not a list or red bracelets used to identify at risk residents for elopement. They stated they were unsure how the resident eloped from the facility.