**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of two residents (Resident R1). This failure created an immediate jeopardy situation for 19 of 91 residents. This was identified as past non-compliance. Review of the facility policy Resident Elopement dated 1/22/25, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the physical structure of the facility without knowledge of facility staff. Review of the clinical record revealed Resident R1 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/31/25, included diagnoses Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and a seizure disorder. Review of Section C: Cognitive Patterns revealed Resident R1 had severe cognitive impairment. Review of an Elopement Risk Assessment completed on 1/31/25, indicated Resident R1 wandered aimlessly/non-goal directed, that her wandering behavior was likely to affect the safety or well-being of self/others, and concluded that Resident R1 had, Risk of Elopement, proceed with identification of resident as an elopement risk including but not limited to wander guard (electronic monitoring bracelet) placement and facility notification. Proceed to the Care Plan and Initiate. Review of the physician's orders indicated Resident R1 was ordered an electronic monitoring bracelet, initially ordered 2/9/17, continuously reordered, and remains a current order. Review of Resident R1's plan of care for At risk for elopement related to: Wandering initiated 8/20/18, undated 8/21/24, included the goal of [Resident R1] will have no incidence of elopement. Review of a late entry progress note dated for 3/12/25, at 3:05 p.m. (created on 3/13/25, at 2:25 p.m.) indicated that the physician was notified of Resident R1's elopement. Further review of Resident R1's progress notes failed to include any other notes on 3/12/25. Review of facility submitted information dated 3/13/25 by the Director of Nursing (DON), indicated that on 3/12/25, at 5:00 p.m. [Resident R1] was observed by a Nurse Aide (NA) Employee E1 outside near [Resident R3's room]. Resident was redirected and brought inside by Registered Nurse (RN) Employee E2. RN Supervisor (RNS) Employee E4 immediately performed assessment on resident with no injury noted. At 5:19 (p.m.) Resident R1 was seen in parking lot by RN Employee E3 and redirected to inside of facility. Resident was dressed appropriately. No injuries noted. Review of an undated employee statement written by the DON indicated, On Wednesday March 12, I had left the building at 3:45 for the day and informed the ADON and RN sup (supervisor). At 4:34 p.m. RN Employee E4 called me and stated there was an elopement. Resident R1 was located outside of a window trying to crawl in. Resident was brought back into the building by NA Employee E1. RN Employee E2 was the med cart nurse, and she was taken back to her. I told RNS Employee E4 to set up a 4 point system to mark all exits to be seen and do an immediate census count. I asked if [ADON, Assistant Director of Nursing] was available, the ADON, she stated yes, and would have her call me. Told her she could assist with this and anyone in the building. Asked her to also complete Wanderguard check and function on all elopement residents I called the [NHA, Nursing Home Administrator] to inform him of the elopement, he stated he would contact [Maintenance Director Employee E5] to assist with alarm system check, as the IDT (inter-disciplinary team) text chain did not have a response from him. He stated he would contact him, Maintenance director Employee E5 has responded back in the text chain on phone and system was reset. ADON stated she had assistance from Social Worker Employee E6, Activities Director Employee E7. I had missed a call from RN Employee E3 while on the phone with RNS Employee E4. Reported that Resident R1 was in the parking lot and had returned her safely. I spoke to RNS Employee E4 again and she had all alarms in place, complete census done/complete. Resident R1 was safe, would continue ½ hour checks on Resident R1 and doors thru the night until safety check done on alarm system. Review of an undated employee statement written by the Human Resources Director (HRD) Employee E8 indicated, NA Employee E9 began telling me they just brought Resident R1 back into the building 5 minutes ago, Resident R1 was standing outside the window around I asked her if she was brought back to her room. The answer was yes. 4:43 pm, I called and texted DON to confirm. If she was aware of these things happening. I went look for NA Employee E9 was hallway ADON also was texted and called to find her. As I was looking for I was approached about Resident R3 trying to get out through the lobby around 5:01 pm. ADON told NA Employee E9 to call DON. I was walking toward the lobby when I (saw) that Resident R1 was outside and refused to come in, I ran to side 2 for nursing staff. Everyone was passing trays and told me Resident R1 was in her room. First by Employee E10, then by RN Employee E2 the nurse tells me twice she is too busy, and resident is in her room. I again state no she is not she is outside. I was told I was late that was earlier by RN Employee E2. I told all 200 (unit) staff she is in a car being brought back to the facility by RN Employee E3 then someone checked her bed. Resident R1 was brought back safe with RN Employee E3. Review of an employee statement dated 3/13/25, by Activities Director Employee E7 indicated, On Wed 3/12/25 I was working and heard someone saying we had an elopement. I came to the front and noticed [Resident R2] in the doorway, and the receptionist trying to tell her she needs to get to her room to have dinner. I then took Resident R2 by the hand and she walked back on the unit. A little bit later, I was getting my things together to leave for the day when I heard staff saying Resident R1 was out front. I went to get a wheelchair, they put her in the chair, and I pushed her to her room and got her sitting on her bed and advised her to eat her dinner. She was calm and agreed to eat. I then took the chair back and helped staff make sure all residents were accounted for. Review of an undated employee statement written by RN Employee E3 I was driving on Monroeville Blvd, as I was about to enter [facility name/address] I noticed one of the residents, Resident R1, getting into a caravan [license plate number]. I parked my car at the entrance of Wecare. Monroeville parking lot got out of my car and began to run towards the van, waving my hands yelling stop, stop, wait as the van was driving away. The caravan stopped and I ran up to the van and motioned my hands to put the window down. The lady that was driving put the window down and I asked her to open the door, and I asked her a second time in a stern voice open the door so I could get the resident out of the van. I tried to remove the resident from the caravan, and she said no, I am going home. I asked the driver where she was going, the driver stated East Liberty [neighborhood approximately 11 miles away]. I told the patient I would take her home to East Liberty and the patient exited the caravan, I walked a patient towards my car, she was very resistant to go with me. As she became aggressive. I tried to sit her on the passenger side of my car and proceeded to call the supervisor, DON and ADON. The supervisor responded, I drove into the parking lot and the supervisor and social worker met me outside in the parking lot to assist with getting the resident back inside the building. Review of a community member witness statement indicated, I was driving home on Wednesday 3/12 and turning right onto Monroeville Blvd at the stoplight around 5:15 p.m. I saw a gold minivan parked on Monroeville Blvd with its hazard lights on and an older woman with tied back gray hair wearing a dark pink shirt standing beside the van on the sidewalk. She was standing between the WeCare sign and the speed limit sign. Another car was parked crooked in the facility driveway, and what appeared to be a staff member was walking towards the older woman. I turned my car around up the street on [NAME] Drive back onto Monroeville Blvd and pulled into the facility driveway in front of the crooked car as the staff member was helping put the woman into her car. I asked her if she needed help and who to get for help. She stated to go to the front door and ask for [RN Employee E3's name]. I drove up to the facility and was able to tell the receptionist that a resident was down the driveway with a staff member. At that time, staff had come to the front and were notified that a resident was down the driveway with a staff member at that current time. They brought out a wheelchair to the lobby, and were able to transfer the resident into the wheelchair and back into the facility safely. No further questions were asked and no nursing staff acknowledgment, except the staff member who was with the resident outside saying thank you. I left the facility. Review of an undated employee statement written by RN Employee E2 indicated, On Wednesday March 12th, I was working the 200's hall. During the resident's first elopement, I was told she was outside by one of the CNA's (nurse aides). Assisted her back into the building. Her Wanderguard was again checked for placement and was present. During her second elopement another resident had a choking incident that utilized multiple staff members and again was notified by staff. Review of an undated, handwritten employee statement written by RNS Employee E4 indicated, RN Employee E2 was assigned as the nurse for Resident R1. She eloped twice on the shift. She did not complete a risk management, vitals, 15 min (minute) checks, head to toe assessment, progress note, did not notify family or Md (Doctor of Medicine). RN Employee E2 was the nurse assigned for 16 hours. Review of a second, typed, undated employee statement written by RNS Employee E4 stated, Resident R1 was observed by NA Employee E1 outside near Resident R3's room, the resident was redirected and brought inside by host of staff. Head to toe assessment completed by writer and no injury noted. MD and family notified. At 5:19 Resident R1 was seen in the parking lot by staff FN and redirected to inside of facility by writer and social worker. Head to toe assessment completed. No new injuries noted. New Wanderguard placed on l (left) ankle. Door checks put in place. Resident R1 was placed on q 15 min (every 15 minute) checks. ADON spoke to maintance and checked door and Accutech (alarm system) for proper functionality, had her check q (every) door that magnets where locked, and had Wanderguard system check at each door. Maintenance provided an all clear. Family, DON, and physician notified. During a follow-up interview on 3/28/25, at 11:58 a.m. RNS Employee E4 confirmed she had been terminated by the facility for lack of actions related to Resident R1's elopement. RNS Employee E4 stated that the evening had been extremely busy, with two residents attempting to leave, one resident having a choking episode, one resident found to be smoking in the facility, and one resident having a seizure while unattended in the dining room. RNS Employee E4 confirmed that she had delegated the 15 minute checks and risk assessment form to the cart nurse, RN Employee E2. The NHA and the DON were made aware that an Immediate Jeopardy situation existed for residents on 3/26/25, at 11:36 a.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at 11:45 a.m. On 3/26/25, at 4:29 p.m. an acceptable Corrective Action Plan was received which included the following interventions: 1. Immediate action(s) taken for the resident(s) found to have been affected include: -Facility immediately recovered resident and provided safety. RN assessed resident and provided safety. -Physician and Resident Representative was notified of event. -Wander guard device -checked for placement and function. -All door alarms checked for function and lock mechanism to ensure facility is secure. -Resident care plan reviewed and updated to ensure accurate and appropriate interventions in place. -Witness statements were obtained, and immediate headcount checks completed. -On 3/12/25 Supervisor immediately conducted door securement and alarm audit and initiated a 4 point system to monitor doors to ensure security -On 3/12/25 Supervisor posted staff at each door while audit conducted to ensure doors are shut, locked, and alarms are on and functioning -On 3/12/25 DON directed RN supervisor and assigned nurse to ensure Resident receives an assessment, and notify physician and family of incident, as well as ensure resident is monitored to prevent reoccurrence. -On 3/13/25 RN Supervisor immediately performed assessment on the resident for injuries; none noted. -On 3/13/25 Door audits completed to ensure doors are secure every 30 minutes. Door alarm checks are completed to ensure alarms are functioning. -On 3/13/25 New alarms were ordered to ensure that alarm sounds are loud enough to hear. -On 3/13/25, Facility notified the attending physician to report findings and conditions of the resident and the resident's legal representative -On 3/13/24, Documentation of incident in residents record completed -On 3/13/25, resident's care plan and orders were reviewed and updated to ensure Wanderguard and exit seeking behaviors addressed in care plan and orders as appropriate -On 3/13 all residents were assessed for Elopement Risk -On 3/13/25, residents newly identified to have potential for elopement had care plans updated with appropriate interventions. -On 3/13, facility-initiated house audit for exit/entry points to ensure alarm function and doors lock appropriately -On 3/13, facility conducted whole house resident head count to ensure accountability of residents. -On 3/13, house audit conducted on resident wanderguard orders to ensure accuracy. -On 3/13, all Wanderguards placed on residents were assessed for function, care plans updated as needed. -On 3/13, Elopement Books were audited to ensure accuracy and placed at each nurses station and reception area. -On 3/17/25- RN Supervisor was provided a discipline due to not following DON directive to ensure that Resident was assessed and notifications occurred and documented- RN was terminated due to failing to complete these tasks. -On 3/17/25 Nurse assigned to resident on cart also failed to ensure resident was accounted for and skin checks performed following incident. DON provided discipline to this nurse for failure to complete tasks. Termination resulted. 2. Identification of other residents having the potential to be affected was accomplished by: -All residents in house will be assessed for elopement risk by the Director of Nursing or designee by 3/18/25. -All care plans for residents identified with elopement risks will be reviewed and updated with elopement risks will be reviewed and updated with interventions to prevent elopement by the Director of Nursing or designee by 3/18/25. -All residents identified to be elopement risk will have wanderguard placed and added to Elopement Binder per protocol by 3/18/25. -House audit on all doors and exit points will be conducted by Maintenance to ensure that facility is secure and alarms are functional by 3/18/25. -House audit on all wanderguards will be conducted to ensure placement and function by 3/18/25. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: -Facility Director of Nursing or designee will conduct education to all facility staff regarding dementia/behavior in LTC residents, Elopement risk and mitigation, and Elopement Policy and Procedures to include keeping doors secure by 3/21/25. -Education will be completed for all clinical staff on Elopement Risks, Assessments, Care Plans, and Supervision of Residents by the Director of Nursing or designee by 3/21/25. -Elopement Books with identified resident photos will be placed on all nurses' stations in addition to the current one at the receptionist's desk by the Administrator or designee 3/21/25. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: -Audits will be conducted on all doors/exits by Supervisor twice per shift daily for 4 weeks and then weekly thereafter. -Maintenance Director or designee will conduct daily (twice per shift) audit on doors to ensure secure and alarmed. Audit will remain ongoing. -All new admissions will be reviewed for elopement risks by IDT 5 days per week weeks and ongoing. -Elopement assessments will be audited for compliance by IDT 5 days per week and will remain ongoing. -An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the Administrator or designee. This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met. Review of facility provided information indicated the facility staged an elopement drill on 3/20/24, at 11:40 a.m. to familiarize staff with procedures. During staff interviews on 3/26/25, between 1:00 p.m. and 4:00 p.m. NA Employees E12, E13, E14, E15, E16, E17, and E18 and LPN Employee E19 confirmed they received education on the elopement policy, elopement prevention and actions to take in the instance of elopement. During an observation on 3/27/25, at approximately 10:00 a.m. Resident R1's and Resident R2's pictures and information were present in the elopement book at the entrance/exit of the building. Further review of the elopement book with resident charts revealed all residents identified as elopement risks were included in the elopement book. During staff interviews on 3/27/25, between 9:00 a.m. and 11:00 a.m. LPN Employees E20 and E21, RN Employee E22, NA Employees E23 and E24, Occupational Therapy Employee E25, Dietary Employees E26, E27, and E28, Environmental Services Employees E29, E30, and E31, and Laundry Employee E32 were provided scenarios to test their knowledge on and confirmed they received education on the elopement policy, elopement prevention and actions to take in the instance of elopement. The Immediate Jeopardy was removed on 3/27/25, at 11:00 a.m. when the action plan implementation was verified. The facility had demonstrated compliance as of 3/18/25. During an interview on 3/31/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent elopement for one of two residents. This failure created an immediate jeopardy situation for 19 of 91 residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.