Based on a review of clinical records, review of facility policies, observations, resident, and staff interviews, it was determined that the facility failed to timely ensure the location of a resident who went on a leave of absence and failed to provide education on how to monitor blood sugar levels per sliding scale and administration of insulin medication. This failure resulted in an Immediate jeopardy situation for Resident R1 who was provided insulin medication without education of blood sugar management and insulin administration prior to a leave of absence and for the failure to ensure the location of Resident R1 who failed to return to the facility per physician's order for one of 31 residents reviewed. (Resident R1). Findings include: Review of facility policy titled Leave of Absence/Therapeutic Leave: Patient revised November 1, 2023, revealed the patient must have a physician's order for a leave of absence (LOA)/ Therapeutic leave Therapeutic leave is described as an absence for the purpose other than required hospitalization. The release of Responsibility for Leave of Absence/ Therapeutic leave form must be completed when the patient leaves and returns to the center. Further review of this policy states Prior to leaving the center, the staff will review patient care and medication needs with the patient/ and or the person accepting responsibility for the patient. Review of the facility abuse policy titled Abuse Prohibition revised on October 24, 2024, revealed the term neglect is defined as the failure indifference, or disregard of the center, its employees, or service providers to provide care, comfort, safety, goods and service to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between the center, patient, practitioners, and patient representatives. Review of insulin manufacturer summary for safety of insulin (brand name Humalog, non-brand name insulin Lispro) revealed that possible side effects of omitted medication could possibly lead to low blood sugar (hypoglycemia), low potassium in your blood (hypokalemia), heart failure, sudden onset of high blood sugar (hyperglycemia) and high amounts of ketones in the blood or urine (ketoacidosis) due to insulin pump, all possible fatal consequences. Review of Resident R81's clinical record revealed that Resident R81 was admitted to the facility June 16, 2023, secondary to deficits in mobility and ADLs (activities of daily living). Review of Resident R81's clinical record revealed that the resident was admited to the facility on June 6, 2023, from the hospital. Review of hospital documentation revealed Patient reported feeling dizzy and fell and was unable to get herself up. In the emergency room, blood sugar was found to be over 1000 (normal levels between 70-100) and sodium level of 113 (normal level 135). She was given IV (intravenous) fluids. CT (computed tomography) of her head showed chronic lacunar infarcts (stroke). Patient's mental status became altered and stopped responding leading her to the facility for skilled nursing. Review of Resident R81's quarterly Minimum Data Set (resident's care needs assessment) dated May 24, 2024, revealed that Resident R81 had diagnoses of asthma (lung disorder characterized by narrowing of the airways), depression (major loss of interest in pleasurable activities), schizophrenia (mental disease characterized by loss of reality), seizure disorder (neurological disorder that cause brief episodes of unresponsiveness), hypertension ( high blood pressure), renal failure, diabetes (failure of the body to produce insulin), and hyponatremia (low blood sodium levels). Continued review of Resident R81's quarterly MDS revealed that the resident had impairment on one side of the body and required assisted devices of a walker and wheelchair. Further review of this assessment revealed that Resident R81 had a BIMS (brief interview of mental status) score of 12 which indicated that the resident had moderate cognitive impairment. Review of Resident R81's current care plan revealed focus areas which included Resident/patient exhibits or has the potential to exhibit physical behaviors related to ineffective coping skills, i.e., poor anger management, poor impulse control. Resident R81 has diagnosis of psychiatric disorder depression and anxiety and is at risk for complications related to the use of psychotropic drugs Trazadone and Quetiapine. The resident has a diagnosis of diabetes and is insulin dependent. Access and record blood glucose levels before meals and administer hypoglycemic medications as ordered. Resident R81 is at risk for falls due to impaired mobility and history of falls. Resident exhibits or is at risk for respiratory complications related to tracheostomy, and a history of sleep apnea. Review of physician order by Nurse practitioner, Employee E10, dated June 3, 2023, revealed that Resident R81 was approved for leave of absence with family from June 8, 2024, at 8:30 a.m. until June 9, 2024, at 6:00 p.m. with medications. Review of Resident R81's nursing notes dated June 10, 2024, revealed that Resident R81 left the faciity on June 8, 2024, and did not return on the anticipated ordered time of June 9, 2024, at 6:00 p.m. Continued review of Resident R81's nursing note dated June 10, 2024, written by Licensed nurse Employee E5 revealed Resident did not return from the LOA (leave of absence) at the time frame ordered. Call placed to listed number on information sheet for this resident and the voice mail said, this person is not accepting calls at this time. Call placed to guardian who did not have a mailbox set up at this time. Called residents sister, who I left a message for, re (reference) above and steps of calling the police for a wellness check. Sister called back states she did not know she went out on an LOA and she will try to get in touch with her. I asked if she had a different number than what I had, and she gave it to me. I called that number and left a message re above. [Resident R81] called back stating, I am on my way back, my sister just called and said that you were calling the police. I conformed the plan of care that was discussed with [resident sister] to which the resident replied that you gave me two bottles of meds so I thought that I could stay out for 2 days I explained to the resident that I ordered the meds that she would need for the time that she had requested her LOA. The resident replied, I am on my way back now my driver is coming now. DON notified of above and phone number updated. There was no documented evidence that the facility attempted to locate the resident prior to June 10, 2024 during the 7-3 shift. The facility was unaware of Resident R81's whereabouts. Continued review of nursing notes revealed that after Resident R81 returned she stated I took no meds but monitored my sugar, and took my insulin. I asked if she had a log of her blood sugars, she said no. Resident was educated on need to take meds as prescribed and to return to facility a time requested from her LOA. Resident was also shown the LOA med form with the time and dates that she the resident requested. The resident replied that she did not know that that paper was in there and that she was confused when she seen the order date of 6/3/24. DON and family advised of residents return. Interview with Nurse Practitioner, Employee E10 confirmed that she authorized Resident R81 leave of absence for the time of June 8, 2024, at 8:30 a.m. to June 9, 2024, at 6:00 p.m. Review of medication order for Resident R81's leave of absence revealed that Licensed nurse, Employee E5 sent a request to the pharmacy for the following medication for Resident R81 to take with her on her LOA. The detailed list of medication included: Metformin 500 mg (milligrams), ordered to take 2 tablets twice a day. (diabetic medication used to lower blood sugar levels) resident given 6 tablets. Quetiapine 100 mg ordered 1 tab at bedtime (antipsychotic used to treat schizophrenia) resident given 1 tablet. Quetiapine 50 mg ordered to take one tablet twice a day (antipsychotic used to treat schizophrenia) resident given 2 tablets. Trazadone 50 mg ordered to take ½ tab / 0.5 tab at bedtime for anxiety daily (antidepressive) Insulin glargine 100 ml ordered admin 4o units sub q at bedtime, (hormone) resident given 40 units. Insulin lispro 100iu inject 6 units inject subcutaneous (just under the skin) at bedtime 1 pen, resident given 1 pen. Insulin lispro 100 iu inject 20 units inject subcutaneous (just under the skin) before meals / hold if not eating resident given 1 pen. Aspirin 81 mg ordered to take 1 tab daily at 9am, resident given 1 tablet to prevent a stroke. Atorvastatin calcium 40 mg (cholesterol medication) ordered for 1 tab daily at 9 am resident given one tablet. Ferrous sulfate 300 mg ordered 1 tab daily at 10 a.m. (iron) resident given 1 tablet. Gabapentin 800 mg ordered (anticonvulsant) 1 tab by mouth three times a day, 6 a.m., 2 p.m., 10 p.m., resident given 4 tablets. Guaifenesin liquid 100mg/15 ml order to take 10 ml at 9 am and 9 pm (cough suppressant) resident given 20 ml. Lacosamide 150 mg ordered one tab every 12 hours (seizures medication), resident given 2 tablets. Interview with Licensed nurse, Employe E5 on August 13, 11:25 a.m. revealed the protocol of a resident's leave of absence was the resident has to request the leave to her (unit manager) a few days prior, (enough time to order medications for the leave) then she will get approval and order from the physician for the leave of absence. Upon returning the resident is required to provide the bag of medication to examine. The residents should then receive an accu check (blood sugar check) and skin check when arriving back to the facility. Licensed nurse, Employee E5 stated that Resident R81 came to her and requested the leave from June 8th through June 9th . Employee E5 then got physician orders for the leave and ordered medication based on the number of hours the resident would be out. Licensed nurse, Employee E5 stated that she was not on duty on June 8, 2024, when the resident left for LOA. When she arrived on the floor on Monday August 10, 2024, at 7:00 a.m. she became aware the Resident R81 has not yet returned. She immediately tried to call the resident and called resident's family to locate her. Licensed nurse, Employee 5 confirmed that she was concerned of the resident's need for crucial medications. When Resident R81 returned Licensed nurse, Employee, E5 requested accu check log, and it was noted that the resident failed to record her blood sugar levels. Interview with Resident R81 on August 13, 2024, at 11: 55 a.m. confirmed that she left for the weekend and everyone went crazy the DON threatened to call the police if she did not come back. Resident R81 stated that she told someone she was not coming back till after the weekend. Resident R81 stated that she went to Licensed nurse, Employee E5 and requested the leave and few days prior to leaving. The morning of June 8, 2024, Resident R81 stated she was in a hurry my ride is downstairs waiting and Licensed nurse, Employee E6 handed her a bag of meds with needles. Resident R81 stated she was not educated or told what to do with the medications. Interview with Director of Nursing, Employee E2 on August 13, 2024, at 1:25 p.m. revealed that the resident had told a nurse that she was going to extend her loa until Monday. Director of Nursing Employee E2 provided a nursing note that stated Resident R81 will be returning on Monday, June 10, 2024. Review of nursing note written by Licensed nurse, Employee E9 on June 8, 2024, at 5:41 p.m. indicated that Resident on LOA w/ friend and will return Monday 6/10/24 resident has all medication with her. Interview with Licensed nurse, Employee E9 on August 15, 2024, at 9:05 a.m. revealed that she was on duty the morning of June 8, 2024, as unit manager and she state that Resident R81 left the facility, she did not remember if anyone was with her, and said she would be coming back on Monday (June 10, 2024). Employee E9 wrote a note in the chart. There was no documented evidence that Licensed nurse, Employee E9 notify the physician or obtain a new order for extended LOA and additional medications required for Resident R81. Interview with Licensed nurse, Employee E6 on August 14, 2024, at 4:45 p.m. revealed that she provided the resident with the bag of medications for her to leave with. Licensed nurse, Employee E6 stated that bag was stapled shut, she stated that she eye bawled the medication to confirm the contents. Employee E6 was not able to confirm if she educated the resident at the time of departure or sometime previously. Licensed nurse, Employee E6 stated that she knew what to do with the medications. Licensed nurse, Employee E6 denied suppling the resident with supplies needed such as accu check glucose meter, lancets, and test strips, stating that Resident R81 told her she had all supplies needed. There was no evidence that the facility initiated efforts to locate the resident for 2 shifts after the resident failed to return to the facility on June 9, 2024. It was not until the 7-3 shifts on June 10, 2024, that the resident was able to be located. There was no additional physician order obtain for the resident stay out of the facility passed June 9, 2024. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on August 15, 2024, at 11:34 a.m. for the facility's failure to ensure that Resident R81 was provided education of how to monitor blood sugar level per sliding scale prior to leave of absence from the facility and how to administer insulin medication. The facility failed to timely ensure the safety and location of Resident R81 who was on a leave of absence. The following action plan was received and accepted on August 15, 2024, at 2:34 p.m. 1.Resident educated on how to assess, monitor, and administer blood sugar levels per sliding scale. 2. Thirty days look back completed on resident with active LOA orders that receive insulin to ensure insulin education has been provided. 3. DON (Director of Nursing) or designee to re-educated Licensed nursing staff on insulin education prior to the resident leaving for an ordered LOA. Licensed nursing staff will also be re-educated on LOA policy and when to initiate effort/ notification to locate a resident who does not return to the facility. 4. Weekly audits x 12 to be completed for all resident who went on a LOA that receive insulin to ensure education was provided prior to LOA occurring. Results of audits to be reviewed at QAPI meeting. Interview with all licensed staff confirm that they were in-service on Interview with Resident R81 confirmed that the resident received education on monitoring blood sugar levels per sliding scale. Interview with licensed nursing staff reported that they received inservice on the LOA policy. Review of facility thirty day look back of leaves of absence confirmed that education was completed on insulin administration. The Immediate Jeopardy was lifted on August 16, 2024, at 2:02 p.m. 2024. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.20 (a)(1)(b) Staff development 28 Pa. Code 211.12 (d)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and documentation, clinical record review and interviews with staff, it was determined that the facility failed to adequately supervise a resident who was at risk for elopement, and failed to secure windows on the unit, for one of five residents reviewed (Resident R1). This failure resulted in an Immediate Jeopardy situation as Resident R1 exited the building through a second-floor window and sustained serious injuries, including a laceration to his head requiring sutures and multiple facial fractures. Findings include: Review of facility policy, Elopement of Patient dated revised October 24, 2022, revealed, Patients/Residents will be evaluated for elopement risk upon admission, re-admission, quarterly, and with a change in condition as part of the clinical assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Continued review revealed, Elopement is defined as any situation in which a patient leaves the premises or a safe area without the facility's knowledge and supervision, if necessary. Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated August 10, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), anxiety disorder (intense, excessive, persistent worry or fear), depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), alcohol dependence with alcohol induced disorder and acquired absence (surgical removal) of both left and right feet. Review of Resident R1's care plan, dated initiated August 8, 2022, revealed that the resident was at risk for elopement related to the resident expressing the desire to leave the facility while not medically ready for discharge and that the resident has made one or more attempts to leave the facility. Goals included for the resident to not attempt to leave the facility without an escort. Interventions included to utilize and monitor security bracelet per protocol. Continued review of Resident R1's care plan revealed that the resident required assistance/was dependent for mobility related to transmetatarsal amputation (surgical removal of part of the foot between the ankle and toes) of bilateral (both) feet. Further review revealed that the resident had impaired/decline in cognitive function or impaired thought processes related to short/long term memory loss. Review of Resident R1's Treatment Administration Records revealed physician's orders, dated August 5, 2022, for Wander Guard (security bracelet) to left lower ankle due to poor safety awareness. The orders specified to check the function of the device every night shift (once daily) and to check the placement of the device every shift (three times per day). Employee E11, licensed nurse, signed that the checks were completed on September 20, 2023, on the evening and night shifts. Review of progress notes for Resident R1 revealed a change in condition note, dated September 21, 2023, at 6:45 a.m. which stated, Resident found by staff outside in the facility's front yard sitting on the guard rail smoking a cigarette. Resident found by nursing supervisor with a laceration above left eyebrow and abrasions to fingers. Resident was transported back to his room via resident wheelchair and provided with assessment and first aide, cleansed with nss [normal saline solution] and gauze and bandaged. Telehealth NP [nurse practitioner] contacted and order was given by [nurse practitioner] to send resident to hospital to get sutures to laceration. Review of facility documentation submitted to the Pennsylvania Department of Health on September 21, 2023, revealed that Resident R1 was observed sitting on guardrail in front of building at 6:44 a.m. by staff with a laceration to his left forehead. Interview on September 25, 2023, at 6:24 a.m. Employee E5, scheduling manager, stated that she was walking up the sidewalk on her way to work on September 21, 2023, at 6:45 a.m. when she noticed an unknown person smoking by the edge of the facility property. Employee E5, scheduling manager, stated that she went into the facility to get the assistance of another staff person, as she did not want to approach the unknown person alone. Employee E5, scheduling manager, stated that she asked Employee E4, licensed nurse, to come outside with her. Upon approaching the person that was outside, Employee E5, scheduling manager, stated that they recognized the person as Resident R1. Employee E5, scheduling manager, stated that she noticed that Resident R1's left eye was swollen shut, that he had a laceration on his head, and that he had dried blood on his head, coat and pants. Employee E5, scheduling manager, stated that the resident reported being in significant pain due to his injuries. Interview on September 25, 2023, at 6:18 a.m. Employee E4, licensed nurse, stated that Employee E5 reported an unknown person smoking on the property and they went together to approach the person. Employee E4, licensed nurse, stated that they recognized the person as Resident R1 and that he had a laceration with dried blood above his left eyebrow as well as blood on his overcoat. Resident R1 told Employee E4, licensed nurse, that he walked down the steps to come outside to smoke. Employee E4, licensed nurse, stated that she went up along the back stairwell but did not see any blood or source for the resident's injuries. Employee E4, licensed nurse, stated that she continued to review the area and saw blood on the concrete and edge of the sidewalk directly below the resident's window. Observation, during the interview, Employee E4, licensed nurse, demonstrated where the blood was noted on the ground and showed that the resident's bedroom window was on the second floor, directly above the area where the blood was found. Employee E4, licensed nurse, stated that Resident R1 wore a Wander Guard device, that he was a known elopement risk and that no alarms were heard on the night of his elopement. Continued observation on September 25, 2023, at 6:34 a.m. with Employee E4, licensed nurse, revealed that Resident R1's bedroom had two windows directly above the PTAC (heating and air conditioning) unit. The window on the left side was bolted closed and unable to be opened. No screen was observed in the left window. The window on the right side opened via a handle on the top of the window with hinges along the bottom of the window. The window opening measured approximately nine inches. Interview on September 25, 2023, at 6:48 a.m. Employee E6, licensed nurse, stated that while she was not the assigned nurse for Resident R1 that night, she worked on the second floor unit on the night of the incident and that she did not hear any alarms or see Resident R1 try to leave the building. Interview on September 25, 2023, at 6:58 a.m. Employee E7, Maintenance Director, stated that he performs checks of the Wander Guard alarmed doors on a weekly basis and that two of the alarms have not been working for weeks, including the first floor middle door (near the receptionist desk) as well as the alarm panel on the elevator. Observation, at the time of the interview, confirmed that the Wander Guard alarm panels were not functioning. Continued interview, Employee E7, Maintenance Director, stated that he was unable to find the screen to Resident R1's window and that he bolted the window shut after the incident. Interview on September 25, 2023, at 8:53 a.m. Employee E11, licensed nurse, confirmed that she was the nurse on duty assigned to care for Resident R1 on the night of the incident. Employee E11, licensed nurse, stated that she last saw the resident between 10:00 p.m. and 10:30 p.m. during medication pass. Employee E11, licensed nurse, stated that she did not round on the resident throughout the night and admitted that it was her fault that the resident eloped. Employee E11, licensed nurse, stated that although she signed the Treatment Record that she checked Resident R1's Wander Guard, she did not actually check it and that she did not know where his Wander Guard was supposed to be located. Employee E11, licensed nurse, confirmed that she falsely signed the Treatment Record related to Resident R1's Wander Guard orders. Employee E11, licensed nurse, also confirmed that she was completely unaware that Resident R1 had eloped from the building until staff had reported that he was found outside. Employee E11, licensed nurse, stated that she assisted with providing first aide after the resident was found outside. Employee E11, licensed nurse, stated that the resident was wearing at least seven layers of clothing and that he had a laceration to his left eye, blood on the left side of his face and blood around his head. Employee E11, licensed nurse, stated that she cleaned up the laceration, cleaned the blood off of his hands and bandaged him up. Employee E11, licensed nurse, stated that she saw a pack of cigarettes tucked into the resident's sock on his right ankle and that she does not remember seeing the resident's Wander Guard. Interview on September 25, 2023, at 9:38 a.m. Employee E13, Housekeeping Director, stated that he assisted reviewing the camera footage of the incident. Employee E13, Housekeeping Director, stated that Resident R1 was seen walking across the parking lot over to the guard rail around 6:45 a.m. Employee E13, Housekeeping Director, stated that he reviewed the camera footage back until about 3:00 a.m. but did not see the resident. Review of the video footage timeline, provided by the Nursing Home Administrator on September 25, 2023, revealed that Resident R1 was attempting to get outside of his room through the window at around 11:15 p.m. In the video his feet were observed outside the window. Approximately 10-15 minutes later, the resident was observed falling to the ground. At approximately 6:25 a.m. resident was observed on the video walking towards the guardrail by the dumpsters. Interview on September 25, 2023, at 10:35 a.m. the Nursing Home Administrator stated that in response to the incident, the facility conducted audits of all windows and ensured that they were fitted with safety devices so that windows can not be opened more than six inches. Interview on September 25, 2023, at 11:20 a.m. the Director of Nursing confirmed the above findings of the video footage timeline, confirmed that the resident fell from his window at approximately 11:30 p.m. and confirmed that he was seen walking towards the guardrail by the dumpsters at 6:25 a.m. Resident R1 was not observed by staff until 6:45 a.m. Review of hospital records, dated September 21, 2023, for Resident R1 revealed that the resident was evaluated by the Trauma Surgery team for traumatic rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood and can result in kidney damage), laceration and multiple facial fractures. Review of Resident R1's CT scan (diagnostic imaging) revealed multiple facial fractures, including: nondisplaced fracture at the left second active process of the temporal bone (side of the skull bone); mildly displaced fracture at the inferior zygomatic process of the left temporal bone (cheek bones); mildly displaced fracture of the left sphenoid bone (middle of the skull base and back of the eye sockets); and nondisplaced fracture at the right lower mandible (jaw bone). Continued review of hospital records for Resident R1 revealed a nurses note, dated September 26, 2023, at 3:44 a.m. which indicated that the resident was received at start of shift from oral surgery. Jaw is wired shut, wire cutters at bedside, suction at bedside . Cold compresses given to help with pain, prn [as needed] dilaudid [pain medication] given with stated relief. Zofran given for nausea. IVF [intravenous fluids] and IV abx [intravenous antibiotics] continue. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to provide adequate supervision of a resident who was identified as an elopement risk by the facility. This failure resulted in the resident exiting the building through a second floor window and sustaining serious injuries, including laceration, traumatic rhabdomyolysis and multiple facial fractures, including: nondisplaced fracture at the left second active process of the temporal bone; mildly displaced fracture at the inferior zygomatic process of the left temporal bone; mildly displaced fracture of the left sphenoid bone; and nondisplaced fracture at the right lower mandible. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator and Director of Nursing on September 25, 2023, at 12:31 p.m. On September 25, 2023, at 5:06 p.m. the facility's action plan was accepted. The action plan included the following: Resident R1 - Supervisor assessed and provided first aid to resident. 911 was notified and transferred resident to emergency department for assessment. R1 was admitted to local hospital. Upon return, resident will be reassessed for wandering risk. Will implement every 15 minute checks for one week, every 30 minute checks for one week, every one hour checks for one week, then every two hour checks for one week. Reassess frequency of checks to ensure safety needs are met. Review elopement policy and protocol with all staff. All staff will be educated September 25, 2023. Education to be completed by Director of Nursing/Designee. Education will include review of elopement policy and protocol. Agency staff will be educated prior to taking their assignment. Education to all staff regarding resident supervision and elopement prevention. All staff will be educated today. Education to be completed by Director of Nursing/Designee. Education will include rounding every two hours, checking function once daily and placement of Wander Guard every shift, CODE [NAME] (elopement drill), updating of care plans. Agency staff will be educated prior to taking their assignment. Conduct audits for all windows to ensure appropriate safety mechanisms are in place. Initial audit completed on September 21, 2023. Eight windows were found to be defective. The defective windows were secured by being bolted. All other remaining windows are able to be opened six inches. An audit of all windows will be completed daily for one week, then weekly for four weeks for proper window function, and that the restrictive mechanisms remain in place. Maintenance Director will conduct audits as indicated. Conduct audits of all door alarms and Wander Guard alarms to ensure proper functioning. September 25, 2023, Audit completed for all doors and Wander Guard alarms to ensure proper functioning. Parts have been ordered for the door alarm system and are awaiting delivery. Receptionist desk will be manned at all times. The electrician and elevator company are working to establish a date for repair. Elevators are equipped with a keypad system. Second floor and third floor units cannot be accessed without a code. Door alarms and Wander Guard alarms will be audited daily. Maintenance Director will conduct audits as indicated for all door alarms and Wander Guard alarms. Conduct audits of residents who are at risk for elopement to ensure interventions are in place in accordance with the resident's care plan. Interventions to include items such as Wander Guard placement and function checks, encouraging residents to attend activities or tasks of interest to the resident and redirecting residents away from elevators and doors. Initial audit was completed on September 21, 2023. Director of Nursing/ Designee to conduct daily audits for two weeks then weekly for four weeks. Results of audits to be reviewed monthly at QAPI meeting. Next QAPI is scheduled for October 23, 2023. A monitoring visit was conducted on September 26, 2023, to verify the implementation of the action plan. Staff on duty were interviewed and reported knowledge of key components of training provided, including rounding on residents, checking Wander Guard devices, elopement policies and procedures, and what to do in the event of an elopement. Observations of resident windows revealed that windows were fitted with safety devices and opened appropriate distances. Observations of door and Wander Guard alarms revealed that doors were functioning properly. Constant supervision was provided near doors that required repairs. Review of facility audits and interviews with staff confirmed that residents at risk for elopement are reviewed to ensure that care plan interventions are in place and staff are knowledgeable of elopement prevention strategies (checking placement and function of Wander Guard device, frequent rounding on resident, etc.). The Immediate Jeopardy was lifted on September 26, 2023, at 4:01 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 201.18(e)(1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services