**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide adequate supervision for one of one resident reviewed, Resident ID #1. This resident successfully eloped from the facility on two separate occasions and later entered an unsecured area within the facility, where they sustained a fall that required a hospital transfer for evaluation.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 9/21/2025 alleges that Resident ID #1 has eloped out of the facility multiple times, and indicated the resident is not appropriate for the facility.Review of an undated facility policy titled, Elopement of Resident, states in part, .All residents will be assessed for potential elopement risk at admission and with a significant change in status.For residents identified as at risk, an interdisciplinary elopement prevention care plan will be developed.Staff witnessing a confused resident or an identified elopement risk resident attempting to leave the Center will intervene as appropriate to redirect the resident to a safe area and prevent elopement.Record review revealed the resident was admitted to the facility in March of 2025, with a diagnosis including, but not limited to, dementia.Review of a Significant Change Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3 out of 15, indicating the resident has severely impaired cognition. Further review revealed the resident displayed wandering behaviors, one to three days, during the seven-day look back period and utilized a wander guard (a device designed to prevent individuals from wandering away by alerting caregivers when a resident breaches a designated perimeter) daily. Review of a Wandering Assessment dated 7/20/2025 revealed a score of 11, indicating s/he is at high risk for wandering. Record review failed to reveal evidence that an Elopement Assessment was completed, after the resident's significant change in status on 7/18/2025, per the facility policy.Review of a care plan focus area initiated on 6/16/2025 revealed the resident has exit seeking behaviors due to his/her diagnosis of dementia. Interventions include, distract resident from wandering by offering pleasant diversions, food, or conversation and to utilize a wander guard, as ordered. Record review revealed the following physician's orders dated 6/14/2025:- Check functional status of wander guard to right wrist, each shift- Check placement of wander guard on right wrist, each shiftReview of a progress note dated 8/26/2025 revealed the resident successfully eloped from the facility and was found by nursing staff outside of the front door. Further review states, additional safety measures implemented.Record review failed to reveal evidence that additional safety measures were identified and implemented, following the resident's successful elopement on 8/26/2025. Record review revealed a progress note dated 9/20/2025, authored by Registered Nurse (RN), Staff A, which states, at 17:25 [5:25 PM] resident was found by RN outside of building in facility parking lot. Wander guards functioning properly on wheelchair and wrist, wander guard system did not activate. On call supervisor notified and made aware.Record review failed to reveal evidence that additional safety measures were identified and implemented, following the resident's successful elopement on 9/20/2025. Record review revealed a progress note dated 9/21/2025, one day after the resident's successful elopement, which states in part, Resident unable to be located, CNA [Certified Nursing Assistant] found resident lying on the floor in dark therapy room on [his/her] back with difficulty to arouse. Resident responded yes when RN called out [his/her] name multiple times in a delayed response. Resident unable to verbalize any pain and gave a blank stare when asked questions. Resident lethargic on assessment, then became alert with 0 orientation. able to move all 4 [extremities] unable to grasp hands to determine hand strength, pupils unequal at baseline with sluggish response to light accommodation .On call provider.notified with new orders to send resident to [NAME] ED [Emergency Department] for treatment and evaluation via EMS [Emergency Medical Services] .Resident transferred off therapy room floor onto stretcher via EMS personnel.Record review revealed the resident retuned to the facility on 9/22/2025 with a diagnosis of a urinary tract infection. During a surveyor observation on 9/24/2025 at 9:29 AM, Resident ID #1 was noted to have a wander guard on his/her right wrist and 2 additional wander guards located on the back of his/her wheelchair. Record review failed to reveal evidence of a physician's orders to check for functionality or placement of the two wander guards located on the resident's wheelchair. During surveyor interviews on 9/24/2025 at 10:39 AM and 12:35 PM, with RN, Staff A, she indicated that she was one of the nurses on duty on 9/20/2025. She acknowledged that Resident ID #1 successfully eloped from the facility on 9/20/2025, through the main entrance door, and was found in the parking lot, in his/her wheelchair. She revealed that when she was unable to locate the resident in the facility and initiated a facility search. She indicated that RN, Staff B found the resident outside in the parking lot. She further revealed that based on surveillance footage, the resident eloped after a visitor had opened the door the resident was able to self-propel outside. She revealed that there is a wander guard system at the front door but indicated the alarm did not go off when the resident exited the facility. Additionally, she revealed that Resident ID #1 frequently wanders around the facility, indicating that staff are constantly questioning his/her whereabouts. Furthermore, she revealed that the resident was found the next day on 9/21/2025, lying on the floor of the therapy room, where s/he should not have been able to enter, indicating the room should have been locked. She further revealed that the resident has previously been found in other rooms, such as a storage room due to his/her wandering behaviors. During a surveyor interview on 9/24/2025 at 10:53 AM, with RN, Staff B, she indicated that she was one of the nurses on duty on 9/20/2025. She revealed that on 9/20/2025 at approximately 5:25 PM, she saw Resident ID #1 self-propelling towards the front doors and indicated that she was following behind him/her. She further revealed that she had stopped to assist another resident, by the time she approached the front doors she observed Resident ID #1 outside in the parking lot with another resident, who was holding his/her wheelchair to prevent the resident from self-propelling further into the parking lot. Additionally, she revealed that Resident ID #1 has previously eloped from the facility. Furthermore, she revealed that the wander guard alarm did not alert when the resident left the faciity on 9/20/2025. Surveyor observation on 9/24/2025 of the facility parking lot reveals, the flat parking lot slopes toward a hill that descends to a highly traveled main road and ultimately ending at a large body of water. During surveyor interviews on 9/24/2025 at 9:46 AM with the Director of Nursing Services (DNS) and the Administrator, they acknowledged that Resident ID #1 successfully eloped from the facility on 8/26/2025 and 9/20/2025. During a surveyor interview on 9/24/2025 at 10:24 AM, with the DNS, she revealed that after the resident's successful elopement on 9/20/2025 and after the incident on 9/21/2025 where the resident was found in the therapy room, the social worker was attempting to find the resident placement on a secured unit at another facility, however, she was unable to provide evidence that any additional interventions or safety measures were in place to prevent the resident from wandering into areas of the facility where s/he should not be and eloping again while s/he was still a resident at the facility. A surveyor observation on 9/24/2025 at 11:19 AM, of the surveillance footage from 9/20/2025, revealed Resident ID #1 self-propelled in his/her wheelchair to the front door and was noted to be sitting at the front door, without the doors opening. Further review revealed a visitor entered the facility, causing the main doors to open, the resident was then able to self-propel outside and elope from the facility. Additionally, no staff were present in the video, when the resident successfully eloped from the facility. During a surveyor interview on 9/24/2025 at 12:23 PM, with the Administrator and DNS, the Administrator acknowledged that the wander guard system did not alarm on 9/20/2025, when the resident exited through the front door perimeter. The Administrator further revealed that she had placed one of the two wander guards on the back of the resident's wheelchair but was unable to recall when she had placed it. Additionally, they were unable to provide evidence that Resident ID #1 received adequate supervision to prevent him/her from eloping from the facility, twice, once on 8/26/2025 and again on 9/20/2025, also they failed to prevent him/her from wandering into an unsecured area of the facility on 9/21/2025.The facility failed to reassess the resident's risk for elopement following a significant change in condition and did not implement adequate supervision interventions. As a result, a cognitively impaired resident previously identified as a wander risk was able to exit the facility through the main doors on two occasions, 8/26/2025 and 9/20/2025. During the second incident, the resident was found in the parking lot, having been stopped by another resident. The facility's continued failure to provide adequate supervision led to the resident being found on the floor of the therapy room on 9/21/2025, following an unwitnessed fall one day after the most recent elopement. This incident required the resident to be transferred to the hospital for further evaluation. These systemic failures placed Resident ID #1 at risk for more than minimal harm, serious injury, or death.