**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy the facility failed to ensure that Resident (R)1 had adequate supervision to prevent an elopement on 07/15/25 at approximately 7:30 PM. R1 was observed by a Laundry Aid staff member lying on the ground by a porch at the bottom of three steps, near an exit door at the rear of building. It was determined that R1 self-propelled herself in her wheelchair off the porch. R1 was observed with visible lacerations to the back of her head and her bilateral upper extremities.On July 24, 2025 at 12:16 PM the the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.On July 24, 2025 at 12:16 PM the Administrator was notified that the failure to provide appropriate supervision for a resident, which resulted in the resident successfully eloping from the facility constituted Immediate Jeopardy at F689.On July 24, 2025 at 12:16 PM the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of July 15, 2025 at approximately 7:30 PM. The IJ was related to 42 CFR S483.25(d) - Free of Accident Hazards/Supervision/Devices.On July 24, 2025 at 1:30 PM the facility provided an acceptable IJ Removal Plan. On July 24, 2025 at 3:35 PM the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Compliance as of July 18, 2025.An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Review of the facility policy titled Elopements and Wandering Residents revealed this facility ensures that resident who exhibit wandering behavior and or/are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy explanation and compliance include: the facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Record review of R1's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to senile degeneration, dysphagia, abnormalities of gait and mobility, lack of coordination, muscle weakness, and history of falling. Record review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/27/25 revealed that R1 had a Brief Interview of Mental Status (BIMS) score of 05 out of 15 indicating a severe cognitive impairment. Further review of the admission MDS revealed R1 utilizes a manual wheelchair and is able to wheel 0 - 150 feet in her with supervision or touching assistance. Record review of R1's Active Physician Orders for July 2025 revealed an order for an electronic monitoring device with a start date of 04/28/25. The electronic monitoring device is to be checked for placement, function, and skin integrity every shift. Record review of R1's Medication Administration Record (MAR)/Treatment Administration Record (TAR) for July 2025 revealed R1's electronic monitoring device was checked for placement daily on each shift from 07/01/25 - 07/22/25. Record review of R1's Progress Notes dated 07/15/25 revealed Back Hall nurse responded to housekeeping yelling for help. Noted resident [R1] outside of back door at the bottom of three steps on the ground lying on her left side with visible laceration to back of head and blue upper extremity. Nurse stayed with resident while the front hall nurse called 911. Vitals were the following: blood pressure 169/72, pulse 72, respiratory rate 20, temperature 98/9, pressure applied to laceration on head. Resident is alert and talking with staff, [R1] unable to state what she was doing, resident is confused as baseline. Multiple areas bleed to bilateral upper extremity and bilateral lower extremity Medical Doctor, Hospice, and Resident Representative made aware. Record review of R1's Elopement Assessment completed on 05/19/25 revealed R1 wanders the budling but does not try to leave. Record review of R1's Care Plan with an intervention initiated on 05/26/25 revealed R1 is an elopement risk/wanderer related to place, history of attempts to leave facility unattended, impaired safety awareness. Resident wanders aimlessly as evidence by frequently requires redirection from staff, resident to accept redirection, poor short-term memory, and failure to follow multiple step instructions at times. Interventions include assess for fall risk, back up door alarms to be checked for function per facility protocol, identify pattern of wandering (is wandering purposeful, aimless, or escapist) intervene as appropriate, monitor for fatigue and weight loss, provide structured activities, electronic monitoring device check placement, function, and skin integrity each shift. Record review of R1's Care Plan with an intervention initiated on 05/09/25 revealed R1 is at risk for falls related to confusion, deconditioning, gait/balance problems, unaware of safety needs, senile degeneration of brain, incontinent episodes, history of falling, and generalized weakness. R1 has been noted to lean forward in her wheelchair, utilize her wheelchair as a walker and fidget/erratically move her body and limbs at times. R1 receives hospice services related to senile degeneration of the brain, hospice to be incorporated into each focus as appropriate. Interventions include ensure resident is wearing non-slip footwear when ambulating or mobilizing in wheelchair, encourage resident to utilize wheelchair as intended (seated in chair, not pushing as though it is a walker). 07/15/25 fall with minor injuries, treatments as ordered, back up door alarms to be checked for function per facility protocol. An attempted phone interview with R1's Resident Representative was unsuccessful; a voicemail was left with contact information. An interview on 07/23/25 at 1:00 PM with Laundry Aid (LA)1 revealed that on 07/15/25 they worked from 3:00 PM - 11:00 PM, on their 7:00 PM 30-minute break around 7:30 PM when it was over, they observed R1 lying on the ground near the back steps. LA1 stated they went to immediately call for help and a nurse came out shortly to check on the resident. LA1 stated she could not recall if any alarms were sounding at the time. LA1 finally stated that prior to going on break they observed the resident a little before 7:00 PM in the dining area sitting in her wheelchair. An attempted phone interview on 07/23/25 at 1:57 PM with Certified Nursing Assistant (CNA)1 was unsuccessful, phone number provided no longer in service. A phone interview with Licensed Practical Nurse (LPN)1 on 07/23/25 at 2:00 PM revealed that they were not the resident's assigned nurse for the evening of 07/15/25 and have never worked with the resident personally. LPN1 stated that on 07/15/25 around 7:30 PM nursing staff just completed a shift change when they overheard LA1 yelling out for help. LPN1 stated that when she went to find out what was wrong, LA1 guided her outside and there they saw R1 lying on the ground at the bottom of three steps. R1 was able to elope the facility in her wheelchair and was observed with visible lacerations to the back of her head. I applied pressure to the areas, while other staff called 911. R1 was alert and talkative but she was unable to describe how she got out of the building/ what happened. LPN1 stated that they could not recall hearing any alarms sounding off at the time. A phone interview with LPN2 on 07/23/25 at 2:17 PM revealed that they were not the resident's assigned nurse for the evening of 07/15/25 but is familiar with R1 and her history of wandering behaviors. LPN2 stated that the resident constantly wanders around the facility, but they have never witnessed the resident be exit seeking while wandering, and usually R1 is able to be re-directed when she wanders into inappropriate areas. LPN2 stated that around 7:05 PM they were receiving report from a staff member when they overheard other staff members saying that R1 had eloped from the building and fell outside. LPN1 stated that they did not witness the resident outside but stayed inside because it was enough staff members assisting R1 at that time and they called 911 and informed appropriate parties. LPN2 also stated that she was unsure if any alarms sounded on that evening but stated that they were on the Front Hall of the facility and staff, specifically housekeeping staff utilize the door R1 was found nearby outside at often (alarms always going off). An interview with LPN3 on 07/23/25 at 3:38 PM revealed that LPN3 is the resident's current nurse for the day and stated that R1's baseline can depend upon the day due to the resident being diagnosis of senile brain degeneration and being under hospice service. LPN3 stated that some days the resident can be extremely active and constantly wandering around the facility but not exit seeking. Other days (like today 07/23/25) the resident can sleep for most of the day. A phone interview on 07/23/25 at 4:17 PM with CNA2 revealed that they were the resident's assigned CNA on 07/15/25 during the 3:00 PM - 11:00 PM shift. CNA2 stated that on 07/15/25 when they came to work the resident was exhibiting wandering behaviors and they had to re-direct the resident from unsafe areas about three separate times prior to the resident eloping around 7:00 PM. CNA2 stated the resident can be redirected if you talk to her and walk beside her as she self-propels herself in her wheelchair. CNA2 stated that the last time she observed the resident she was in dining room with other residents about 15- 20 minutes prior to the resident being found by the Laundry Aid. CNA2 stated that she was informed that R1 had eloped and had fallen by LA1 and another CNA and immediately went outside to assist with LPN1 and helping the resident. R1 was sent to the hospital shortly after being found due to the resident having excessive bleeding and lacerations. CNA2 finally stated that she could not recall hearing any alarms sounding and R1 wears an electronic monitoring device, and the door should have locked and started to alarm if R1 pushed on the door to exit, it would eventually open about 15 seconds later, but it should also be alarming with sound. An interview on 07/23/25 at 5:06 PM with the Director of Nursing (DON) and Administrator revealed that on 07/15/25 at approximately 7:30 PM R1 was observed by LA1 outside at the rear of the building at the bottom of 3 steps. Prior to being found outside R1 was having a very anxious day and had to be re-directed by other staff members several times related to her wandering behaviors. R1 was also redirected by a resident when she attempted to follow R2, (R2's room is close to the door R1 eloped from). The DON and Administrator stated that had left for the day but believe that the resident did not have adequate supervision due to nursing staff recently completing a shift change. A phone interview after the exit conference on 07/25/25 at 12:05 PM with R1's Attending Physician (AP) revealed that they were notified of the resident's elopement. They further stated that the resident was evaluated by the Nurse Practitioner the next day 07/16/25 and sustained no major injury from the elopement or fall. On 07/24/25 at 1:30 PM the facility provided an acceptable IJ Removal Plan, which included the following:R1's electronic monitoring device bracelet was checked and found to be activated. R1 was promptly sent to the emergency room for a comprehensive evaluation as per the Physician Orders. The attending Medical Director (MD), the responsible party, the Director of Nursing (DON), and the facility's Administrator were all promptly informed of the situation and the actions taken. Following the evaluation, R1 returned from the hospital with no major injuries reported, according to the hospital record. All residents equipped with electronic monitoring devices were thoroughly inspected to confirm that each device was present and functioning properly, any that needed to be replaced were replaced. A headcount was conducted to verify that all residents were accounted for within the facility, every resident was present in the building at the time of the count. All back-up alarms on exit doors thoroughly checked and successfully activated. All entry and exit coding alarms were checked on all doors and were found to be functional. A detailed inspection of all exit doors to ensure they were operating as intended. The electronic monitoring device system was inspected, and any necessary upgrades have been ordered and are currently underway. All back-up alarms on the exit doors are activated, providing an additional layer of security to protect the residents. Additionally, an extensive audit was conducted on all resident to identify those who have undergone risk assessments related to potential to elopement. The policy regarding the development and management of electronic monitoring devices and falls management was reviewed, and it was determined that no revisions are necessary at this time. All nursing staff across all shifts have undergone comprehensive education on several critical topics, the training included essential protocols such as resident safety measures; exit door protocols; response to alarms. This training was conducted by the DON or designated representative, for any staff members on leave during the training, education will be rescheduled and provided on their first scheduled workday upon their return. Additionally, agency staff will also receive similar training before commencing tier duties. This training was started on 07/15/25 and will continue until all staff have received training with the exception of those on leave and they will be educated when they return to work. Newly hired staff will receive education during orientation that includes guidance on monitoring electronic monitoring devices, responding to alarms, adhering to exit door protocols, and ensuring overall resident safety. The DON or designee will conduct audits on new admissions, specifically those at risk for elopement. The Maintenance Supervisor is responsible for daily monitoring of all electronic monitoring alarms and back-up alarms to confirm their activation and proper function and reports any issues to the Administrator. The Administrator will oversee the back-up alarms and electronic monitoring device alarms on a weekly basis to ensure they are operational, any issues noted with alarms that need repairs will be reported to the corporation. Additionally nursing staff will perform checks on the backup alarms every two hours for an initial two-week period, transitioning to checks every four hours thereafter until the facility determined that this is no longer significant risk and can move to less intensive, yet routine ongoing monitoring. A gate has been ordered and will be installed on the back porch to enhance safety and discouraging residents from exiting this area unsupervised. The Medical Records Clerk or designee will be responsible for conducting daily check on the placement and functionality of the electronic monitoring devices. This includes verifying that the devices are properly functioning as intended, the designee will document the results of these findings using the electronic monitoring device tester. The facility will maintain the use of secure, locked security alarms on all doors that necessitate a code for entry and exit. As part of our commitment to quality improvement a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) has been established. To prevent recurrence of these deficiencies all finding and improvement measures will be discussed at the monthly Quality Assurance and Assessment (QAA) meeting for a minimum of three months, followed by quarterly until substantial compliance is met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, and interview, the facility failed to ensure adequate supervision of Resident (R)4 to prevent elopement from the facility on 02/24/24 at approximately 6:30 AM. On 04/05/24 at 4:11 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 04/05/24 at 4:11 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 02/24/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 04/05/24 the facility provided an acceptable IJ Removal Plan. On 04/05/24 the survey team, validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Complaince as of 02/27/24. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the undated facility policy titled, Elopements and Wandering Residents revealed, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Under policy and explanation and compliance guidelines states under section D, Adequate supervision will be provided to help prevent accidents or elopements. Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE] with diagnoses including but not limited to: Schizophrenia, nontraumatic subdural hemorrhage, insomnia, anorexia, bacterial meningitis, severe sepsis with septic shock, and muscle weakness. Review of R4's unspecified Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/28/24, revealed R4 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating R4 had moderate cognitive impairment. Further review of the MDS revealed R4 had wandering behaviors. The MDS also indicated R4 is at risk for falls r/t (related to) confusion, deconditioning, gait/balance problems, incontinence, unaware of safety needs, wandering, and hx (history) of falls. Review of R4's Elopement Risk assessment dated [DATE] revealed the following: resident is disoriented daily, complacent, ambulatory or able to self propel W/C (wheelchair), full mobility, medications that alter mental status, and wanders the building but does not try to leave. Total Score: 10 or greater elopement risk. Further review of the assessment did not indicate a score. The heading of the assessment under the score section, indicated NA. Review of R4's Care Plan initiated on 02/02/24, revealed, The resident is an elopement risk r/t Disoriented to place, impaired safety awareness, wandering behavior noted, schizophrenia, impaired cognitive status. The goals of the care plan documented, The resident's safety will be maintained through the review date. The resident will demonstrate happiness with daily routine through the review date. The resident will not leave facility unattended through the review date. Interventions included but were not limited to, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . Review of R4's Body Audit Sheet dated 02/24/24, revealed a picture of a front view and back view of the human body. The back view revealed R4 suffered skin tears on both elbows and swelling/laceration to the back of the head. Review of R4's Discharge Summary [local hospital] with an admission date of 02/24/24 and discharge date of 02/27/24, revealed R4 was admitted due to subdural hematoma (a pool of blood between the brain and its outermost covering. Usually caused by a head injury strong enough to burst blood vessels) from a fall. Further review of the Discharge Summary revealed, multiple fractures of ribs, right side, other specified fracture of right pubis, and fracture of other specified skull and facial bones, right side. Review of Weatherunderground.com revealed the weather on the morning of 02/24/24 at approximately 6:45 AM, was 43 degrees Fahrenheit. During an interview on 04/05/24 at 10:04 AM, Environmental Services (ES) stated she arrived to work at approximately 7:00 AM, and was sitting in the office. ES stated she heard another employee yell that R4 was outside. ES stated she held the door for them to bring R4 back into the facility. ES further stated R4 was unsteady when walking. During an interview on 04/05/24 at 10:08 AM, Licensed Practical Nurse (LPN)3 stated she arrived at work at 7:00 AM and was getting the morning report from another nurse when a staff member notified her that R4 was outside. LPN3 assessed R4 and noted scratches and bleeding and she called 911. LPN3 stated the alarm is loud and staff are to check the door when the alarm sounds. LPN3 further stated with the wander guard she does not believe the door should open, that morning she did not check for R4's wander guard. She was focused on getting him medical attention. During an interview on 04/05/24 at 10:16 AM, LPN2 stated, I last saw [R4] when I was passing 6:00 AM meds, I am unaware if he had his wander guard. I do recall hearing a noise and asking a CNA [certified nursing assistance] about it. During an interview on 04/05/24 at 10:38 AM, the Housekeeper stated, I arrived to work around 7:00 AM and clocked in. When I went outside to get my cart, I saw [R4] sitting at the picnic table, he was cold and bleeding. I went into the facility to get help and the nurse came and called 911. The door alarms are loud at the facility and any staff can check when the door alarms. During an interview on 04/05/24 at 12:11 PM, Certified Nursing Assistant (CNA)2 stated, I worked the 11:00 PM - 7:00 AM shift that day, I changed [R4] between 6:00 AM - 6:25 AM, after that he was sitting in the back living room area like he always did. [R4] is normally always walking around, if he is near the door staff redirect. During an interview on 04/05/24 at 2:58 PM, CNA1 stated R4 was wearing pants, t-shirt, and skid-socks. During an interview on 04/05/24 at 4:03 PM, the Administrator revealed the emergency fire door that R4 exited the building through has an alarm system that when pushed an alarm will sound for 15 seconds and the door will open after the 15 seconds. On 04/05/24 the facility provided an acceptable IJ Removal Plan, which included: 1. What was done for resident affected - The wander guard of [initials](R#4) had been checked on 2/23/24 on 7p/7a and was present and functional per MAR. - The doors had been checked by the maintenance supervisor on 2/22/24 and were all functional per his wander guard log. - Resident [initials](R#4) was given first aid by the nurse and was sent out to the hospital 2/24/24. - Resident [initials](R#4) returned to the facility on 2/27/24 and was placed on 15 minute checks x 72 hours. - A therapy referral was made for resident [initials]#4 to be assessed. - Resident [initials](R#4) had another wander guard applied when he returned to the facility and his care plan was updated to reflect fall and wandering/elopement risk. 2. How to identify other residents with potential to be affected - All other residents with wander guards were checked to assure they had their wander guards intact and they were functional. - The head count was done all other residents to assure all were in the building. - All doors were checked to assure that they were functioning, and all were. - An audit was completed on all residents to identify residents who had risk assessments for potential of elopement and to assure interventions such as wander guards were in place. - Staff were placed at exit doors to monitor doors until wander guard system on doors were properly functioning. (the alarm was adjusted so it did not self silence its self) - Residents with wander guards were placed on 15 minute checks until wander guard system on doors was properly functioning. (the alarm was adjusted so it did not self silence its self) 1. Actions to Prevent Occurrence/Recurrence: - The wander guard system to the doors was adjusted so that it could only be turned off by staff and would not silence its self. This was completed on 02/27/24. - The development and wandering residents' policy was reviewed no revision required. - All nursing staff on all shifts received education on resident safety checking alarms and checking guards from the DON or designee(s). Any staff on leave will receive education on their next scheduled workday. Agency staff will also be educated on resident safety and checking alarms and wander guards prior to work. All newly hired staff will receive training during orientation regarding monitoring wander guards, responding to alarms and resident safety. - The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. - The maintenance supervisor will monitor doors to assure that alarms are functioning properly. The results of this monitoring will be reviewed monthly by the administrator. - New hires will receive education on wandering, elopement, and resident safety by the DON or designee, - A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings to determine root cause. Root cause findings were identified to be an issue with the wander guard alarm silencing its self after only a few seconds (15) of sounding. The issue was resolved 2/27/24. 2. How ill you ensure the deficient practice is not likely to recur? All findings will be discussed at the monthly QAA meeting for a minimum of three months and then quarterly until the pattern of compliance is maintained. Date of completion 2/27/24