**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, video footage and interviews, the facility failed to prevent accidents/hazards for 1 of 3 residents reviewed. Specifically, on 8/30/25, Resident (R)1 had a successful elopement from the facility. R1 was placed at an increased risk of being struck by a vehicle and/or suffering a heat related and inclement illness.On 09/11/25 at 2:22 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 09/11/25 at 2:22 PM, the Executive Director (ED) was notified that the failure to protect R1 from having a successful elopement from the facility constituted Immediate Jeopardy (IJ) at F689.On 09/11/25 at 2:22 PM, the survey team provided the Executive Director with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 8/30/25. The IJ was related to S483.25 Quality of Care- F689: Free of Accident Hazards/Supervision/Devices.On 09/11/25 at 4:28 PM, the facility provided an acceptable IJ Removal Plan. On 09/11/25, the survey team validated the facility's corrective actions and determined the facility made good faith attempts at correcting the non-compliance. The IJ is considered at Past Non-Compliance as of 09/03/25. The survey team concluded all corrective actions were put in place prior to arrival onsite.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 facility's undated policy titled, Roam Alert Policy and Procedure Version 1.2 revealed, Policy Statement: The Roam Alert Notification System is a Wander Management system used to monitor cognitively impaired individuals with wandering, exit-seeking, or aggressive behaviors. The Member wears a Roam Alert wrist/ankle band signaling device. When the Member is near a monitored doorway and the door is open, an alarm sounds at the door, displays on the Staff Station Computer, and alarms to the direct care staff pagers. Staff shall manage the implementation, maintenance and monitoring according to the following procedures: 1. SYSTEM DESRIPTION AND PARAMETERSa. Each monitored doorway is connected via the [NAME]-Care Nurse Call system to the direct care pagers.b. The direct care pager alerts caregivers to alarms when they are out of hearing range,c. Each doorway that has a keypad has a code that will by-pass the door alarm temporarily.d. Each doorway that has a keypad has a code that will reset the system.e. The code will be given to staff members only and will be changed when needed by the Facility Services Director.f. The Roam Alert Tags are battery-operated with a unique ID number that must be programmed into the [NAME]-Care software.g. The Roam Alert Tag has a 3-year expiration date upon time of purchase)h. Members must be programmed into the [NAME]-Care software and assigned specific tags.2. DETERMINING THE NEED FOR A ROAM ALERT TAG.a. If, at any time the Staff believes a Member is a Wander Risk and needs a Roam Alert tag, the CSA, DON, RCD, or RCC will be consulted to determine if the request is appropriate.3. ISSUING A ROAM ALERT [NAME]. New Member . Review of the facility's policy titled, ELOPEMENT PREVENTION with a revision date of 1/11 (no year) revealed: GENERAL: The community recognizes that other than our designated memory care units, the entrances and exits to all other levels of care are not secure.POLICY: The purpose of this policy is to insure the assessment, identification, and supervision of at risk residents who deliberately elope and those who may wander due to a confused state. It also promotes the immediate and proper response when a resident goes missing by specifying detailed duties and requiring quarterly drill. An elopement is defined as anytime a resident is missing and not located within community's campus within 60 minutes of initial report . Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's disease with late onset, dementia, hypothyroidism, and diabetes mellitus with hyperglycemia.Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/05/25 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 4 out of 15, indicating R1 was cognitively impaired.Review of R1's Elopement Assessment noted on his care plan, revised 09/05/25, revealed R1 was at risk for wandering and elopement.Review of the facility's statement dated 09/04/25 revealed, On 8/30/25 at approximately 12:39pm, Life Enrichment Coordinator (later defined as LEL) received telephone call at the front desk from a former employee who stated she was driving by and observed a gentleman out front of the SNF/AL building wearing what appeared to a roam alert and she was worried he could be from the community. LEL (Life Enrichment Leader) immediately left out the front door and went left towards the SNF/AL (Skilled Nursing Facility/Assisted Living) and observed resident near the garages of the adjoining community. Resident continued to propel self forward while in eyesight of the employee and she was able to get him to stop in front of the main entrance of the adjoining community. She was able to redirect him back to community with encouragement and returned him to his room in SNF at approximately 12:49pm. LEL notified ED, Administrator, DON (Director of Nursing), ADON (Assistant Director of Nursing), and Nursing Station regarding incident. Community On-Call Nurse also provided notification. Staff provided 1:1 to ensure safety after return to floor until a 1:1 sitter could be obtained. The on-call provider and family were notified. The unit nurse, Registered Nurse 1 completed a skin observation, no injuries were sustained, and vital were WNL. New wander risk assessments were completed on all residents. DON onsite to provide education to staff and Administrator/HRD reviewed camera footage to determine a timeline.On 8/30/25 the state agency received an Initial/24-hour report alleging that on 8/30/25 R1 was reported to have an alleged elopement. He is safe, no injuries noted, and he has a 1:1 sitte(r). All exits were assessed by Maintenance to be in good working order. As part of the investigation, immediate education provided to all SNF team members present on the date of incident 8/30/25, all team members were re-educated via Regroup on the roam alert policy, and pager policy, they were also re-educated regarding responding to roam alerts across all service lines, 9/2/25. Immediate interventions taken to reduce the risk of elopement by the IDT (Interdisciplinary Team). At the conclusion of the investigation, it was determined that the elopement was substantiated. He was brought back to the community by the facility team members with no visible injuries. He was then assessed by the nurse and found to have no injuries. Increased supervision was put in place for 72 hours, on-call provider and family were notified.During an interview on 09/11/25 at approximately 11:16 AM, the Executive Director/Administrator confirmed that R1 did elope through the main SNF (Skilled Nursing Facility) exit located on the first floor adjacent to the elevator.During an interview on 09/11/25 at approximately 11:23 AM, the Executive Director and the Care Services Administrator (CSA), via telephone stated, The staff station computer display is in the nursing station overlooking the dining area and when the alarm system is triggered, the computer and the pager are alerted at the same time, and that a pager works throughout the whole property. She stated that they still have concerns about why Registered Nurse (RN)1 did not hear the page, since she had a pager.During an interview on 09/11/25 at approximately 12:11 PM, the Scheduler stated after speaking with R1 and sitting with him, he stated he was trying to leave behind his wife. His caregiver stated she had just left to take his wife home. He wanted to go home to be with his wife. The Scheduler confirmed that his wife had visited that day and stated her office is near the Activity Room, on the first floor, near the main exit.During an interview on 09/11/25 at approximately 12:25 PM, the Life Enrichment Leader (LEL), not LEC as stated in the 5-day report, confirmed her statement as to how she was working the Main Building front desk when she received call from an ex-employee who recognized that a resident was in a wheelchair outside the building heading toward [NAME] Pointe. She went outside and saw him in a non-motorized wheelchair about a block away from the SNF building near some garages and was able to assist him back into the SNF and to his room. She stated it was a hot and humid day with intermittent rain, but it was not raining at the time.During an interview on 09/11/25 at approximately 12:42 PM, the Care Services Administrator (CSA) confirmed the following timeline was developed from the 8/30/25 camera footage review: 12:03 pm - resident propels himself to [NAME] Staff Workroom12:03:37 - resident propels himself down the hallway12:04:18 - resident reaches the elevator lobby on the 2nd floor of SNF and goes out of frame12:04:29 - resident presses button on elevator12:04:33 - resident enters elevator12:04:51 - elevator doors close12:05:03 - elevator doors open on 1st floor12:05:07 - resident exits elevator12:05:50 - resident pushes on doors to exit the main entrance doors of SNF12:06:07 - resident fully exits SNF12:06:11 - SNF door fully closes12:11:05 - resident is fully out of camera view12:38:59 - former employee calls facility to report resident outside of SNF/AL building12:40:00 pm - LEC exits front doors of community to respond to needUpon completion of timeline investigation, it was determined that resident was unattended when he left off the SNF unit.Attempts were made to contact the eye-witness/ex-employee via telephone with no success.During a telephone interview on 09/11/25 at approximately 12:38 PM, RN1 stated that she was working on the [NAME] Unit, on the second floor and had last seen R1 in the dining room, eating lunch, with two Certified Nursing Assistants (CNA)s sitting in attendance and that she had gone on a 15-minute break to visit another nurse on the Folly Unit, also on the second floor. When asked, she stated she was not wearing her pager because she was on break. During an interview on 09/11/25 at approximately 12:54 PM, CNA1 stated that she last saw R1 shortly after 12:30 PM, sitting in his wheelchair, in front of the television, in the dining room, with other residents and that he left wandering in the hallway, near the nursing station and then came back. She stated wandering is his normal habit and is more out of curiosity than exit seeking. On 9/11/25 at approximately 12:58 PM, CNA1 stated that she was not wearing her pager at the time, because she was on break.During a telephone interview on 9/11/25 at approximately 1:06 PM, R1's spouse stated she had visited on 8/30/25 and had been informed after leaving that he had eloped, stating that she still felt he was safe in the facility. On 9/11/25 at approximately 1:36 PM, camera footage provided by the Executive Director was reviewed by this Surveyor showed R1 leaving the facility alone at 12:06 PM, wearing short pants and a short-sleeved tee-shirt, in his wheelchair. The temperature outside was 90 degrees Fahrenheit, with intermittent rain on [NAME] Island, according to Weather Channel records. The facility's Immediate Jeopardy Removal Plan included the following:Date: September 11, 2025Subject: Immediate Jeopardy Removal Team - F689Dear Survey TeamThis letter serves as our formal Immediate Jeopardy (IJ) Removal Plan in response to the identified deficiency F689 regarding resident safety and elopement prevention. Our facility takes the matter with the utmost seriousness and has implemented the following corrective actions to ensure resident safety and regulatory compliance.I. Ensuring Harm Will Not OCCUR or Reoccur: To prevent recurrence of elopement incidents, our facility has taken immediate and ongoing actions to eliminate the risk associated with unsafe wandering and elopement. These steps include the reassessment of all residents at risk, reinforcement of security measures, and staff education to ensure proper monitoring and response. All actions taken are designed to provide an accident=- environment while ensuring adequate supervision for all at-[NAME] residents.II. Date of Implementation: While all corrective actions were initiated immediately upon discovery of the deficiency, the official implementation dates for specific actions are listed below:1. August 30, 2025 - Member, [R1] was returned to his apartment and immediately assessed by the Registered Nurse (RN)1 for any injury. No injuries were identified. Skin checks were initiated for 48 hours, and no injuries were noted. The family was notified. Medical Director was notified, and provider team completed an assessment. Safety checks were completed for the Member for 72 hours. The Community implemented 1:1 sitter immediately following the event. The Pharmacy consultant completed a med review that was provided to the Medical Provider. The Administrator met with the family and updated the Member's care plan. Pending room availability and appropriateness the Community has made the recommendation to move to Memory Care Assisted Living when appropriate.2. August 30, 2025 - New elopement screening conducted for all residents by Unit Nurse.3. August 30, 2025 - Residents assessed by Unit Nurse for ambulatory status and BIMS (Behavioral Interview for Mental Status) level of 5 or below. Roam Alert tags and corresponding physician orders obtained for qualifying residents.4. August 30, 2025 - RN and C.N.A. assigned to Member [R1] were given immediate education on pager and call bell system use by the DON.5. August 30, 2025, and September 2, 2025 - DON (Director of Nursing) completed immediate reeducation to SNF staff in day of incident, 8/30/2025 and All community staff reeducated by CSA on Roam Alert and Pager Policy, 9/2/2025. Working pagers and radios verified for all staff.6. September 2, 2025 - Maintenance staff assessed all exit points to ensure they were in proper working order.7. September 2, 2025 - elopement binders updated by ADON for all service lines.8. September 2, 2025 - Maintenance increased the sound frequency on squealers from 90 decibels to 10 decibels at all SNF exit points.9. September 2, 2025 - Maintenance reviewed [NAME]-Tone monitor volumes and ordered eternal speakers to increase sound of call bells/roam alerts.10. September 3, 2025 - VP of Construction ordered Desk Top pagers that will be secured in hallways to provide additional alert of call bells/roam alerts.11. Ongoing - Upon admission, each resident will undergo elopement screening, including evaluation of ambulatory status by Unit Nurse, to then be reviewed by DON and/or ADON.12. Ongoing - Nursing staff will complete daily Roam Alert Tag audits to verify device functionality, proper placement, and skin integrity monitoring once per shift. Documentation will be maintained in the medical record and Roam Alert List.III. Identifying Those Affected or at Risk: The resident involved in the elopement incident, along with all residents assigned a Roam Alert tag, have been identified as at risk. Immediate interventions were implemented for these residents, including reassessment and reinforcement of monitoring protocols to prevent further occurrences.IV. Systematic Process Changes to Prevent Recurrence: The facility has taken the following steps to alter systemic failures and prevent adverse outcomes:1. Increased Monitoring and Audits:- CSA, DON, and/or Designee will conduct audits daily for two weeks, weekly for eight weeks, and monthly for three months or longer until 100% compliance is met to ensure Roam Alert tags are functioning and in proper use. All negative findings will be corrected immediately. Involved Team Members will be reeducated immediately.- Audit results will be reviewed in monthly Quality Assurance (QA) meetings for further recommendations.- The facility's assessment will be updated to incorporate specific Roam Alert system requirements.2. Enhanced Staff Training and Education:- All staff re-educated by DON and CA on elopement prevention policies. Including the proper use of Roam Alert tags, immediate response protocols, and the importance of timely supervision.-New hires will receive elopement training during orientation, and annual refresher training will be conducted for all staff by Administrative Nurse Staff.3. Family and Resident Engagement:-Family input will be incorporated into individualized care plans to enhance elopement prevention strategies at start of admission and will be carried out by the IDT. Through these measures, our facility is committed to maintaining resident safety, addressing all deficiencies, and ensuring ongoing compliance with federal regulations. The facility alleges compliance on 9/3/2025.