**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, and staff interview, the facility failed to provide adequate supervision for 1 of 1 resident reviewed. Specifically, on 09/01/25 a demented, confused resident was found across the street, approximately 500 feet, from the nursing home facility by a citizen passing by in a car. This citizen contacted 911 emergency services, detailing that a young lady was on the ground in front of a local grocery store. On 09/04/25 at 7:45PM, the State Agency determined that the facility's noncompliance with one or more federal health, safety, and/or quality regulations had caused or was likely to cause serious harm, psychosocial harm, serious impairment or death.On 09/04/25 at 7:45 PM, the Administrator was notified that the failure to provide appropriate supervision to Resident (R)1, resulting in a successful elopement from the facility, constituted Immediate Jeopardy (IJ) at F689.On 09/04/25 at 7:45 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 09/01/25. The IJ was related to 42 CFR 483.25 - Free of Accident Hazards, Supervision, and Devices.On 09/05/25 at 2:00 PM, the facility provided an acceptable IJ Removal Plan. The survey team verified that the facility put forth due diligence in addressing this non-compliance. The SA is considering the IJ at Past Non-Compliance as of 09/02/25.An extended survey was conducted in conjunction with the Compliant Survey for non-compliance at F689, constituting substandard quality of care.Findings Include: Review of the facility policy titled Elopement with a complete revision date of 11/01/17, revealed, Policy: To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. The Facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/resident. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Alzheimer's dementia, depression, anxiety disorder, multiple falls, muscle weakness, and impaired gait and mobility. Review of R1's Quarterly Minimum Data Set (MDS) Nursing assessment dated [DATE] revealed R1 has a short-term memory problem, and her decision-making ability is moderately impaired. R1 shows little interest or pleasure in doing things and can be short-tempered. R1 was noted to wander, which placed resident at significant risk of getting to a potentially dangerous place. R1 uses a walker and has an impairment of her left upper extremity. R1 had one fall in the prior 31-180 days. R1's balance was not steady, but she was able to stabilize without human assistance. R1 is on anticoagulant therapy. Review of R1's Care Plan revealed R1 is at risk for unwanted side effects of antianxiety medication prescribed for treatment of anxiety, insomnia, behaviors associated with Alzheimer's Dementia with agitation. Further review of the Care Plan revealed on 01/21/25 it was identified the resident wanders through out the facility, on 09/19/24 she is unaware of her surroundings, very confused and unable to make decisions related to Alzheimer's Disease and she has potential for falls and injuries. Review of R1's Assessments reveals R1 had an Elopement assessment completed on 09/01/25, and she was at risk for elopement/wandering as evidenced by, Resident wanders in the facility and went out of an exit door. There were no prior Elopement assessments completed. Review of R1's Nurse's Note on 09/01/25 revealed the resident left the building at 2:36 PM, she was found by a local grocery store and was taken to the hospital by EMS (emergency medical services). Resident returned to the facility at around 5:49 PM. Body audit was conducted skin was warm and dry with no apparent issues. Resident was pleasant and calm. Lungs were clear and there were no signs and symptoms of pain or being in stress. No acute changes of condition. During an observation on 09/04/25 at an unspecified time revealed the local grocery store is located on a busy street. There were two abandoned houses that neighbor the facility doors, and across the street was a house that had demolished material in a large trash container. The local grocery store was closed due to the holiday. According to a weather report the temperature for the day of the elopement was 82 degrees Fahrenheit. During an interview on 09/04/25 at 11:22 AM, the Facility Administrator (FA) revealed the facility does not have wander guards for their residents. They have an elopement book that is kept at each nurse's station and one at the front desk. During an interview on 09/04/25 at 12:38 PM, the Minimum Data Set (MDS) Coordinator 1 revealed that they are located on D hall with the business office, supply room, social services director, classrooms, and therapy. She includes that deliveries are received at that door, and one would have to have a key and a code to open the door. The supply room has a key to open the door. The MDS Coordinator 1 stated that she was off that day, so she was informed of the incident upon her return on Tuesday. She also includes that maintenance has been working on the door, and they have received a mitigation plan about elopement. She includes that residents are always on the hall either with therapy or visiting one of the other administrative offices on the hall. MDS Coordinator 1 further stated she is not familiar with a time that the door is left open or unlocked without the alarm. She is responsible for making sure that the care plan and interventions are updated. During an interview on 09/04/25 at 1:16 PM, the Maintenance Director (MD) revealed that alarm systems are mag locks and are controlled if the fire alarm goes off, they are released. The red alarms are back up battery operated, if the door is opened by anyone the alarm will go off. Both alarms must be cut off with a key if the alarm sounds. In the evenings before the MD leaves, the MD verifies if the mag locks are locked on all halls. He checks and makes sure the red box is armed and makes sure the LED lights are red and not green and check a quick push on the door it to make sure it beeps to make sure that it is on. The MD stated shipment, and deliveries are delivered on the D hall, at least twice a month, and to keep the alarm from resetting, the staff would turn off the alarm with the key to both alarms, the mag lock and the red box. We received a delivery today and on last Thursday. The MD states that he has a set of keys, the administrator, housekeeping supervisor, and the supply staff also have keys. The MD also stated that the last day he worked was last Friday, of which he went through and checked all the doors. Friday, everything checked out fine to my knowledge. Tuesday, when he returned, he was informed that a resident had gotten out the building from D hall and they wanted him to assess the area to see if there were any defects or improvements to eliminate the threat of any resident being able to get out that area. The MD stated no one goes in and out of the door just for deliveries. The MD stated that he thinks that the mag lock malfunctioned and it could have been possible that the red box had been turned off/disabled. During an interview on 09/04/25 at 1:52 PM, Central Supply (CS) revealed that she gets deliveries every Tuesday and Thursday. The delivery person would come to D hall, would ring the bell, it rings in my office, and I go and open the door. The CS states she uses a key to the mag lock, and she must punch in a code and then open the door. The alarm will not sound due to the key being turned in the mag loc. Once the Mag lock is turned off with the key, you must go back and reset it with the key, there is no way to enter or exit without a key or code. The CS includes that no one enters through the door on D hall for any other reason. If the door is held open, then the alarm will automatically sound after about 15 seconds. The CS revealed she knows if the door is locked or not by looking for the red light on the box. That indicates that it is locked and if it is green then it is unlocked. The CS further stated she checks the door every day. The CS stated that staff on D hall and C hall, which is perpendicular to D hall, would be able to hear the alarm if it were to go off. The last day she was here was Saturday and she had checked the door to ensure that it was locked. The CS also states that residents are on the hall frequently with therapy, but she has never had to redirect residents from attempting to go out that door. During an interview on 09/04/25 at 2:00 PM Licensed Practical Nurse (LPN)1 revealed she was off the day of the elopement. LPN1 stated my understanding is one of the residents went out one of the doors. The resident went to the hospital to get checked out because she fell, she does have a history or bradycardia. LPN1 stated I know they did neuro checks, body audits after the resident came back from the emergency room (ER). When asked what her understanding was of the elopement on Monday, LPN1 stated, I understand a passerby called the ambulance because they saw her sitting. I don't believe they witnessed her falling. I think they assumed she fell because she was on the ground. We didn't receive any real records from the ER when the resident returned. It was just a form saying to follow up with her Primary Care Physician (PCP) and a list of her medications. There wasn't a note about what the ER did or found. I'm not sure how they determined the resident belonged to this facility. LPN1 further stated, I was the one who tried to notify the representative, but he is hard to get ahold of. I called him twice. I finally left a message with his assistant to let him know what had /happened and gave her my phone number for him to call if he had any questions. I plan to call him today to let him know about the discontinuation of the medication because of her low heart rate. During an interview on 09/04/25 at 2:13 PM the Facility Administrator (FA) revealed that the facility has cameras, but they do not record, the footage recycles after a 24-hour period. He also states that the local grocery store wouldn't provide them with footage, but they stated on their cameras they saw a young lady fall between 2:15 PM and 2:30 PM. The FA stated he saw the resident exit through the door on D hall from the cameras, but the time was not as accurate, so they provided an approximate time of when a nursing assistant was clocking back in from lunch to pinpoint a time. The FA stated that he was informed that the resident was sitting on the ground at a local grocery and someone from the grocery store called 911, he received the call at 2:45 PM. The FA indicated that the Emergency Medical Services (EMS) contacted the facility, of which he thinks that they assumed that it was one of their patients and called to check if in fact it was. The call was transferred to Registered Nurse (RN)1 on the skilled hall of which she notified the scheduler, and she proceeded to check for all the residents in the building. The FA stated that the MD informed him that he had worked on the door on D hall about three days prior and he left it unlocked. The FA included the MD stated that he was working on the door and he went outside but, when he came back in, he forgot to turn the alarm back on. When the resident exited out of the door on D hall, an alarm never went off, because both alarms were disconnected, the mag lock and the red alarm. The FA revealed there were staff on that hall, even though it was a holiday and two staff members had seen her in passing. The FA stated that the door would automatically shut back, so it would never be left open to identify if someone had exited the door. During an interview on 09/04/25 at 2:23 PM LPN2 revealed, The incident happened before I came in. I spoke to the Nurse Practitioner [NP] about 10:45 PM to report the elopement to her. She ordered vital signs every four hours, body audit, and 15-minute checks of the resident for 36 hours. When asked how the resident acted the evening of 09/01/25, she stated, She was great. She was walking up and down the hall. There were no changes from her norm. She was cheerful the next morning too. During an interview on 09/04/25 at 2:45 PM the Director of Nursing (DON) revealed she was called at 2:52 PM by the Unit Manager and stated that a resident had eloped. The DON stated, I was told the resident had been found by a passerby, who called 911, and the resident was taken to the hospital. I then called and reported it to our Clinical Regional Consultant. I called the Assistant Director of Nursing, and we immediately came into the facility. Before our arrival, the nursing staff had conducted a 100% check of the residents. They also checked the doors to ensure they were functional. They found that the D-Hall door was unlocked. They immediately locked it when it was found unlocked. The DON was unsure of how the hospital knew R1 was a resident at this facility. I just know that EMS called the facility to see if she was a resident here. The DON further stated, I guess they assumed she belonged to us since [local grocery store] is just down the street from here. After the incident, we spoke with everyone - housekeeping, maintenance, therapy, nursing, etc. We discovered the D-Hall door had been left unlocked. Supposedly, it was being worked on by Maintenance. I don't know if the work had been done on that day or when it was done. The D-Hall door was an exit/entrance as well as for deliveries. During an interview on 09/04/25 at 2:46 PM, the Scheduler revealed that she was walking down the hall, RN1 was on the phone with EMS. The Schedular stated that RN1 stated a resident was found across the street and she then did a check of all the doors in the building and then did a resident check. She includes she checked D hall, and it was not locked. It usually has the red light, and it was not on, when she attempted to push the door it opened, and no alarm came on. She then locked the door. The Scheduler states that she saw R1 about 1:00 PM walking up and down the hall, she typically walks up and down the hall, but she usually is not on D hall. The Scheduler concluded the resident does not have therapy, so she is not on that hall frequently. During an interview on 09/04/25 at 3:34 PM, LPN3 revealed that a little bit after 2:00 PM on 09/01/25, EMS called and asked if R1 was one of our residents. They stated they had her and they were transporting her to a local hospital; a lady had called in and stated they found her at the store across the street. LPN3 stated she then sent the Scheduler and a CNA (certified nursing assistant) to see what was going on. EMS stated they were taking her to the hospital because she was confused and asked what hospital they wanted them to take her to. LPN3 further revealed that residents don't have any identification cards or bracelets to be identified. LPN3 keeps a check on all doors, and she looks for the red-light indicator, red light on the keypad denotes that the door is locked and when you put in the code it will turn green, and it will open. LPN3 stated that she typically works the skilled nursing hall, and she had seen R1 walking around earlier that day and sometimes she must be redirected, but she is easy to redirect. On 09/05/25 at 2:00 PM the facility provided an acceptable IJ Removal Plan which included the following:Resident #1 evaluated at emergency room on 9/1/25. No injuries indicated Each Exit door was checked and secured on 9/1/25 by Manager on Duty.Resident returned to facility and placed on 15-minute checks. Physical Assessment Completed by Licensed Nurse with no injuries identified.Upon Resident return, Elopement Risk Assessment Updated to reflect current status by Licensed Nurse. Care Plan and resident profile updated on 9/1/25 by licensed Nurse.Maintenance Director was reeducated by the Administrator on 9/1/25 on validating doors are engaged and secure after any repair to door.Residents residing in the facility had an Elopement Risk Assessments updated on 9/2/25 by Director of Nursing/Designee. Residents identified as elopement risk were placed in the elopement binder and had care plans and profiles updated by Director of Nursing/Designee on 9/2/25.Facility Staff were reeducated by the Director of Nursing/Designee on Elopement Policy and Process on 9/1/25.Designated doors were set for facility staff to enter and exit the building. Any keys to disable door locks or alarms were placed with the Administrator on 9/1/25. The identified side door will remain locked and alarmed at all times.Facility Staff were reeducated by the Administrator/Designee on the use of the designated doors for entry and exit on 9/1/25.Any staff not receiving this education by 9/1/25 will receive prior to their next scheduled shift.Doors will be checked daily validating they are secure and properly functioning by Administrator/Designee for 3 months.Maintenance Director will validate exit doors are secure and functioning properly weekly. Elopement Drills will be completed with facility staff three times a month for 3 months.September: 1st shift 9/3/25, 2nd shift 9/9/25, 3rd shift 9/16/25 October: 1st shift 10/7/25, 2nd shift 10/14/25, 3rd shift 10/21/25November: l51 shift 11/4/25, 2nd shift 11/11/25, 3rd 11/18/25The Medical Director was notified of the contents of this plan on 9/2/25 and the Immediate Jeopardy on 9/4/25.Ad Hoc QAPI was held on 9/2/25.