**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, review of a police incident report, witness statements, and interviews, the facility failed to ensure that Resident (R)1 received adequate supervision to prevent a successful elopement from the facility on 06/22/25 at approximately 3:15 PM. Specifically, R1 was found by 2 Samaritans, facility staff, and law enforcement outside of the facility. Per police incident documentation, R1 was found near a wooded swamp area near the facility's parking lot. R1 was observed covered in dirt and in need of toileting care (R1's pants was saturated with urine).On 07/18/25 at 12:57 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 07/18/25 at 12:57 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 07/18/25 at 12:57 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 06/22/25. The IJ was related to 42 CFR S483.25(d) - Free of Accident Hazards/Supervision/Devices.On 07/18/25 at 4:52 PM, the facility provided an acceptable IJ Removal Plan. On 07/18/25 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 06/27/25. 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 policy titled, Elopement Prevention Procedure revealed Elopement occurs when a patient wanders, walks, runs away, escapes or otherwise leave the facility grounds/perimeter unnoticed and unsupervised and and/or prior to a scheduled discharge .Review of R1's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's disease, urinary incontinence, history of falling, muscle weakness, and anxiety disorder.Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/11/25, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicates that R1 has severe cognitive impairment. Further review of the MDS under the behavior section revealed, [R1] exhibited wandering behaviors one to three days during the look back period. Review of the functional abilities section revealed [R1] has no impairment with his upper or lower body extremities. [R1] requires substantial/maximal assistance with toileting hygiene and can walk independently from 10 - 150 feet, [R1] does not require a wheelchair.Review of R1's Elopement assessment dated [DATE], revealed the resident is at risk for elopement, continue current plan of care [R1] is on the memory care unit.Review of an Officer Report for Incident reported on 06/22/25 at 3:58 PM and occurred on 06/22/25 between 3:58 PM and 4:36 PM, revealed, On 06/22/25 at approximately 3:58 PM I received a call for service regarding a missing person located at the facility, when I arrived on scene, I discovered the following information. Observations leading up to the scene: a good Samaritan white male and a nurse were assisting an older gentleman [R1] from the wooded swamp area into the parking lot. [R1] was covered in dirt and had urinated his pants. According to dispatch [R1] had escaped/eloped the facility and was missing for a period of time. When I arrived on scene, I spoke with [R1] who was being escorted away from the swamp behind the facility. I asked [R1] how he was doing, he barely was able to speak but while stuttering and mumbling he was able to say he was okay and tried to ask how I was doing, [R1] suffers from dementia. A second good Samaritan was able to provide [R1] with a wheelchair and assist in getting him back into the facility. On the scene I met with [R1's] Resident Representative (RR) who visits [R1] two to three times a week on a normal basis. [R1's] RR stated that [R1] was seriously injured at least five times in the last six months. [R1's] RR stated that she arrived at the facility at approximately 3:15 PM and was advised that [R1] was missing from the facility. [R1's] RR stated that [R1] has dementia and has suffered from approximately five head injuries within the last six months. [R1's] RR stated that these head injuries have cause [R1] to not be able to think on his own or recall memories and only repeats words back to the speaker. [R1] RR stated that each one of instances were not explained to her by nursing staff and documented it as an unwitnessed fall.A phone interview on 07/15/25 at 12:08 PM, with R1's RR revealed that the resident was successfully able to elope from the facility on 06/22/25 around 2:30 PM or 3:00 PM. RR stated that she came to visit the resident on 06/22/25 and was unable to locate him in his room or other resident areas. RR stated that she questioned staff and they were unaware of where the resident was as well, the RR and staff began to look in other resident rooms and on other units for the resident, RR stated that when they called law enforcement to notify them that the resident was missing, staff became irate towards her but called anyways because staff were unaware of how long the resident was missing. RR stated that on 06/22/25 around 3:15 PM, it was over 90 degrees Fahrenheit outside, law enforcement arrived at the facility and they along with the nursing staff assisted the resident back into the facility. R1 was found near a wooded swamp area, was observed with swelling to his face and forehead, R1 also urinated on himself and was covered in dirt. R1 was observed in the wooded area with two non-staff members/bystanders.An observation and interview with the Unit Manager (UM) on 07/15/25 at 1:27 PM revealed that she was not working on the date the resident eloped from the facility on 06/22/25 but was notified by Licensed Practical Nurse (LPN)1 that R1 was observed in a parking lot by the facility. UM also revealed that R1 has a history of wandering/exit seeking behaviors. Interventions that are currently in place include offering the resident food/drinks, provide 1:1 supervision with R1 when he is exhibiting unsafe exit seeking behaviors, and walk with the resident to the courtyard area when he is wandering. UM finally stated that the facility does not utilize electronic monitoring devices for residents. Observation with the UM consisted of observing all exit doors on the memory care/locked unit.An observation and interview with the UM and Director of Nursing (DON) on 07/15/25 at 1:41 PM, of the Okatie Hall and exit door revealed a parking lot where the resident was found by facility staff. An interview and observation on 07/16/25 at 9:37 AM with LPN1 revealed, on 06/22/25 they were not the resident's assigned nurse but assisted with searching for R1 after it was discovered by nursing staff and R1's RR, that he was missing from the facility. R1 has a history of exit seeking behaviors which is why he is located on the memory care/lock unit and was able to safely wander the unit and courtyard areas that are fenced in. LPN1 stated that she is unsure of how the resident was able to leave the unit and make his way outside but stated that exit doors can be held for certain period (about 10 - 15 seconds) and it will open. LPN1 believes that's how R1 was able to elope. LPN1 further stated on 06/22/25 they overheard the alarm going off, a Certified Nursing Assistant (CNA) was already in the process of looking for R1 when R1's RR came to the nurse's station and stated that she was unable to find the resident as well. Observation with LPN1 consisted of walking from R1's room on the memory care/locked unit to the area where R1 was found by staff and 2 Samaritans near a wooded area. According to an Apple fitness watch the distance between the two areas was about 442 feet. LPN1 stated that the resident did not have any harm or injury when found by the facility staff and was assessed by nursing staff once returned to the building. LPN1 finally stated that on 06/22/25 around 3:30 PM it was extremely hot with temperatures above 90F degrees.An interview on 07/16/25 at 9:54 AM with LPN2 revealed on 06/22/25 they were the resident assigned nurse for the day. LPN2 stated on 06/22/25 she overheard an alarm sounding, a CNA began to look for the resident when R1's RR came to the nurses' station and notified staff that she was unable to locate the resident as well. We began to search other resident rooms (at times R1 will wander into other resident rooms and fall asleep), and resident area, when that was unsuccessful, I went to other units of the facility to alert other staff members there. LPN2 stated that she last saw the resident about 15 - 20 minutes prior to the alarm sounding off. LPN2 stated when she returned to the unit she alerted by staff that R1 was found and was assisted to the unit in a wheelchair. LPN2 stated that she spoke briefly with law enforcement that was called by R1's RR and re-assessed the resident. On 07/18/25 at 4:52 PM, the facility provided an acceptable IJ Removal Plan, which included the following:The patient was brought back in the facility and walked back on the locked unit by a staff LPN. The Medical Director was notified by the patient's assigned nurse on 6/22/2025. The patient was assessed by his assigned Licensed Nurse. The patient was also placed with a one-on-one caregiver for observation on 6/22/2025. The patient is being monitored twice a day for safe behaviors. Patient remains a one-on-one observation while he is awake. This will continue until the QA Committee has determined the patient is not exhibiting exit seeking behavior.A systematic review of all patients was completed on 66/23/2025,specifically observing for those patients who wander. All patients have the potential for wandering. 2/116 patients were found to be affected.All departments were educated on our elopement process by the DON or designee and included non-clinical departments such as food and nutritional services, laundry, housekeeping, and bookkeeping/ administrative services as well as alt clinical departments such as nursing, social services, and therapy, were also provided education on the elopement process. Education was completed by the Director of Maintenance and Administrator to include our elopement procedure, elopement drill, environmental safety checks of doors and alarms on 6/27/2025.The identified at risk patient(s) will be monitored daily for 14 days to ensure interventions are effective. After the 14 days if no further occurrences happen, the monitoring will be decreased to three times a week for 14 days. After the 14 days of monitoring three times a week, If no further elopement occurrences happen, the monitoring will decrease to once a week for one month. If no elopement episodes occur during the weekly monitoring for one month the elopement monitoring will decrease to monthly. The monthly monitoring will continue until substantial compliance is met.All findings will be reported to the QA Committee. The monitoring will continue until the QA Committee has determined substantial compliance has been achieved.A QAPI meeting was held on 6/27/2025 with the Administrator, DON, Medical Director, ADON, HIM, Business Office Manager, Life Enrichment Director, Nursing Unit Managers, Food Service Manager, Social Workers, and Licensed Nurses and Nurse Aides. The alleged event was discussed in detail processes that were implemented related to the event.The processes were put into place and compliance was achieved by 6/27/2025.