**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to provide appropriate supervision for Resident (R)1, resulting in R1 successfully eloping from the facility on 06/22/25.On 07/15/25 at 1:51 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations had caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 07/15/25 at 1:55 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility that IJ existed as of 6/22/25. The IJ was related to 42 CFR 483.25 - Free of Accident Hazards/Supervision/Devices.On 07/15/25 at 4:17 PM, the facility provided an acceptable IJ Removal Plan. On 07/15/25 at 4:17 PM, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in identifying and addressing the non-compliance. The SA is considering this as Past Non-Compliance as of 06/23/25.An Extended Survey was conducted in addition to the Complaint Survey for F689, constituting substandard quality of care.Findings Include:Review of the facility policy titled Elopement with a complete revision date of 11/01/17, states, To safely and timely redirect patients/residents to a safe environment.Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: other speech and language deficits following cerebral infarction, symptoms and signs involving cognitive functions following cerebral infarction, orthostatic hypotension, cognitive communication deficit, unsteadiness on feet, and abnormalities of gait and mobility. Review of R1's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date of 06/10/25, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated R1 had severe cognitive impairment. Further review of the MDS revealed that R1 had wandering behaviors during the assessment period.Review of Quarterly Nursing - Elopement Risk Observation dated 6/11/25, revealed R1 requires frequent redirection.Review of R1's Care Plan with revealed the following active problems, [R1] is at risk for falls R/T wondering the halls DX: decreased cognion, CVA, Seizures with a start date of 06/16/25, [R1] has displayed signs or symptoms of delirium: New or ACUTELY worsening confusion, disorderly expressions of thought, change in level of consciousness or hallucinations with a start date of 06/16/25, [R1] wanders throughout the facility and recently displayed exit seeking behavior, as evidenced by exiting facility, is a risk for 1. Elopement 2. Entering into others private space 3. Increased fall risk. Related to diagnosis of CVA. with a start date of 06/12/25.Review of R1's Progress Notes dated 06/22/25 revealed, 9:43 PM- At approximately 8:10 PM Staff left resident outside to sit on the porch; resident sat in rocking chair. After a few minutes staff seen resident get up and walk across the lawn to stand on the sidewalk. CNA reported to this nurse that resident was outside on the sidewalk walking, this nurse and other staff immediately went outside to assist resident back into the building. Resident was easily redirected and was brought back in the facility. NP did a skin assessment NAD. Upon speaking with resident NP had concerns regarding resident mental status, flat facial affect NP noted resident began staring blankly at her, hands trembling, body shaking. NP sent resident out for a psych evaluation. Resident left facility via stretcher at 9:35 PM DON aware. Resident's brother made aware of resident's transfer to TRMC for psych eval.Review of R1's Progress Notes dated 06/22/25 at 3:00 PM, revealed, Progress note to clarify events of 6/22/25 after interviews and further investigation. Event: an employee exited the facility front doors after entering the code. A visitor entered the facility before the doors automatically lock down. After the visitor entered, the resident got up from his wheelchair and exited the building sitting in a rocking chair on the front porch. The witness was an alert and oriented resident. The alert resident stated R1 wheeled up to the front lobby and stated to the alert resident he was 'going home'. The alert res stated he told [R1] he shouldn't leave. The alert resident stated [R1] exited before he could stop him. The alert resident alerted staff who in turn alerted nursing staff who immediately went out of the facility to retrieve [R1]. The alert resident stated [R1] sat on the porch then got up and started walking to the front (driveway). The resident did walk down the side of the road for a short distance before staff could stop him. A nursing staff member picked up the resident in her car due to unsteady gate and risk for fall. [R1] was returned to the facility without incident. A skin assessment was completed. NP was in facility and examined the resident. Order received to transfer to ER due to resident's behavior: blank stare, flat affect, and body shaking. Returned from ER with no new orders and with 1:1 supervision.During a phone interview with Certified Nursing Assistant (CNA)1 on 07/15/25 at 11:23 AM, CNA1 revealed that she was the CNA assigned to R1 on the day of the incident. She stated that she was changing another resident when one of the nurses asked her if she had seen R1 and then told her that they were looking for him. CNA1 stated that the last time she saw R1 was in the dining room. CNA1 proceeded to drive down to Arby's and Circle K in attempts to locate R1 but didn't see him. By the time she got back to the facility, R1 had been found. She was informed that R1 was sitting at the front door with another resident prior to walking out. CNA1 further stated he did not have any injuries upon return but kept wandering around the facility, so he was sent out to the ER for a psychiatric evaluation. CNA1 concluded that she isn't sure if any alarms went off, and she is unsure if he had on a wander guard. CNA1 revealed that R1 was out of the line of sight of facility staff during the elopement.During a phone interview with Licensed Practical Nurse (LPN)1 on 07/15/25 at 11:56 AM, LPN1 revealed that between 8 and 8:30 PM, a CNA came to the desk and told her that R1 walked outside. LPN1 then had all the CNAs go room to room to look for him. LPN1 and the Nurse Practitioner (NP) went out to the front door and a witnessing resident stated that R1 walked outside to the front porch after the door was opened for a visiting family member, he sat down for a few minutes and then got up and walked across the lawn. The NP, LPN1, multiple CNAs, and another nurse walked outside to look around the building. An agency nurse and another CNA drove in their vehicles to look for him. When R1 was located by a CNA, he told the CNA that he was trying to go to Arby's. Upon return to the facility, LPN1 completed a body audit, the NP spoke with him for 20 minutes, and he was sent out for a psych eval. The entire incident happened in less than an hour. LPN1 confirmed that R1 did get out of the line of sight of staff during the elopement. During an interview with the Administrator, in the presence of the Director of Nursing (DON) on 07/15/25 at 11:43 AM, it was revealed that she learned about the elopement when the DON called and notified her. The Administrator confirmed that R1 did elope out of the line of sight of staff members. A witnessing resident saw him sitting in the front before he left. R1 had no injuries upon return. He was located around the Arby's area, which is on the same side of the facility, so it is unlikely that R1 crossed any dangerous roads. Prior to the elopement, R1 was known to be a wanderer but at the time he wasn't exit-seeking. He always walked around the building but had never tried to leave up until this point. Elopement observations are completed for all residents upon admission. Elopement drills are done monthly for different shifts, and elopement precautions are spoken about during new hire orientation. There have been no more elopements since this incident.On 07/15/25 at 4:17 PM, the facility provided an acceptable IJ Removal Plan, which included the following:Resident #1 discharged home.Director of Nursing and Administrator were reeducated on the Elopement Policy and Process on 6/23/25 by the Clinical Consultant including: Completing the elopement risk evaluation thoroughly and implementing interventions based on risk identified. Documentation of exit seeking behavior and completing elopement risk evaluation for increased exit seeking behaviors.Elopement risk Assessments were reviewed for completion and accuracy on 6/23/25 by the Director of Nursing/Designee on current residents in facility to identify residents at risk for elopement. Those residents identified at risk had interventions validated and care plan updated on 6/23/25.Licensed Nurses were reeducated on the Elopement Policy and Process and Abuse & Neglect Policy on 6/23/25 by the Director of Nursing/Designee including: Completing the elopement risk evaluation thoroughly and implementing interventions based on risk identified. Documentation of exit seeking behavior and completing elopement risk evaluation for increased exit seeking behaviorsCertified Nursing Assistants were reeducated on Elopement Policy and Process and Abuse/Neglect on 6/23/25 by the Director of Nursing/Designee on 6/23/25.Target staff not receiving this education by 6/23/25 will receive prior to their next scheduled shift.An elopement Drill was completed on 6/23/25 with facility staff.Facility Activity Report and 24hour report will be reviewed Monday - Friday in clinical morning meeting to validate elopement assessments completed. The Director of Nursing/Designee will review completed elopement assessments Monday - Friday in clinical morning meeting to validate accuracy and interventions have been implemented if necessaryAd hoc QAPI held on 6/23/25.Medical Director was notified of the Immediate Jeopardy and the contents of this plan on 6/23/25.Date of alleged compliance: AOC 6/23/2025.