**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, facility camera footage review, weather website review, observation, and interview, the facility failed to provide adequate supervision and ensure a safe and secure environment to prevent an incident of elopement for 2 of 5 sampled residents (Resident #9 and Resident #174). Resident #9 had three elopments on 6/16/2023: one elopement at 5:01 AM when she exited the dining room door to the smoking patio and was brought back by Certified Nursing Assistant (CNA) #10, a second elopement at approximately 5:30 AM when she was found in the facility parking lot by Maintenance Personnel #1 who escorted her back inside the facility, and a third elopement at 5:56 AM when she was found outside the front gate of the facility by the Human Resources (HR) Director and Medical Records (MR) Director after Resident #9 exited the facility and walked down a service road to the front gate. The HR Director and MR Director escorted Resident #9 back inside the facility. Resident #9 eloped a fourth time on 7/26/2023 during dinner time when she exited from the exit door on the 500 hall to the service road behind the facility and was brought back by CNA #14 and Unit Manager #2. Resident #174 eloped on 2/10/2023 at approximately 6:20 PM when she unlocked the front lobby door and wheeled herself to the gate of a set of neighboring apartments. Licensed Practical Nurse (LPN) #3 received a call from one of the tenants of the apartment complex to report Resident #174 was outside the gate of the apartments. Resident #174 was escorted back to the facility by facility staff. The failure of the facility to provide adequate supervision and ensure a safe and secure enviroment to prevent incidents of elopements for Resident #9 and #174 resulted in Immediate Jeopardy (IJ). Immediate Jeopardy (IJ) is a situation in which the provider's non compliance with one or more requirments of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy for F-689 on 7/26/2023 at 3:00 PM in the Administrator's office. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective 2/10/2023 and is ongoing. The findings include: Review of the facility's policy titled, Elopement/Wandering, Unsafe Resident dated 2/1/2009, revealed, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .will identify residents who are at risk for harm because of unsafe wandering (including elopement) .will assess at-risk individuals for potentially correctible risk factors related to unsafe wandering .care plan will indicate the resident is at risk for elopement or other safety issues .Interventions to try to maintain safety will be included in the resident's care plan .document circumstances related to unsafe actions, including wandering by a resident .institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behaviors .all residents admitted to the facility will have an elopement assessment done within first 24 hours .elopement assessment will then be completed every 90 days, and interventions updated as needed .staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Post Traumatic Seizures, Schizophrenia, Anoxic Brain Damage, Abnormalities of Gait and Mobility, Muscle Weakness, and Restlessness and Agitation. Review of Resident #9's Order Summary Report on 8/2/2022 revealed .Change Wanderguard [a lightweight transmitter worn on the wrist, ankle, or wheelchair to prevent elopements] device Q 3 months and PRN every day shift every 3 month (s) starting on the 2nd for 1 day (s) for safety .Wanderguard: Check battery weekly for proper functioning. (Every week on Thursday) Detector is located in DON's office .Monitor resident with Wanderguard for risk of elopement Q shift every shift for safety . Review of the Quarterly MDS assessment dated [DATE] for Resident #9 revealed, a BIMS score of 8 which indicated moderate cognitive impairment. Resident #9 required a Wanderguard. Review of a Care Plan dated 6/2/2023 revealed, .(ASSISTIVE DEVICES) Resident needs assistive devices/enabler .wanderguard .(WANDERING) [Resident #9] is at risk for Elopement or Wandering AS EVIDENCED BY exit seeking . The interventions listed on the care plan at the time of the elopements on 6/16/2023 were as follows, .Wanderguard: check battery weekly for proper functioning Q week. Functional Wander Guard attached to resident. Make sure all staff are aware of elopement risk. Monitor resident with Wanderguard for risk of elopement Q shift . Review of Resident #9's Wandering Risk assessment dated [DATE] revealed a wandering risk assessment score of 11 (High Risk to Wander) and, .E. History of Wandering .2. Has history of wandering (past hospitalization or history from resident/family . Review of the Resident #9's Progress Notes dated 6/16/2023 revealed, .Resident was found in the parking lot heading for driveway by a maintenance personnel [Elopement #2]. She was brought into the bldg. [building]. Resident stated she was going to go catch the bus to school. Asked resident to sit down in the main DR [dining room] with the other residents. Meanwhile, when starting paperwork, another employee called and asked if we were missing a resident. At the time writer [LPN #4] thought the resident was still in DR. Checked the DR and resident was not sitting where she was a few minutes prior to call. Another resident tried to let us know she went out the DR door and through the fence to the front of the bldg. to again to check the bus [Elopement #3] .Resident was put on every 15 min [minutes] [observed by facility staff every 15 minutes] . Review of the facility's investigation dated 6/16/2023 revealed an elopement occurred at 5:45 AM (Elopement #2 occurred approximately at 5:30 AM based on interview, and Elopement #3 occurred at 5:56 AM based on review of facility camera footage). Resident #9 had exited (Elopement #2) through the dining room door at approximately 30 minutes prior to Elopement #3. Maintenance Personnel #1 saw Resident #9 walking from around the back of the facility unsupervised (Elopement #2). Resident #9 exited the building through the dining room door which led to the resident patio and smoking area and then exited through the patio gate (Elopement #3). Staff arriving at work noticed Resident #9 right outside the front gate. The facility did not include Elopement #1 (6/16/2023 at 5:01 AM) in their investigation on 6/16/2023. Review of the facility camera footage for Elopement #1 dated 6/16/2023 revealed the following: At 5:01:31 AM, Resident #9 exited the dining room door, entered onto the resident patio and smoking area, and headed toward the gate which exited the smoking area. At 5:01:50 AM, CNA #10 exited out the same dining room door to go after Resident #9. At 05:01:50 AM, Resident #9 turned around and headed back toward the dining room door. At 5:01:58 AM Resident #9 entered back into the dining room with CNA #10 behind her. Review of the facility camera footage for Elopement #3 dated 6/16/2023 revealed the following: At 5:56:43 AM, Resident #9 walked down a paved service road (the service road ran adjacent to the facility) alone at a steady speed. At 5:57:32 AM, Resident #9 walked toward the entrance gate of the facility. At 5:57:43 AM, Resident #9 was outside the entrance gate of the facility. At 5:57:46 AM, Resident #9 exited out of sight of the facility camera. The entrance gate led to a road located between two apartment complexes near the facility. Review of the Wunderground website revealed the temperature outside on 6/16/2023 from 5:00 AM to 6:00 AM was approximately 66 degrees Fahrenheit with winds at approximately 3 miles per hour. Review of the Psychiatric Progress Notes dated 6/20/2023 for Resident #9 revealed, .type of visit: Regulatory .Behavior Problem: Wandering/Exit-Seeking .needs secure facility .should be considered a high risk for elopement behaviors .a transfer to a more secure facility locked memory unit is recommended due to multiple elopement attempts .wandering and elopement behaviors need to be addressed .continue 1 on 1 supervision until a transfer to more secure facility can be achieved . Review of Resident #9's Wandering Risk Assessment with score of 11 (High Risk to Wander) dated 7/25/2023, showed .E. History of Wandering .Has history of wandering (past hospitalization or history from resident/family .has wandered within the home without leaving the grounds .has wandered within the past month . During an interview on 7/25/2023 at 8:56 AM, the MR Director stated at approximately 6:00 AM (on 6/16/2023), she arrived in a personal vehicle along with the Human Resource (HR) Director and observed Resident #9 standing close to the entrance gate with a small bag and smiling (Elopement #3). The MR Director stated she stopped the car and asked the HR Director to get Resident #9 and bring her inside. She stated she called the nurse's station to inform them Resident #9 was outside the facility. During an interview on 7/25/2023 at 9:08 AM, the Administrator stated when she arrived at the facility at approximately 8:15 AM on 6/16/2023, LPN #4 explained Resident #9 had eloped from the facility through the dining room exit door that leads into the resident patio and smoking area (Elopement #2 on 6/16/2023 at approximately 5:30 AM). Resident #9 was put on every 15 minutes checks. LPN #4 assumed the responsibility to perform the first 15 minute check. Resident #9 was sitting in the dining room in the line of sight for LPN #4 at the nurse's station. LPN #4 was filling out the incident paperwork and after turning away to make some calls, LPN #4 noticed Resident #9 had exited out the dining room door. The Administrator stated the HR Director and MR Director arrived at work and observed Resident #9 at the edge of the parking lot on the other side of the gate next to the light post. During an interview on 7/25/2023 at 9:21 AM, the HR Director stated she and the MR Director entered the parking lot and saw Resident #9 in the parking lot by a light post (Elopement #3 on 6/16/2023 sometime after 5:57 AM). The HR Director stated the MR Director told her to step out of the car and get Resident #9. The HR Director stated Resident #9 told her that she (Resident #9) was looking for the bus stop. During an interview on 7/25/2023 at 10:24 AM, LPN #5 stated she checked all Wanderguards every Thursday since April 2023, but the order was in the MAR for the nurse to sign off. She stated she went to each resident, located the Wanderguard, and checked it against the monitor. If the monitor lights were red, the Wanderguard was not working. LPN #5 then stated she took each resident to the front door to make sure the Wanderguard was working properly with the door. She stated the front door was the only door that would alarm for the Wanderguards. During an interview on 7/25/2023 at 10:54 AM, Maintenance Personnel #1 stated he was outside, seated in his car at approximately 5:30 AM (6/16/2023) when he observed Resident #9 walking in front of the car (Elopement #2). Maintenance Personnel #1 stated Resident #9 told him she was going home. Maintenance Personnel #1 stated he helped Resident #9 inside the facility and noticed upon entrance the alarm was on. Maintenance Personnel #1 stated he took Resident #9 to the nurse's station, but no one was there. Maintenance Personnel #1 found a nurse at the back of the hall passing medications. During an interview on 7/25/2023 at 10:56 AM, the DON confirmed she had previously watched the footage of Resident #9 going out of the dining room exit door and walking down the service road (Elopement #2 on 6/16/2023 at approximately 5:30 AM). The facility did not provide camera footage of Elopement #2 for Resident #9. During an observation and interview outside of the facility on 7/25/2023 at 11:59 AM, Maintenance Personnel #1 showed the surveyors the side of the building Resident #9 left from to walk to the parking lot (Elopement #2 on 6/16/2023 at approximately 5:30 AM). Maintenance Personnel #1 stated he saw Resident #9 on the left side of the parking lot where the generator and trash receptacles were stationed. Maintenance Personnel #1 stated he brought Resident #9 into the building through the front door, and the Wanderguard system alarmed. Maintenance Personnel #1 stated he took Resident #9 to the nurse's station and confirmed no other staff met him at the door when he escorted Resident #9 inside. Observations of 100-hall, 200-hall, 500-hall, 600-hall, and the main dining room exit doors on 7/25/2023 at 3:46 PM, revealed all exits had an alarm on top of the doors with a mesh stop sign in front of the doors. There was no Wanderguard system available on these exit doors to notify staff of residents attempting to exit through the doors. During an interview on 7/25/2023 at 3:46 PM, the Director of Maintenance stated the door alarm sounded for the facility exit doors when a resident pushed the door to go out. The Director of Maintenance stated that if any resident hit the door, the alarm would sound. The Director of Maintenance stated the door alarm would have to be turned off manually with a key. The Director of Maintenance stated the alarm for the front door in the main lobby would activate and alarm when any resident got close to the door. The Director of Maintenance confirmed he did not log the door checks. During an interview on 7/26/2023 at 2:52 PM, LPN #4 stated on 6/16/2023 she and CNA #10 were assigned to Resident #9. LPN #4 stated CNA #10 had got Resident #9 up for the morning, but the staff was busy that morning getting up patients and giving medications. LPN #4 stated that at approximately 5:30 AM, Resident #9 went out the front lobby door, but the alarm did not go off (Elopement #2). LPN #4 stated Maintenance Personnel #1 arrived to work early and escorted Resident #9 back into the facility. LPN #4 stated staff had Resident #9 go to her room, but she would not stay there. Resident #9 was then put in front of the nurse's station. Resident #9 moved to the main dining room but was still in sight of LPN #4. LPN #4 stated she was on the phone asking the DON what to fill out for an elopement. LPN #4 stated when she finished the phone conversation with the DON, the MR Director called on the phone and asked her if she was missing a resident. LPN #4 stated she was unaware of any residents missing. LPN #4 stated she then looked in the dining room, and Resident #9 was gone. LPN #4 stated the door from the dining room to the resident patio and smoking area was not locked. During an observation on the back hallway adjacent to the laundry room on 7/26/2023 at 3:16 PM, State Surveyor #1 opened an exterior door (the door was labeled service door and was used by staff to take trash to the dumpster), but no alarm sounded because the alarm was not set. During an interview on 7/26/2023 at 3:28 PM, the Laundry Department Director confirmed the exterior door (labeled service door) was supposed to alarm at all times. The Laundry Department Director acknowledged the door alarm for the exterior door was not set. The Laundry Department Director also confirmed the service door was not equipped with the Wanderguard system (door would not alarm when a resident with a Wanderguard exited through the door). During an interview on 7/26/2023 at 3:29 PM, the Administrator confirmed the alarm to the service door should be set at all times. During an interview on 7/27/2023 at 8:24 AM, the Administrator confirmed Resident #9 eloped from the facility through the 500 hall exit door and was found on the service road (Elopement #2 on 6/16/2023 at approximately 5:30 AM). The Administrator confirmed CNA #10 was assigned to Resident #9 on 6/16/2023. The Administrator stated CNA #10 was in another room on the 500 hall assisting a resident, and another CNA working that morning was with Resident #9's roommate performing one-to-one monitoring when Resident #9 eloped at approximately 5:30 AM. Observations on the service road on 7/27/2023 at 8:25 AM, revealed a black gate which was fastened by a latch (gate was not locked). The black gate led to a paved service road which ran adjacent to the building. The service road ran from the left side to the front of the building past a trash receptacle and a generator. During an interview on 7/27/2023 at 8:37 AM, Unit Manager #1 stated that on 7/26/2023 while he was in the office, he heard the door alarm for the exit door on the 500-hall. Unit Manager #1 stated Resident #9 had eloped but by the time he reached the 500-hall door, she had already been brought back into the facility by staff. Unit Manager #1 stated staff reported Resident #9 came out of her room, went down the hallway, pushed on the door, and exited the facility (Elopement #4). During a telephone interview on 7/27/2023 at 1:57 PM, CNA #14 stated he was assigned on the 500 hall and was in room [ROOM NUMBER] assisting a resident with their dinner along with another CNA providing one on one supervision to the roommate in the room. CNA #14 confirmed he heard the door alarm sound and left the room. CNA #14 took off the mesh stop sign on the door and opened the exit door. When CNA #14 reached Resident #9, Resident #9 had stepped off the square(square concrete flooring connected to the facility exit door) to the service road (Elopement #4). CNA #14 reached out and grabbed Resident #9's arm, and Resident #9 told him, I'm leaving. CNA #14 stated that he and Unit Manager #2 was able to assist Resident #9 back inside. CNA #14 stated there was another CNA assigned to 500 hall but unsure where the other CNA was at during the elopement. During an interview on 7/31/2023 at 10:27 AM, the Administrator stated facility camera footage kept footage for 2 weeks, but then the video taped over the existing footage, and the facility did not have camera footage over 2 weeks old. The facility did not provide any camera footage for Resident #9's Elopement #2 which occurred on 6/16/2023 at approximately 5:30 AM. During a telephone interview on 8/1/2023 at 12:01 PM, CNA #10 stated she had given Resident #9 her shower first of the group of residents she had assigned to get up or give showers on 6/16/2023. CNA #10 stated she then had Resident #9 sit in the dining room while she went back to her hall to provide care to the other residents. CNA #10 stated she told LPN #4 that she could not watch Resident #9 and give showers to the residents who needed them. CNA #10 stated the nurse was supposed to help watch the residents too. CNA #10 stated that after she finished showering another resident, she saw Resident #9 outside and brought her back inside and told the nurse she needed to watch Resident #9. CNA #10 confirmed Resident #9 had gone outside on the smoking patio by herself unattended (Elopement #1 on 6/16/2023 at 5:01 AM). CNA #10 confirmed Resident #9 had eloped again a little while later on the same day and was told staff found her in the front of the building (Elopement #3 on 6/16/2023 at 5:56 AM). CNA #10 stated Resident #9 had told her that she left the building because she needed to go to the food stamp office. During an interview on 8/1/2023 at 12:41 PM, the Director of Nursing (DON) stated she was not aware Resident #9 had another elopement (Elopement #1 on 6/16/2023 at 5:01 AM) on 6/16/2023 and if staff had made her aware, she would have put Resident #9 on 15-minute or one-to-one observations. The DON stated she expected staff to call to and let her know of any elopements, falls, deaths, or a resident leaving against medical advice (AMA). The DON stated staff could have prevented the elopements if she had known about the first elopement sooner. The DON stated 15-minute observations worked for some residents, but the staff needed to do one-to-one observation for Resident #9 (Resident #9 was placed on 15-minute checks after Elopement #2 on 6/16/2023 at approximately 5:30 AM and placed on one-to-one observation after Elopement #3 on 6/16/2023 at 5:56 AM). During an interview on 8/1/2023 at 1:43 PM, LPN #4 stated she remembered Resident #9 had only two elopements on 6/16/2023 (Elopement #2 at approximately 5:30 AM and Elopement #3 at 5:56 AM). LPN #4 stated the CNAs put residents who got up early in the morning in the dining room. LPN #4 stated she was administering medications to other residents from 5 AM to 6:30 AM, and there was no staff to observe or sit with the residents in the dining room. During a telephone interview on 8/1/2023 at 2:41 PM, the Psychiatric Nurse Practitioner (NP) stated she felt Resident #9 needed a secure unit for safety. The Psychiatric NP stated elopement risk was discussed extensively as well as not accepting residents with these behaviors. The Psychiatric NP stated elopements were a significant concern at the facility. The Psychiatric NP stated the DON tried to have Resident #9 placed at another facility but was unsuccessful. The Psychiatric NP stated Resident #9 had been placed on one-to-one observation but was taken off for the COVID outbreak. The NP stated Resident #9 should have been placed back on one-to-one observation after the outbreak. Review of the medical record revealed Resident #174 was admitted to the facility on [DATE] with diagnoses which included Dementia with Behavioral Disturbances, Schizoaffective Disorder Bipolar Type, and End Stage Renal Disease. Review of Resident #174's Order Summary Report 9/21/2022 revealed .Change Wanderguard [a lightweight transmitter worn on the wrist, ankle, or wheelchair to prevent elopements] device Q [every] 3 months and PRN [as needed] every day shift every 3 month (s) starting on the 2nd for 1 day (s) for safety .Wanderguard: Check battery weekly for proper functioning. (Every week on Thursday) Detector is located in Director of Nursing [DON's] office .Monitor resident with Wanderguard for risk of elopement Q shift every shift for safety . Review of Resident #174's Wandering Risk assessment dated [DATE] revealed Resident #174 had a wandering risk assessment score of 12, which indicated a high risk for elopement. Review of Resident #174's Psychotherapy Progress Notes dated 2/8/2023 revealed, .Having a bad day thought she had a dr [doctors] appt [appointment] and reports spending a longtime waiting to go. Mild irritability is not taking it out on others. Increased restlessness . Review of Resident #174's Quarterly MDS assessment dated [DATE] revealed Resident #174 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Resident #174 required a wheelchair for ambulation and needed supervision with setup help from staff while in her room. Continued review revealed Resident #174 required limited help with one staff member while in the wheelchair at other locations in the facility. Resident #174 was not steady but able to stabilize without staff assistance for walking. Resident #174 could wheel herself in the wheelchair manually 150 feet with supervision or touch assistance. Continued review revealed Resident #174 required a wander/elopement alarm to monitor Resident #174's movement and to alert staff. Review of an undated care plan revealed Resident #174 was care planned for wandering and elopement. The interventions listed on the care plan at the time of the elopement (2/10/2023) were as follows, .Wanderguard: check battery weekly for proper functioning Q week. Change Wanderguard device Q 3 months and PRN. Monitor resident with Wanderguard for risk of elopement Q shift. Functional Wanderguard attached to resident or resident wheelchair if resident is non-compliant with wearing her Wanderguard . Review of Resident #174's Progress Notes dated 2/10/2023 revealed .This PM at 6:20 this facility got a call notifying us that one of our residents in a W/C [wheelchair] was next door at the gate of the neighboring apts [apartments]. A code GRAY [a signal which alerts staff of an elopement] was immediately called per this writer. DON was in the facility at this time. Resident was seen on the monitor located at the nurse's station. She [Resident #174] was in the parking lot .She said she traveled to the front door, stood up from her W/C pushed the exit button and rolled out the door. She said she was going to smoke . Review of Resident #174's Wandering Risk assessment dated [DATE] revealed Resident #174 had a wandering risk assessment score of 16, which indicated a high risk for elopement. Review of the facility's investigation dated 2/10/2023 revealed the elopement happened at 6:20 PM and Resident #174 wheeled herself to the front door and stood up and pushed the exit button to let herself out of the facility. Resident #174 wheeled herself to the gate of the apartments next to the facility. A tenant of the apartment called the facility to inform them of Resident #174's whereabouts. Continued review revealed Resident #174 was alert with .periods of confusion . CNA #9 reported she was assigned to Resident #174 and recalled seeing Resident #174 in the dining room. CNA #9 was assisting another resident at the time of the elopement. LPN #3 assigned to Resident #174 received the phone call from the tenant. Continued review revealed Resident #174's Wanderguard was not working during the elopement. Review of the Wunderground website revealed the temperature outside on 2/10/2023 at 6:20 PM was approximately 47 degrees Fahrenheit with winds at approximately 15 miles per hour and wind gusts up to 28 miles per hour. During an interview on 7/25/2023 at 9:28 AM, the Medical Records (MR) Director stated she worked from 11 AM to 8 PM on 2/10/2023. One of her job duties was to answer the phone and watch the camera monitors. The MR Director stated she did not see Resident #174 leave the facility on the monitor on 2/10/2023, and she was not always seated at the monitor due to filing records. The MR Director stated she received a phone call from an unknown caller saying one of the facility's residents was in a wheelchair at the apartment complex to the right of the facility. The MR Director confirmed she did not know which door Resident #174 exited because the Wanderguard system did not alarm. The MR Director confirmed the front lobby door did not automatically open to allow exit. The MR Director stated a person or resident had to push the button on the left side wall near the front lobby door to exit the facility. The MR Director confirmed she remembered it was cold outside when she received the phone call about Resident #174 being outside the facility at the neighboring apartments. The MR Director stated that when Resident #174 was brought back to the facility after the elopement, Resident #174 was wearing a sweater, pants, and shoes but did not have a jacket on. The MR Director asked Resident #174 where she was going and the resident told her she wanted to go to the store. During an interview on 7/25/2023 at 9:44 AM, CNA #8 confirmed when Resident #174 wanted to the leave the facility, it was to go out and smoke. CNA #8 confirmed Resident #174 could stand and transfer to her wheelchair. During a telephone interview on 7/25/2023 at 9:59 AM, LPN #3 stated Resident #174 was quick and often tried to get out of the building. LPN #3 stated Resident #174 often wanted to smoke before the assigned times or just sit outside and liked to go outside through the dining room by pushing the door open to the smoking patio. LPN #3 confirmed the exit button was at the front lobby door up high, but Resident #174 could reach the button and push it if she locked her wheelchair and stood up. LPN #3 confirmed the exit button was not encased. LPN #3 stated a lady called from the apartment complex, which was a family member of one of the CNAs, informed the facility Resident #174 was outside. LPN #3 confirmed Resident #174's Wanderguard was not working at the time of the incident and was unsure if anyone had checked it. During an interview on 7/25/2023 at 10:28 AM, the Quality Assurance (QA) Nurse, who was the DON at the time of the incident, confirmed she was at the facility at the time of Resident #174's elopement. The QA Nurse heard the MR Director tell LPN #3 one of the residents was at the gate in the parking lot. The QA Nurse confirmed she did not hear the Wanderguard system alarm. The QA Nurse checked Resident #174's Wanderguard device after the elopement and found it was not working. Resident #174 told the staff after she returned to the facility that she went out the front door to smoke, realized she did not have cigarettes, and then tried to go to the store to buy some. The QA Nurse stated a person who lived at the apartment complex called the facility to inform them Resident #174 was outside. During an interview on 7/25/2023 at 10:52 AM, the Social Service Director (SSD) stated she checked the Wanderguards every Thursday and told the nurses if they worked or not. The SSD stated the nurses then charted on the MAR that the Wanderguards were checked. The SSD confirmed the nurses charted the Wanderguard checks even though they did not perform the checks themselves. During an interview on 7/25/2023 at 10:56 AM, the Director of Nursing (DON) stated she worked at the facility as a consultant to train the MDS nurse at the time of the elopement. The DON confirmed she watched video footage (dated 2/10/2023) which revealed that Resident #174 came to the front lobby in a wheelchair, stood up at the front door, pressed the exit button, and exited the building in the wheelchair (the video footage was not archived and no longer available). The DON stated Resident #174 wanted to exit the building whenever she wanted to smoke.

Based on facility policy review, facility document review, medical rcord review, observation, and interview, the facility Quality Assurance and Performance Improvement (QAPI) committee failed to reassess and monitor ongoing concerns and develop an effective QAPI program that recognized concerns related to exit seeking behavior, and failed to ensure systems and processes were in place and consistently followed by staff to prevent an elopement. Failure of the QAPI Committee to identify the root cause of an elopement, develop and implement new interventions to prevent further elopements, and ensure a safe environment for residents placed 2 of 5 sampled residents (Resident #9 and Resident #174) in Immediate Jeopardy (IJ). Resident #9, a cognitively impaired resident with known wandering and exit seeking behaviors, eloped from the facility three times on 6/16/2023 (5:01 AM, 5:30 AM, and 5:56 AM) and once on 7/26/2023 (dinner time). Resident #174, a cognitively impaired resident with known wandering and exit seeking behaviors, eloped from the facility in a wheelchair on 2/10/2023 at 6:20 PM during cold and windy weather without wearing a jacket and wheeled herself to the adjacent apartments before a tenant from the apartments called the facility to alert staff that Resident #9 was outside. This resulted in an Immediate Jeopardy (IJ). Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death. The Administrator was notified of the Immediate Jeopardy (IJ) on 7/31/2023 at 4:59 PM in the Administrator's Office. The facility was cited Immediate Jeopardy at F-865. The facility was cited at F-865 at a scope and severity of J. The Immediate Jeopardy was effective 2/10/2023 and is ongoing. The findings include: Review of the facility's policy titled, Elopement/Wandering, Unsafe Resident, dated 2/1/2009 revealed .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .Staff will institute a detailed monitoring plan, as showed for residents who are assessed to have a high risk of elopement or other unsafe behavior . Review of the facility's policy titled, Quality Assurance & Performance Improvement (QAPI) Committee dated 11/28/2017 revealed .Systematic analysis and systemic action: a. Root Cause Analysis (RCA) process is used as a structured approach to fully understand the nature of an identified problem, its cause and the implications of making changes to improve the problem. b. A process to assist in determining the RCA of an area of interest will be done by the IDT (Interdisciplinary Team)/QAPI committee members and appropriate interventions for corrective action will be implemented . Review of the facility's investigation dated 2/10/2023 revealed an elopement occurred at 6:20 PM when Resident #174 wheeled herself in a wheelchair to the front door, stood up and pushed the exit button, and exited the facility. Resident #174 wheeled herself to the gate of an apartment complex next to the facility. A tenant of the apartment complex called the facility to inform them of Resident #174's whereabouts. Continued review revealed Resident #174 was alert with .periods of confusion . CNA #9 reported she was assigned to Resident #174 and recalled seeing Resident #174 in the dining room. CNA #9 was assisting another resident at the time of the elopement. LPN #3 who assigned to Resident #174 received the phone call from the tenant that Resident #174 was outside. Continued review revealed Resident #174's Wanderguard was not working during the elopement. Refer to F-689 Review of an undated QAPI CAP (Corrective Action Plan is a step by step plan of action to be followed to ensure below par outcomes are swiftly addressed and mitigated) revealed the facility replaced Resident #174's Wanderguard after staff discovered Resident #174's Wanderguard was not working. The facility placed Resident on 15 minute observation checks (resident safety check performed in 15 minute intervals). The facility checked the Wanderguards on all residents who were on the Wanderguard program and checked the device functioning at the door. Residents on the Wanderguard program were placed on 15 minute observation checks. The facility reviewed and updated as indicated physician orders for Wanderguard program orders and care plans for all residents in the Wanderguard program. The facility reviewed and updated as indicated all Wander assessments. The facility inserviced staff on the Code Gray process (code to alert staff that a resident has eloped). The facility's QAPI committee failed to thoroughly analyze the cause of the elopement, develop and maintain interventions to prevent further elopement, and effectively monitor and reassess interventions implemented to prevent further elopement. Resident #174 was able to exit through the front door by pushing the exit button to open the door and leave the facility. This was not addressed in the facility's documented corrective action plan. Wanderguards would only alarm at the front door. None of the other exit doors of the facility were equipped with the Wanderguard system. There was no documentation in the facility's corrective action plan that any of the other doors or exits were assessed for potential elopement risks. There was no documentation in the facility's action plan of how long Resident #174 or any of the other residents would be monitored with 15 minute observation checks or the criteria the facility would use to determine a resident no longer required these safety checks. There was no documentation provided that the facility inserviced staff on identifying exit seeking behaviors or interventions to prevent elopements (Code Gray is the code called after a resident has eloped). Review of the MONTHYLY QA MEETING .JANUARY 2023 [review data from January 2023] dated 2/23/2023 revealed two sections on the sheet: Focus Areas and Report data Provided. The Focus Areas included, Reportable Investigation & [and] Elopement unsafe program. The facility failed to provide any documentation of the minutes from the meeting, and there was no documentation the QAPI committee discussed the elopement by Resident #174, any interventions to prevent further elopements, or any monitoring of interventions or residents to determine the effectiveness of the interventions. Review of the MONTHYLY QA MEETING .FEBRUARY 2023 [review data from February 2023] dated 3/30/2023 revealed two sections on the sheet: Focus Areas and Report data Provided. The facility failed to provide any documentation of the minutes from the meeting, and there was no documentation the QAPI committee discussed the elopement by Resident #174, any interventions to prevent further elopements, or any monitoring of interventions or residents to determine the effectiveness of the interventions. The facility failed to provide the documentation of QAPI meeting minutes after multiple requests by the survey team. Review of the facility's investigation dated 6/16/2023 revealed an elopement (Resident #9 eloped 3 times on 6/16/2023: Elopement #1 occurred at 5:01 AM, Elopement #2 occurred at approximately 5:30 AM, and Elopement #3 occurred at 5:56 AM) occurred at 5:45 AM. Resident #9 exited (Elopement #2) through the dining room door at approximately 30 minutes prior to Elopement #3. Maintenance Personnel #1 saw Resident #9 walking from around the back of the facility unsupervised (Elopement #2). Resident #9 exited the building through the dining room door which led to the resident patio and smoking area and then exited through the patio gate (Elopement #3). Staff arriving at work noticed Resident #9 right outside the front gate. The facility did not include Elopement #1 (6/16/2023 at 5:01 AM) in their investigation on 6/16/2023. Refer to F-689 Review of the QAPI CAP dated 6/23/2023 revealed the facility referred Resident #9 to psychiatric services and moved Resident #9 to another room to allow for one-to-one monitoring (resident safety intervention in which the resident is in continuous proximity and sight of a staff member). The facility planned to update Resident #9's elopement risk assessment and care plan. The facility tested all exit doors and alarms and found that they were all functioning properly except for the dining room door. The alarm on the dining room door was replaced, and the new alarm functioned properly. The facility installed a new latch on the gate of the resident patio/smoking area which is easy for staff to access and open but not for residents. The facility planned on installing a new latch on the facility service road gate. The facility posted a sign on the dining room door. The facility inserviced staff on the gate latches and new alarm device with keys. The facility's QAPI committee failed to thoroughly analyze the cause of the elopement, develop and maintain interventions to prevent further elopement, and effectively monitor and reassess interventions implemented to prevent further elopement. Resident #9 eloped on 6/16/2023 at 5:01 AM (Elopement #1) when she exited the building through the dining room door and across the patio toward the fence which enclosed the patio (Resident #9 walked approximately 50-60 feet from the dining room door before a staff member came through the dining room door and called Resident #9 back inside the building). The facility did not include this elopement on their investigation. The Administrator and Director of Nursing stated in interview, they were unaware Resident #9 eloped on 6/16/2023 at 5:01 AM, but surveyor observed Resident #9 exiting the building on 6/16/2023 at 5:01 AM (Elopement #1) while reviewing the facility camera footage. Resident #9 eloped on 6/16/2023 at approximately 5:30 AM (Elopement #2) when she exited the building through the dining room door, across the patio, through the latched gate on the fence, and into the facility parking lot. Maintenance Personnel #1 was seated in his car in the parking lot and saw Resident #9 in the parking lot and escorted her back inside the facility. Maintenance Personnel #1 reported that the alarm sounded when Resident #9 entered the facility, but no staff responded to the alarm. Maintenance Personnel #1 escorted Resident #9 to the nurses' station, but there was no staff present. Maintenance Personnel #1 found a nurse on the back hall passing medication, and he notified the nurse about Resident #9's elopement. There was no documentation in the facility's corrective action plan that addressed why the staff was either not able to hear the alarm when Resident #9 re-entered the building or why the staff did not respond to the alarm. There was no documentation in the facility's corrective action plan to address why staff failed to put interventions in place after the first elopement to prevent further recurrences. Resident #9 eloped on 6/16/2023 at 5:56 AM (Elopement #3) when she exited the building through the dining room door, across the patio, through the gate on the fence, and down the paved service road. Resident #9 was seen near the front gate (which exited the grounds of the facility) by the Human Resources (HR) Director and Medical Records (MR) Director who were seated in a vehicle in the parking lot. The HR Director and MR Director escorted Resident #9 back to the facility. There was no documentation in the facility's corrective action plan which addressed how Resident #9, who had already eloped twice within the last hour and was supposed to be on 15 minute observation checks (for safety), exited through the same dining room door for the third time in less than an hour and walked from the dining room door, across the patio, through the gate, down the service road, and up the drive way to the front gate without any staff in the building recognizing that Resident #9 had left. There was no documentation that any staff was aware of Resident #9 being outside of the facility (no documentation of a Code Gray called) until the MR Director called nursing staff on the phone to inform them that Resident #9 was outside at the front gate. The facility failed to provide the documentation of any QAPI meeting minutes after multiple requests by the survey team which addressed these 3 elopements. Resident #9 eloped on 7/26/2023 at approximately dinner time (exact time unknown) (Elopement #4) when she exited the building through the exit door on the 500-hall. The door alarm sounded, and staff (CNA #14 and Unit Manager #2) went outside to assist Resident #9 back to the facility. Resident #9 crossed the concrete flooring and had stepped off to the service road when the staff stopped her and escorted her back to the facility. There was no documentation provided by the facility that the QAPI committee investigated this elopement to identify the root cause or evaluate the systems and processes in place to prevent elopements. Observations of 100-hall, 200-hall, 500-hall, 600-hall, and the main dining room exit doors on 7/25/2023 at 3:46 PM, revealed all exits had an alarm on top of the doors with a mesh stop sign in front of the doors. There was no Wanderguard system available on these exit doors to notify staff of residents attempting to exit through the doors. Observations on the back hallway adjacent to the laundry room on 7/26/2023 at 3:16 PM, revealed State Surveyor #1 opened an exterior door (the door was labeled service door and was used by staff to take trash to the dumpster), but no alarm sounded because the alarm was not set. There was no documentation in the facility's corrective action plan or any documentation in the QAPI committee meeting minutes that addressed staff turning off the door alarms During an interview on 7/25/2023 at 2:12 PM, the Director of Nursing (DON) stated if a resident eloped from the facility they were automatically placed on every 15 minute observation checks. If the exit seeking behavior continued the resident was placed on one-to-one monitoring. These interventions were ongoing until the behaviors resolved. The DON confirmed the facility did not implement different interventions if the immediate interventions of Q 15 minutes checks or one-to-one monitoring worked. The DON stated she did not use other interventions initally because she did not want to run out of interventions. During an interview on 7/26/2023 at 3:28 PM, the Laundry Department Director confirmed the exterior door (labeled service door) was supposed to alarm at all times. The Laundry Department Director acknowledged the door alarm for the exterior door was not set. The Laundry Department Director also confirmed the service door was not equipped with the Wanderguard system (door would not alarm when a resident with a Wanderguard exited through the door). During an interview on 7/26/2023 at 3:29 PM, the Administrator confirmed the alarm to the service door should be set at all times. During an interview on 7/31/2023 at 2:53 PM, the Administrator stated the QAPI committee had a meeting on July 27, 2023, and the committee discussed Resident #9's elopements. The Administrator stated the notes were not complete or available at this time. After multiple requests for the QAPI committee meeting minutes, the Administrator failed to provide any QAPI meeting minutes for a meeting on July 27, 2023 or any QAPI meeting minutes which addressed any of Resident #9's four elopements. The Administrator confirmed that the front door was the only door or exit in the facility that would alarm from the Wanderguard system. The Administrator confirmed this was a system failure because the exit alarm system was not a Wanderguard system. During an interview on 8/1/2023 at 12:41 PM, the DON stated she was not aware that Resident #9 had an elopement on 6/16/2023 at 5:01 AM. The DON stated if staff had made her aware of the elopement, she would have put Resident #9 on 15-minute or one-to-one observations. The DON stated she expected staff to call to and let her know of any elopements, falls, deaths, or a resident leaving against medical advice (AMA). The DON stated staff could have prevented the elopements if she had known about the first elopement. During a telephone interview on 8/1/2023 at 2:41 PM, the Psychiatric Nurse Practitioner (NP) stated she felt Resident #9 needed a secure unit. The Psychiatric NP stated elopements were a significant concern at the facility. The Psychiatric NP stated the DON tried to have Resident #9 placed at another facility but was unsuccessful. The NP stated Resident #9 should have been placed on one-to-one observation to prevent her elopements. There was no documentation in the facility's corrective action plan or QAPI committee meeting minutes that mentioned Resident #9 being moved to a secure unit or transferred to another facility for her safety.