**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, facility investigation review, weather website review, medical record review, and interview, the facility failed to ensure a safe environment with adequate supervision to prevent elopement for 1 of 6 (Resident #5) sampled residents reviewed for elopement/wandering behaviors. The facility's failure to ensure residents were adequately supervised resulted in Immediate Jeopardy when Resident #5, who had severe cognitive impairment, exited the facility unsupervised, when a visitor entered the building through the front door of the facility and Resident #5 walked out of the door before it had closed, and was found by staff sitting on the front porch of the facility. The resident was unsupervised and out of the facility for approximately 58 minutes. The facility's failure to ensure residents that were severely cognitive impaired were adequately supervised resulted in Immediate Jeopardy. 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 to a resident. The Chief Operation Officer, Chief Nursing Officer, Regional Director of Operation and the Administrator, were notified of the Immediate Jeopardy (IJ) for F-689 on 4/24/2023, at 6:48 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and a severity of J, which is Substandard Quality of Care. The IJ existed from 2/13/2023 through 2/20/2023. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The corrective actions and monitoring plan were validated onsite by the surveyor on 4/25/2023 - 4/26/2023 through review of sign in sheets, interviews with staff and families, interview with the Administrator, review of audits, observations of plan interventions, and review of the facility QAPI meeting for 3/23/2023. The facility was cited for past noncompliance for F-689 and is not required to submit a Plan of Correction. The findings include: 1. Review of the facility's undated policy titled, ELOPEMENT AND WANDERING RESIDENTS, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .The facility is equipped with door locks/alarms to help avoid elopements .Adequate supervision will be provided to help prevent accidents or elopements . 2. Review of the medical records revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Diabetes Mellitus, Osteoarthritis, Dementia, Glaucoma, and Anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had severe cognitive impairment, required supervision with one person assist for walking, and was not a risk for elopement. Review of the nurses' note dated 2/13/2023 at 12:45 [PM], written by Licensed Practical Nurse (LPN) #1 revealed, .Resident noted by staff member sitting in chair on front porch. Resident stated a man carrying boxes in the building-opened the door for me .I just wanted to sit on the porch like I do at home. I like fresh air sometimes-I wasn't going anywhere else. Resident escorted into building . Resident was immediately assessed per nurse-0 [no] s/s [signs/symptoms] injury noted. 0 [no] complaints voiced. resident will be placed in elopement risk book . Review of Timeanddate.com website revealed the outside temperature on 2/13/2023 at 12:00 PM, was 66 degrees Fahrenheit. During a telephone interview on 4/17/2023 at 11:38 AM, Visitor #1 stated, .arrived at [the facility] .she was standing right outside the entry door .I thought she was a visitor .and I walked in and she walked out .I held the door for her .I went into the lobby and she was already outside .staff was in the office busy working .didn't look like a patient .had her normal street clothes on .I remembered letting that lady out .I didn't even think about dementia patient having to be watched closely .now that I know it .I can see that's important . During a telephone interview on 4/17/2023 at 11:51 AM, Former Business Office Manager (BOM) stated, .it was the day before my last day .she was sitting outside on the patio furniture .had cards in her hands .when you talk to her long enough you will see she isn't with it .she was sitting there by herself .it was lunch hour .there were a lot going on that day .transportation van .I think they were dropping someone off .I thought they might be dropping her off . Former BOM confirmed she went on to lunch and stated, .she had on jeans and t-shirt .don't remember seeing a jacket . During an interview on 4/18/2023 at 1:27 PM, Patient Care Liaison #1 stated, .it was 12:45 PM, .I was leaving the building .saw her through the glass .asleep in the chair .had her eyes closed .I said are you ok .she was sitting in the sun .it was one of those unseasonable warm day .she wanted to stay there . During an interview on 4/19/2023 at 12:50 PM, Nurse Practitioner (NP) #2 confirmed Resident #5 was severely cognitive impaired. NP #2 was asked was it safe for her to be outside unsupervised. NP #2 stated, No. During an interview on 4/25/2023 at 3:45 PM, the Administrator was asked is it safe for a severely cognitively impaired resident to be outside of the facility and unsupervised. The Administrator stated, No. The facility's corrective actions were validated onsite by the surveyor on 4/25/2023 and 4/26/2023 through policy review, observation, review of education, review of elopement books, sign in sheets and staff and visitor interviews conducted on all shifts. 1. On 2/13/2023 Resident #5 was assisted back into the facility. Resident #1 was present at the facility during the investigation. 2. On 2/13/2023 Resident #5 was assessed by NP #2 with no injuries. This was verified by the surveyor by interview with NP #2. 3. Beginning on 2/13/2023, staff sat at the front door, until the door code could be changed, and education provided to visitors and families. This was verified by the surveyor through medical record review and interviews with staff and family. 4. On 2/13/2023 the Responsible Party, Physician Extender and Medical Director was notified of event. This was verified by the surveyor though medical record review and interviews. 5. Beginning on 2/13/2023 all staff, including ancillary staff, received in-service training related to Elopement, and Tips For Prevention of Elopements with a complete date of 2/20/2023. The training was verified by the surveyor through review of all active staff sign-in sheets for in-services and staff interviews on all shifts. 6. On 2/13/2023, the front door that Resident #5 eloped from is locked from 7:30 PM to 6:30 AM, 7 days a week. This was verified by the surveyor through office and Administration staff interviews. 7. On 2/13/2023 Resident #5's elopement risk assessment was reassessed and revised to at risk for elopement and was placed in the elopement book. This was verified by the surveyor through review of the elopement risk assessment and elopement book. 8. On 2/13/2023 Resident #5's Care Plan was initiated to include at risk for elopement with interventions. This was verified by the surveyor through review of the Care Plan. 9. On 2/13/2023 Resident #5's Care Plan was initiated to include 1:1 activities outside. This was verified by the surveyor through review of the Care Plan and interview with the Activity Director. 10. On 2/13/2023 Resident #5 was placed in 1:1 for 24 hours, then 15 minute checks for 72 hours. This was verified by the surveyor through review of medical records and staff interviews. 11. On 2/13/2023 education was provided to the staff member that had left Resident #5 sitting on the porch unsupervised. This was verified by the surveyor through review of the education and interview with that staff member. 12. On 2/13/2023 to have the front office receptionist (assigned to monitor the front door) to ensure someone remains at the desk when stepping away from the desk, so they have a clear view of the front door. This was verified through random observations and interviews of the front office staff. 13. On 2/15/2023, the door code was changed and will be changed every 3 months. This was verified by the surveyor through interview with the Administrator. 14. New admission families were educated on not allowing anyone out the front door that was not with them and to tell other family members that would be visiting. This was verified by the surveyor through family interviews. 15. On 2/13/2023 an additional bright colored signage was added to the front door, saying not to let anyone out that is not with your family/group. This was verified by the surveyor through observations of the front door. 16. On 2/13/2023 visitors and families that came to the facility were educated and this was ongoing for everyone that entered the facility and had to be let in by staff because they didn't know the code and the code had been changed, this continued for all new visitors and families. This was verified by the surveyor through interview with the Administrator and interviews with families. 17. On 2/13/2023 all new hires were educated on elopement upon hire. This was verified by the surveyor by review of the new employee's education in-service. 18. On 2/13/20223 an elopement policy review was conducted with no necessary changes. This was verified by the surveyor through interview with the Administrator. 19. On 2/13/2023 new admissions are assessed for elopement and care plans are put in place. This was verified by the surveyor through review of the elopement assessments and Care Plans. 20. On 2/13/2023 all residents identified at risk for elopements are in the elopement book and care planned at risk. This was verified by the surveyor through review of the elopement binders, Care Plans and staff interviews. 21. Beginning on 2/13/2023 elopement drills were conducted. This was verified by the surveyor through review of the completed elopement drill sign in sheets, interviews with the Maintenance Supervisor and staff on all three shifts. 22. On 2/13/2023 the Interdisciplinary Team (IDT) spoke with the Medical Director and conducted a Adhoc, Quality Assurance and Performance Improvement (QAPI) review to discuss incident and interventions put in place and preventative measures. On 3/23/2023 the IDT met with the Medial Director for their monthly meeting of QAPI and continued to discuss the elopement risk. This was verified by the surveyor through review of the QAPI meeting minutes, sign in sheet and interview with the Medical Director and Administrator. On 2/20/2023 a monitoring plan was implemented. The corrective actions and monitoring plan were validated onsite by the surveyor on 4/25/2023 - 4/26/2023 through review of sign in sheets, interviews with staff from nursing, housekeeping, maintenance and front desk, interview with families, interviews with the Administrator, review of audits, observations of plan interventions, and review of minutes for the 3/23/2023 QAPI meeting. 23. The facility implemented the following interventions and monitoring, the Administrator or Director of Nursing will audit new hire orientation/training and current staff quarterly training education on elopement policy and procedures to include location of elopement book. Audits will be conducted monthly and reported to the QAPI committee during meeting. Any deficient practice identified will be reported to the Administrator and that employee will receive re-education or counseling regarding policy and procedure as needed. Audits will be conducted until QAPI committee determines substantial compliance. 24. The facility implemented the following interventions and monitoring, the Social Services Director or Nursing Unit Manager will audit monthly the Elopement Book daily and report any deficient practice to the QAPI committee during monthly of any deficient practice. Any deficient practice identified will be reported to the Administrator and that employee will receive re-education or counseling regarding policy and procedures as need. Audits will be conducted until QAPI committee determines substantial compliance. 25. The facility implemented the following interventions and monitoring, the MDS employee or Director of Nursing will audit the Elopement Risk Assessments and Care Plan for completion on admission and quarterly. Any deficient practice identified will be reported to the Administrator and that employee will receive re-education or counseling regarding policy and procedures as need. Audits will be conducted until QAPI committee determines substantial compliance. 26. The facility implemented the following interventions and monitoring, Administrator or Patient Care Liaison will audit signage, kiosk, front office and weekend coverage, automatic evening door locking schedule, monthly PCC robo [automated] call to contact list, new resident admission education for elopement risk needs monthly and report to the QAPI committee of any deficient practice. Any deficient practice identified will be reported to the Administrator and that employee will receive re-education or counseling regarding policy and procedures as need. Audits will be conducted until QAPI committee determines substantial compliance. 27. The facility implemented the following interventions and monitoring, Administrator or Maintenance Director will audit elopement drills and doors, to include coded doors, and report to QAPI committee of any deficient practice during monthly. Any deficient practice identified will be reported to the Administrator and that employee will receive re-education or counseling regarding policy and procedures as need. Audits will be conducted until QAPI committee determines substantial compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on weather website review, policy review, medical record review, observation, and interview, the facility failed to report incidents of elopement for 2 of 7 sampled residents (Resident #45 and #87) reviewed for wandering and elopement. The facility's failure to report incidents of elopement to the State Survey Agency resulted in Immediate Jeopardy when Resident #45, a vulnerable, severely cognitively impaired resident, exited the facility without staff knowledge or supervision and was found approximately 94.6 feet from the New Wing North exit door, standing in the parking lot on a cold January day, out of sight of the staff for approximately five to ten minutes and when Resident #87 a vulnerable, moderately cognitively impaired resident exited the facility without staff knowledge or supervision and was found leaning against the building, outside the New Wing South exit door, at approximately Midnight, out of sight of the staff for an undetermined amount of time. 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 to a resident. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager #1, and the Staff Development Coordinator were notified of the Immediate Jeopardy for F-609 on 7/21/2022 at 7:18 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-609. The facility was cited at F-609 at a scope and a severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 1/22/2022 to 7/24/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 7/24/2022 at 7:06 PM. The corrective actions were validated onsite by the surveyors on 7/24/2022 and 7/25/2022 through medical record review, review of education records, auditing tools, observations, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed .This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents .'Elopement' occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so .Appropriate reporting requirements to the State Survey agency shall be conducted . Review of the facility's undated policy titled, Incidents and Accidents, revealed .It is the policy of this facility for staff .to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident .The purpose of incident reporting can include .Meeting regulatory requirements for analysis and reporting of incidents and accidents .the following incidents/accidents require an incident/accident report .Elopement . Review of the medical record, revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Encephalopathy, Dementia, Anxiety, Depression, Epilepsy, Hypertension, and Spinal Stenosis. Review of the Incident Report dated 1/22/2022, revealed .CNA [Certified Nursing Assistant] [#1] alerted nurse that while she was putting another resident to bed she saw resident [resident] [#45] ambulating down sidewalk and standing at the corner of the parking lot where the white lines are .Staff exited the building and assisted resident back in building .Resident was placed into a wheelchair and wheeled back into the building without difficulty. 15 minuee [minute] checks iknitiated [initiated] .No Injuries observed at time of incident .oriented to person .Oriented to Place .No Injuries observed Post Incident . Review of an Alert Note dated 1/22/2022 at 1:36 PM, revealed Res [resident] [#45] was found walking at corner of parking lot nearest back door of new wing. Was re-directed back into building and 15 minute checks initiated .CNA that saw res [resident] filled out statement. Family, DON, and MD [Medical Doctor] notified .Her primary nurse witnessed her at the desk 11:50am [11:50 AM]. The panel on the wall alarm was in place and working. It takes approximately 3-4 min [minutes] for the resident to walk to the door based on poor gait. The team responded and the resident was escorted back in the facility 1200 1201 [12:00 PM 12:01 PM] . Review of Time and Date.com/weather revealed the high temperature for 1/22/2022 was 36 degrees Fahrenheit (F) and the recorded low temperature was 34 degrees F at 12:00 PM. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severely impaired cognition and exhibited wandering behaviors on 1 to 3 days of the assessment period. Observation of the New Hall North exit door on 7/20/2022 at 3:13 PM, revealed a Loud Mate Safety Alarm secured to the upper frame of the door with Velcro, with a string coming from the alarm box and secured to the upper part of the blind with a clip. The door was opened, and the alarm was activated. LPN #9 identified the location where Resident #45 was found. The Maintenance Director used a walking wheel to measure the distance from the door to the area where LPN #9 indicated Resident #45 was found. The distance measured approximately 94.6 feet. During a telephone interview on 7/20/2022 at 4:12 PM, CNA #1 was asked to describe the incident of Resident #45's elopement. CNA #1 stated, .I was walking with [Named Resident #1] to put her to bed, and I got to the room .I look up out the window and saw [Named Resident #45] standing on the sidewalk. CNA #1 was asked how far down the sidewalk she Resident #45 was. CNA #1 stated, An inch from the parking lot, I think she was by the white lines. CNA #1 was asked if the resident's exit from the building was witnessed by staff. CNA #1 stated, No ma'am, I only saw her out the window. CNA #1 was asked if the alarm sounded. CNA #1 stated, .I heard the alarm going off as I was approaching the door. CNA #1 was asked how long the resident was out of the building. CNA #1 stated, About 5 or 10 minutes . During a telephone interview on 7/22/2022 at 10:32 AM, the Social Services Director confirmed Resident #45's elopement was not reported to the State Survey agency. The Social Services Director stated, .it wasn't reportable because the tech [CNA] was with her, she was in no danger .we realize now this wasn't the case . Review of the medical record, revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Encephalopathy, Heart Failure, Prostate Cancer, and Altered Mental Status. Review of the Behavior Charting dated 5/9/2022 at 4:28 AM, revealed .recently woke up from his sleep. res [resident] [#87] is slightly confused when found .res was in bed (passed by staff who was answering another res' call light) about 15 min [minutes] before he triggered door alarm. res found standing right outside new wind [wing] south exit . Review of the Nurse Practitioner Note dated 5/9/2022 at 4:39 PM, revealed .5/9 [2022] seeing pt [patient] [Resident #87] today per [by] nursing request .pt attempted to elope facility over the weekend. pt unsure why he did it. staff states pt experiencing increased confusion . Review of the quarterly MDS dated [DATE], revealed Resident #87 had a BIMS of 9, indicating he was moderately cognitively impaired, and had no wandering behaviors. During a telephone interview on 7/21/2022 at 11:30 AM, LPN #6 was asked about the incident when Resident #87 exited the building. LPN #6 stated, .it was around late-night midnight .passed his room and noticed he wasn't there and then he was found by the techs [CNAs], just right outside the back door. I believe the alarm went off, and when we opened the door he was standing out to the side of the door. When we opened the door, the door swings out to the left, he was leaning against the right side of the building with a blanket over him . LPN #6 was asked if she saw him exit the door. LPN #6 stated, No. LPN #6 was asked if the CNA saw him exit the door. LPN #6 stated, I don't think so . During an interview on 7/21/2022 at 6:11 PM, the Administrator, DON, ADON, Unit Manager #1 and the Staff Development Coordinator were asked what the definition of elopement was. The Administrator stated, When a resident leaves the premises, from safe area to unsafe area . The Administrator was asked what defines a safe area. The Administrator stated, Inside the building. The Administrator was asked what defines an unsafe area. The Administrator stated, .if they [residents] are not accompanied with a staff member. The Administrator was asked when an elopement should be reported. The Administrator stated, When a resident leaves the premises. The Administrator was asked to define premises. The Administrator stated, The property . The Administrator confirmed the incidents of elopements for Resident #45 and #87 were not reported to the State Survey agency. Observation outside the New Hall South exit door on 7/24/2022 at 8:00 PM, revealed the Maintenance Director used a walking wheel to measure the distance from the area outside the New Hall South exit door where Resident #87 was found, to the parking lot. The distance measured approximately 61.2 feet. During an interview on 7/24/2022 at 8:14 PM, CNA #2 confirmed she had observed Resident #87 in his room approximately 10-15 minutes before hearing the exit door alarm. CNA #2 stated, I [had] just got done with rounds and throwing the trash away, when I come [came] out we heard the door [alarm] go off. I go down, seen [saw] the door close, I go and open the door and I seen [saw] him right by the bushes .he was already out the door when we went down the hallway . During an interview on 7/24/2022 at 8:40 PM, LPN #6 confirmed she had notified the DON of the elopement the morning it occurred. During an interview on 7/24/2022 at 5:31 PM, the Regional Director of Clinical Operations confirmed he was not working with this facility at the time of Resident #45's elopement and that he was not made aware of the elopement of Resident #87 at the time it occurred. Refer to F-610, F-689, F-835, and F-867. The surveyors verified the removal plan by: 1. The elopements were reported to the state agency on 7/21/2022 by the Administrator. The surveyors verified by email with the State agency. 2. Staff education was initiated on 7/21/2022 on the following: a. Policies and procedures for Elopement, Incidents/Accidents b. 15-minute (min) safety checks, 24 hours (hrs.) a day, 7 days a week c. Reporting to State Agencies no later than 2 hrs. after any reportable event. d. Safety checks every (q) 15 min for 24 hrs. times 7 days a week until new door alarms are installed. c. This plan was updated 7/24/2022 to reflect an Adhoc (impromptu) Quality Assurance Performance Improvement (QAPI) committee met on 7/24/2022 at 10:00 AM to discuss the effectiveness of the safety check plan. The team concluded continual presence with 15-minute documented checks 24 hrs. a day, 7 days a week until door alarm/mag (magnetic) locking system is installed and working properly to ensure resident safety. The surveyors reviewed the training, QAPI minutes, in-service sign-in sheets, and interviewed staff from all departments on all shifts. 3. The DON and the Administrator were educated on the reporting requirements to the State agencies regarding unusual incidents of abuse, neglect, or elopement by the Chief Nursing Officer (CNO) on 7/23/2022. The surveyors reviewed the training and interviewed the CNO, Administrator, and DON. 4. A Quality Assurance auditing tool will be implemented by 7/27/2022 to ensure compliance with this plan and will be completed daily by the Unit Manager or designee. Any changes to the schedule will be reported immediately to a Unit Manager by the scheduler or department manager to ensure no staff member works without this in-service education. Audits will be double checked by the ADON daily. The Quality Auditing Tool will be utilized until agency staff is no longer working in our building and 100 percent (%) of facility employed staff have been in-serviced. All in-service education mentioned in this plan will immediately be included in facility new hire employee orientation to ensure continued compliance. The surveyors reviewed the audits and interviewed nursing management staff and the Administrator. 5. After an unusual event of Elopement, Incident & Accident or Abuse, a thorough and complete investigation will be initiated by the Charge Nurse to include assessments of any resident involved, notification of the Physician or Nurse Practitioner, DON, ADON, or Administrator and the resident involved Responsible Party. The DON or ADON will review investigations daily for completion and compliance. The surveyors reviewed the training, in-service sign in sheets, and interviewed nursing staff on all shifts, the ADON, and the DON. 6. A written statement will be obtained from all staff working the current shift, the shift prior and the shift after an incident of elopement or allegation of abuse. Statements from all staff will be dated and signed by the employee on the day of the event. The surveyors reviewed the training, in-service sign in sheets, and interviewed staff. 7. Statements from families, visitors, and other residents will be obtained if deemed necessary and appropriate. The surveyors reviewed the training, in-service sign in sheets, and interviewed staff on all shifts, the DON, and the Administrator. 8. Statements will be turned in to the DON or Designee by the end of the shift. The surveyors reviewed the training, in-service sign in sheets, and interviewed staff, the DON, and the Administrator. 9. After an elopement or allegation of Abuse, interventions will be implemented based on a Root Cause Analysis (RCA) and will then be Care Planned by the Resident Assessment Coordinator or the DON. The surveyors reviewed the training, in-service sign in sheets, and interviewed nursing staff on all shifts, the DON, and the Administrator. 10. The Physician or Nurse Practitioner will be notified immediately after an incident of abuse or elopement and will complete a follow up assessment. The surveyors reviewed the training, in-service sign in sheets, and interviewed nursing staff on all shifts, the DON, and the Administrator. 11. Follow up discussion about any new elopement, new elopement risk incident or accident or allegation of abuse will take place in the daily morning clinical meeting, daily morning stand-up meeting, and daily afternoon stand-down meeting which will be ongoing. The surveyors reviewed the training, in-service sign in sheets, and interviewed members of the Interdisciplinary Team, the DON, and the Administrator. 12. All auditing will continue 2 times a week for 4 weeks, if substantial compliance is reached, auditing will continue weekly for 1 month and then it will be 1 time per month thereafter. This will be reviewed in QAPI monthly or PRN (as needed) if concerns are identified to re-evaluate the need to reinstate frequent monitoring. The surveyors interviewed nursing management staff, members of the QAPI team, the DON, and the Administrator. The facility's noncompliance at F-609 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job description review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure incidents of elopement, staff-to-resident abuse, and drug diversions were thoroughly investigated for 5 of 10 sampled residents (Resident #45, #87, #19, #68, and #90) reviewed for wandering/elopement behaviors and at risk for abuse. The facility's failure to thoroughly investigate incidents of elopement resulted in Immediate Jeopardy when Resident #45, a cognitively impaired resident at risk for wandering/elopement, exited the facility without staff knowledge, walked approximately 94.6 feet from the facility, and was found standing in the parking lot in the back of the facility and when Resident #87 a vulnerable, moderately cognitively impaired resident exited the facility without staff knowledge or supervision and was found leaning against the building, outside the New Wing South exit door, at approximately Midnight, out of sight of the staff for an undetermined amount of time. 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 to a resident. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager #1, and Staff Development Coordinator were notified of the Immediate Jeopardy (IJ) for F-610 on 7/21/2022 at 7:18 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 1/22/2022 through 7/24/2022. An acceptable Removal Plan for F-610, which removed the immediacy of the Jeopardy, was received on 7/25/2022 at 11:43 AM. The corrective actions were validated onsite by the surveyors on 7/25/2022 through observations, review of education records, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled, ABUSE/NEGLECT/EXPLOITATION, dated 11/2017, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect occur .Written procedures for investigation include .Identifying staff responsible for the investigation .Investigating different types of alleged violations .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation .focusing the investigation on determining if abuse, neglect, exploitation, and /or mistreatment has occurred, the extent, and cause .Providing complete and thorough documentation of the investigation . Review of the facility's undated policy titled, Quality Assurance and Performance Improvement (QAPI), revealed .Systems and reports demonstrating systematic identification, reporting, investigating, analysis, and prevention of adverse events . Review of the facility's undated DON Job Description, revealed .The Director of Nursing ('DON') is responsible for .She/he also monitors the outcomes of nursing services activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, policies and procedures, coordinating facility committees . Review of the medical record, revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Encephalopathy, Dementia, Anxiety, Depression, Epilepsy, Hypertension, and Spinal Stenosis. Review of an Elopement Evaluation dated 7/21/2021, revealed Resident #45 had a history of attempting to leave the facility without staff knowledge and expressed a desire to go home, packed her belongings to go home, or stayed near an exit door. Review of an Elopement Evaluation dated 8/13/2021, revealed Resident #45 had a history of attempting to leave the facility without staff knowledge. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment, had wandering behavior, and required supervision when walking in her room or in the hallway. Review of the Incident Report dated 1/22/2022, revealed .CNA [Certified Nursing Assistant] [#1] alerted nurse that while she was putting another resident to bed she saw resident [Resident #45] ambulating down sidewalk and standing at the corner of the parking lot where the white lines are .Staff exited the building and assisted resident back in building .Predisposing Physiological Factors .Dementia .Predisposing Situation Factors .Wandering . The Incident Report did not specify what time Resident #45 was located and returned to the facility. Review of the medical record, revealed there were no Social Service Progress Notes related to Resident #45's behavior or psychological status after the 1/22/2022 elopement. Review of the facility's investigation revealed no written statements or interviews with the staff from the shift prior to the elopement. Elopement drills and education were not provided to all staff on all shifts. Observation in the resident's room on 7/20/2022 at 9:48 AM, revealed Resident #45 was seated in her wheelchair, neatly dressed, her head bowed, and her eyes closed. During a telephone interview on 7/20/2022 at 4:12 PM, CNA #1 was asked to describe the incident of Resident #45's elopement. CNA #1 stated, .I was walking with [Named Resident #1] to put her to bed and I got to the room .I looked out the window and saw [Named Resident #45] standing on the sidewalk . CNA #1 was asked how far down the sidewalk she Resident #45 was. CNA #1 stated, An inch from the parking lot, I think she was by the white lines. CNA #1 was asked if the resident's exit from the building was witnessed by staff. CNA #1 stated, No ma'am, I only saw her out the window. CNA #1 was asked if the alarm sounded. CNA #1 stated, .I heard the alarm going off as I was approaching the door. CNA #1 was asked how long the resident was out of the building. CNA #1 stated, About 5 or 10 minutes . Review of the medical record, revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Encephalopathy, Heart Failure, Prostate Cancer, and Altered Mental Status. Review of the Behavior Charting dated 5/9/2022 at 4:28 AM, revealed .recently woke up from his sleep. res [resident] [#87] is slightly confused when found .res was in bed (passed by staff who was answering another res' call light) about 15min [15 minutes] before he triggered door alarm. res found standing right outside new wind [wing] south exit . Review of the facility's investigation revealed no written statements or interviews with the staff related to Resident #87's elopement. There was no documentation staff received education related to the elopement, and there were no Social Services Progress Notes related to Resident #87's behavior or psychological status after the elopement on 5/9/2022. Review of the quarterly MDS dated [DATE], revealed Resident #87 had a BIMS of 9, indicating he had moderate cognitive impairment. During a telephone interview on 7/21/2022 at 11:30 AM, Licensed Practical Nurse (LPN) #6 was asked about Resident #87's elopement. She stated, .he [Resident #87] was found by the techs [CNAs] .outside the back door .leaning against the right side of the building . She was asked how he was dressed. She stated, I'm not sure . She was asked if she saw him exit the facility. She stated, No. She was asked if the technician saw him exit the facility. She stated, I don't think so. She was asked if the black box door alarm was on the door frame. She stated, I'm not sure. She was asked if she had the staff write statements regarding this event. She stated, I don't remember writing a statement. She was asked if the facility provided education to staff about elopement after this occurrence. She stated, I'm not sure. Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Diabetes, Osteoarthritis, and Chronic Kidney Disease. Review of the quarterly MDS dated [DATE], revealed Resident #19 had moderately impaired cognition, had behaviors directed toward herself and others, rejected care, had wandering behaviors, and required extensive assistance from staff for her activities of daily living (ADLs). Review of an Incident Report dated 5/20/2022, revealed .An allegation of physical and verbal abuse was reported .by the floor technician .This even [event] happened 5/10/2022 or 5/11/2022 per the reporter .He [Technician] saw the aide [CNA #9] .in the common area on the unit .as [Resident #19] attempted to get up out of a common chair in the common area, the aide .stood in front of her in the hair [chair] placed both his hands on her shoulder from the front. He told her per the reporter, 'Sit your ass down' . and pushed her down in the chair with both hands. He witnessed him take her rollator from her as she attempted to stand again and stated, 'I said sit your ass down' . Review of the facility investigation revealed statements were not obtained from all staff on the unit, on the shift before the allegation of abuse or the shift after the allegation of abuse, and all staff were not educated about abuse after the alleged abuse incident. Review of the medical record, revealed Resident #68 was admitted to the facility on [DATE] with diagnoses of Dementia, Alzheimer's Disease, Depression, Diabetes, Heart Disease, and Hypertension. Review of an Incident Report dated 5/20/2022 revealed, An allegation of abuse was reported by the floor technician on 5/20/2022 .event occurred approximately on 5/10 [5/10/2022] .or 5/11/2022 in the evening hours .It was reported that the specific male aide [CNA #9] .was at the residents [resident's] door. The resident was also standing at the door from the inside of her room .the aide place [placed] his arm up in a fast abrupt manner and the physical gesture noted with the aide doing a push back at the door with his arm and closing the door abruptly with the resident at the inside of the door .he was unable to say if physical contact was made with this resident .The employee [accused] has voiced to the DON that he denies the allegations. He feels attacked because he is a male and the only male aide . Review of the quarterly MDS dated [DATE] revealed Resident #68 had severely impaired cognition, had behaviors directed toward herself and others, rejected care, had wandering behavior, and required extensive assistance from staff for her ADLs. During a telephone interview on 7/21/2022 at 9:51 AM, Floor Technician #1 was asked about his statement alleging CNA #9 was verbally and physically abusive to Resident #68 and Resident #19. He stated, .that day I was buffing the floor, and I stayed over to let it dry .[CNA #9] and I had words .[Resident #68] was trying to come out of the room and he stood in the door, he was closing the door while she was trying to open the door. He said something like, 'keep your [a**] in there,' I didn't say anything .another day, it was [Resident #19] was sitting in the day area. She tried to get up. He pushed her down and said, 'sit your [a**] down' . Review of the facility investigation revealed statements were not obtained from all staff on the unit on the shift before the allegation of abuse or the shift after the allegation of abuse, and all staff were not educated about abuse after the alleged abuse incident. During an interview on 7/20/2022 at 3:38 PM, the Administrator stated, We are .in-servicing staff beginning today . Review of the medical record, revealed Resident #90 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Chronic Kidney Disease, Anxiety Disorder, Atrial Fibrillation, and Chronic Pain. Review of the Physician Orders dated 6/23/2022, revealed .oxyCODONE [a narcotic pain medication] .Tablet 5 MG [milligrams] Give 1 tablet by mouth .every 6 hours as needed for pain . Review of the annual MDS assessment dated [DATE], revealed Resident #90 had a BIMS of 15, indicating she was cognitively intact for decision making. Review of the facility's investigation, revealed on 7/8/2022, two 30 count medication cards of Resident #90's Oxycodone 5 milligram (mg) and the corresponding narcotic sheets had been removed from the medication cart. This was discovered during the 3:00 PM-11:00 PM narcotic count. The facility failed to obtain witness statements on 7/8/2022, the day of the incident. The facility did not obtain staff member statements until 7/19/2022. During an interview on 7/19/2022 at 4:02 PM, the DON confirmed she did not obtain witness statements from the staff members on each shift after the drug diversion incident was identified. During an interview on 7/20/2022 at 7:43 AM, LPN #11 confirmed she did not write a statement on the day of the drug diversion incident. During an interview on 7/20/2022 at 11:11 AM, LPN #7 confirmed she did not write a witness statement until 7/20/2022 for the drug diversion incident. During an interview on 7/21/2022 at 7:22 PM, the Administrator was asked what constitutes a thorough investigation. She stated, Interviews, statements from involved parties to include staff, residents, family members, vendors . The Administrator was asked when an incident investigation should begin. She stated, Immediately. She was asked if the facility did a thorough investigation for the incidents of elopement, abuse, and drug diversion. She stated, .through the process of providing information to the survey team, we identified a more thorough investigation would be helpful in situations like these in providing education or additional training to the staff . During an interview on 7/22/2022 at 9:31 AM, the DON was asked if the facility completed a thorough investigation for the drug diversion. The DON stated, .we can improve . During an interview on 7/22/2022 at 3:53 PM, Agency CNA #9 was asked what training she had received in the facility related to abuse allegations or elopement. She stated, .I don't remember any training at all . During an interview on 7/22/2022 at 5:07 PM, Unit Manager #1 confirmed she did not get statements from other staff members. She only obtained a statement from agency Registered Nurse (RN) #1 related to the drug diversion incident. During a telephone interview on 7/24/2022 at 6:59 PM, CNA #11 confirmed she had worked with CNA #9. She confirmed she had not written a statement after the abuse allegation related to CNA #9. She was asked if she had received education about elopements after Resident #45's elopement in January. She stated, .no Ma'am .it's a sundowner situation or full moon. They are going to be off the map. Everybody [has] got to have their thinking caps on because something [is] going to happen. They can push those doors so quick. They will shove that door, and that door will pop open, and they get out quick. If you [are] way at the bottom of the hall and you [are] in with a patient you might not hear that alarm .they can move quicker than you think, certain ones you [have] got to watch .[Named Resident #45] [in January] she was walking with her walker and going to the bathroom on her own and push [pushed] that door open .Sometimes she would park the walker and walk without it . During a telephone interview on 7/24/2022 at 7:02 PM, LPN #8 confirmed she worked with CNA #9. She confirmed she had not been asked to write a statement after the abuse allegation related to CNA #9. During a telephone interview on 7/24/2022 at 7:17 PM, CNA #10 confirmed she worked the same shift with CNA #9. She was asked if she had written a statement after the abuse allegation related to CNA #9. She stated, No, Ma'am. During a telephone interview on 7/24/2022 at 7:32 PM, CNA #8 confirmed she was not asked to write a statement related to CNA #9's abuse allegation and did not receive any education related to abuse or elopement in January, May, or June. During a telephone interview on 7/24/2022 at 7:41 PM, LPN #10 confirmed she had worked with CNA #9 on numerous occasions. She was asked if she was asked to write a statement after the abuse allegation related to CNA #9. She stated, .no, not about that . During a telephone interview on 7/25/2022 at 10:29 AM, agency CNA #8 was asked if she had received abuse education after the abuse allegation related to CNA #9. She stated, I did not . She was asked if she had received education on elopement in May or June. She stated, .not that I recall. During a telephone interview on 7/25/2022 at 1:47 PM, CNA #6 was asked if she wrote a statement or had any education on abuse after the abuse allegation related to CNA #9. CNA #6 confirmed she didn't remember getting abuse education or writing a statement. The facility failed to provide documentation of witness statements, an investigation of the events and behaviors prior to the incidents, and failed to provide staff education based on the findings of the investigation. Refer to F-609, F-689, F-835, and F-867. The surveyors verified the removal plan by: 1. The facility will complete a risk management investigation prior to the end of the shift when any new elopement, incident & accident or allegation of abuse has been reported. This was confirmed through record review and interviews with staff and administration. 2. A written statement will be obtained from all staff working the current shift, the shift prior and the shift after an incident of elopement or allegation of abuse. Statements from all staff will be dated and signed by the employee on the day of the event. This was confirmed through interviews with staff on all shifts. 3. A root cause analysis will be documented on the risk assessment for any new elopement, incident & accident, or allegation of abuse to prevent recurrences. This was confirmed through observations, record review, and interviews with staff and administration. 4. The DON and Administrator were educated on the reporting requirements to State agencies regarding unusual incidents of abuse, neglect, or elopement by the Chief Nursing Officer (CNO) on 7/23/2022. This was confirmed through interviews with the DON, Administrator and CNO. 5. Staff education was initiated on 7/22/2022 on the policies and procedures for Elopement, Incidents & Accidents, Allegations of Abuse, and reporting to State Agencies no later than 2 hours after any reportable event. This was confirmed through record review and interviews. 6. Auditing of each new event will be reviewed by the clinical interdisciplinary team during the daily clinical start up meeting by members of the Interdisciplinary Team (IDT) team to ensure investigations are completed in a thorough and timely manner. This will be ongoing. This was confirmed through interviews with the DON, Administrator and the IDT. 7. All investigations of elopement, incidents, accidents, and allegations of abuse and suggestions will also be reviewed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. This will be ongoing. This was confirmed through interviews. 8. All auditing will continue 2 times a week for 4 weeks, if substantial compliance is reached, auditing will continue weekly for 1 month and then it will be 1 time per month thereafter. This will be reviewed in QAPI monthly or as needed. If concerns are identified, the need to reinstate frequent monitoring will be re-evaluated. The surveyors reviewed the audits. 9. Education related to what is considered/defined as a full investigation was initiated on 7/24/2022 at 10:00 AM for all staff and will continue until ALL staff confirm by signing training their understanding of their responsibility in participating in a thorough investigation. The training included: a. What type of investigation is it? Elopement, abuse, other? b. Elopement/Abuse must be reported immediately to the Administrator/DON and charted. c. Notify Administrator/DON immediately and chart/complete assessment of the resident. d. Administrator/DON must report this to the State/ appropriate reporting agency within 2 hours of the occurrence. e. Assessment of the resident and document the Medical Doctor/Nurse Practitioner were notified in the medical record. Notify Responsible party and document. f. Obtain written statement from ALL staff in facility which must include the date/time of the incident. Statements will be obtained from the shift before the incident and after the incident occurred. g. Any staff not present for this initial in-service will not work until they have been in serviced and confirm understanding by signature. This was confirmed by review of the education and interviews with staff on all shifts. The facility's noncompliance at F-610 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on weather website review, policy review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement for 2 of 7 sampled residents (Resident #45 and #87) reviewed for elopement/wandering behaviors. Resident #45, who had severely impaired cognition, was at risk for wandering, and was a fall risk, exited the facility without staff knowledge through the New Wing North exit door on a cold January day, walked approximately 94.6 feet and was found by staff standing in the parking lot for an undetermined amount of time. Resident #87, who had severely impaired cognition, was at risk for wandering, and was a fall risk, exited the facility without staff knowledge through the New Wing South exit door and was found leaning against the building outside the door, out of view of the staff. The facility's failure to ensure residents at risk for wandering/elopement behaviors were adequately supervised resulted in Immediate Jeopardy. 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 to a resident. The Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), Unit Manager #1, and the Staff Development Coordinator were notified of the Immediate Jeopardy (IJ) for F-689 on 7/21/2022 at 7:18 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and a severity of J, which is Substandard Quality of Care. The IJ existed from 1/22/2022 through 7/24/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 7/24/2022 at 7:06 PM. The corrective actions were validated onsite by the surveyors on 7/24/2022 and 7/25/2022 through policy review, observation, review of education and audit tools, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated policy titled, Incidents and Accidents, revealed .An 'incident' is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization .The following incidents/accidents require an incident/accident report but are not limited to .Elopement . Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .The facility is equipped with door locks/alarms to help avoid elopements .Staff are to be vigilant in responding to alarms in a timely manner .Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team .in order to develop a person-centered care plan .Adequate supervision will be provided to help prevent accidents or elopements .A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults .Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior .Documentation in the medical record will include findings from nursing and social service assessments, physician/family notification, care plan discussions, and consultant notes . Review of the medical record, revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Encephalopathy, Dementia, Anxiety, Depression, Epilepsy, Hypertension, and Spinal Stenosis. Review of an Elopement Evaluation dated 7/21/2021, revealed .History of or attempted leaving the facility without informing staff: Yes .Verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes . Review of an Elopement Evaluation dated 8/13/2021, revealed .Does the resident have a history of or attempted leaving the facility without informing staff .Yes . Review of a Nurses' Progress Note dated 12/19/2021, revealed .Resident observed kicking and banging on closed doors with hands .not able to be re-oriented by staff members . Review of a Social Services Note dated 1/20/2022, revealed .Annual .Reviewed .behavior .frequent crying, repeat movement, and wandering . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #45 had a Brief Interview of Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment, had wandering behavior, and required supervision when walking in her room or in the hallway. Review of an Alert Note, written by Licensed Practical Nurse (LPN) #2, on 1/22/2022 at 1:36 PM, revealed .Res [resident] [#45] was found walking at corner of parking lot nearest back door of new wing. Was re-directed back into building . The Alert Note did not specify what time Resident #45 was found. Review of the Incident Report dated 1/22/2022, revealed .CNA [Certified Nursing Assistant] [#1] alerted nurse that while she was putting another resident to bed she saw resident [Resident #45] ambulating down sidewalk and standing at the corner of the parking lot where the white lines are .Staff exited the building and assisted resident back in building .Predisposing Physiological Factors .Dementia .Predisposing Situation Factors .Wandering . The Incident Report did not specify what time Resident #45 was found. Review of the facility investigation file dated 1/22/2022, revealed a written statement from CNA #1 who saw Resident #45 outside. The statement revealed, .In the process of putting [Named Resident] to bed I [named herself] looked up and saw [Named Resident #45] out the window she was standing in the back parking lot the last time I saw her was [at] 12:00 [12:00 PM] in her room . Review of the facility investigation file dated 1/22/2022, revealed a written statement from LPN #9 who was providing care for Resident #45 the day of the elopement. The statement revealed, .I saw res [Resident #45] outside on pavement painted lined in area just past the sidewalk. Res had coat draped over her shoulders and was using walker .walking towards the cars in parking lot .last saw patient approx. [approximately] 1145 [11:45 AM]/1150 [11:50 AM] in front of nurses [nurses'] station facing activity room door .Had coat on at that time . Review of Time and Date.com/weather revealed on 1/22/2022, the high temperature for the day was 36 degrees Fahrenheit (F) and the recorded low temperature was 34 degrees F at 12:00 PM. Review of the medical record, revealed there were no Social Service Progress Notes related to Resident #45's behavior or psychological status after the 1/22/2022 elopement. Observation in the resident's room on 7/20/2022 at 9:48 AM, revealed Resident #45 was seated in her wheelchair, neatly dressed, her head was bowed, and her eyes were closed. During an interview on 7/20/2022 at 2:45 PM, LPN #9 was asked about Resident #45's elopement. She stated, I was working on New Wing, was the only nurse on that side . She confirmed she was at the Nurses' Station and did not see Resident #45 walk by the Nurses' Station. She confirmed the resident would have had to walk by the Nurses' Station to get to the New Wing North exit door. She stated, .I saw her when she was outside .she was in that back parking lot .she was on the pavement of the parking lot. She confirmed she did not see Resident #45 exit the facility. LPN #9 was asked if she heard the alarm go off. She stated, .I did not hear the alarm on the door, that wasn't going off. I was still learning the alarm system . Observation in the New Wing North Hall exit door on 7/20/2022 at 3:13 PM, with the Maintenance Director, revealed a small black Safety Alarm box attached to the frame of the New Wing North exit door with Velcro. The Alarm Box had a string attached to a pin that fit inside the box. The string was clipped on the upper part of the blind on the window of the door. The Maintenance Director demonstrated that when the door was opened, the string was stretched to the point it would pop the pin out of the alarm box, and the alarm would sound. The door also alarmed at the Nurses' Station when the door was opened. The door alarm at the Nurses' Station was not audible near the North end of New Wing. The Maintenance Director confirmed the small black Safety Alarm box could easily be removed by anyone in the facility, it was not a good alarm system, and the facility had discussed replacing it with a Magnetic Lock. The Maintenance Director used a walking wheel, beginning at the new Wing North exit door and walked down the sidewalk where LPN #9 indicated she found Resident #45 after the resident eloped. The Maintenance Director confirmed the distance measured was approximately 94.6 feet from the threshold of the New Wing North exit door to the point where Resident #45 was found. During a telephone interview on 7/20/2022 at 4:12 PM, CNA #1 was asked about Resident #45's elopement. CNA #1 stated, .I was walking with [Named Resident #1] to put her to bed, and I got to the room before she did .was pulling back her bed .look up out the window and saw [Named Resident #45] standing on the sidewalk .I think she was by the white lines . She confirmed she did not see Resident #45 exit the facility and stated, .I only saw her out the window . She was asked when she had last seen Resident #45 before she saw her outside. CNA #1 stated, .she was in her room, right after lunch . CNA #1 was asked if she heard the alarm sound in the room where she was. She stated, .No, I just saw her out the window .ran out of the room and yelled [Named Resident #45] is out the door . She was asked how long the resident was outside. She stated, .5 or 10 minutes . Review of the medical record, revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Encephalopathy, Heart Failure, Prostate Cancer, and Altered Mental Status. Review of the admission MDS dated [DATE], revealed Resident #87 had a BIMS of 3, which indicated severe cognitive impairment and required staff assistance for activities of daily living. Review of the Care Plan dated 10/31/2021 revealed .At risk for elopement related to .Wandering .10/13/2021 .The resident speaks of leaving the facility .10/19/2021 .talking about leaving the facility wanting a beer/placing hat/shoes on to walk to the store/walker . Review of the Behavior Charting dated 5/9/2022 at 4:28 AM, revealed .recently woke up from his sleep. res [resident] [#87] is slightly confused when found .res was in bed (passed by staff who was answering another res' call light) about 15min [15 minutes] before he triggered door alarm. res found standing right outside new wind [wing] south exit . Review of the Nurse Practitioner Note dated 5/9/2022 at 4:39 PM, revealed .5/9 [2022] seeing pt [patient] today per [by] nursing request .pt attempted to elope facility over the weekend. pt unsure why he did it. staff states pt experiencing increased confusion . Review of the medical record, revealed there were no Social Service Progress Notes related to Resident #87's behavior or psychological status after the elopement on 5/9/2022. During an interview on 7/20/2022 at 1:57 PM, the DON and the Administrator confirmed they did not think the elopement incidents on 1/22/2022 and 5/9/2022 were elopements because the residents did not leave the premises. During a telephone interview on 7/21/2022 at 11:30 AM, LPN #6 was asked about the incident when Resident #87 got outside the building. LPN #6 stated, .passed his room and noticed he wasn't there and then he was found by the techs [CNAs], just right outside the back door .I believe the alarm went off, and when we opened the door he was standing out to the side of the door. When we opened the door, the door swings out to the left, he was leaning against the right side of the building with a blanket over him . LPN #6 was asked if she saw him exit the door. LPN #6 stated, No. LPN #6 was asked if the tech saw him exit the door. LPN #6 stated, I don't think so .When we were looking for him we found him .then the alarm went off. We knew what door, we thought maybe its [Named Resident #87]. During an interview on 7/21/2022 at 6:11 PM, the Administrator confirmed an elopement is when a resident leaves the premises, or from a safe area to an unsafe area. The Administrator was asked if the premises outside the facility was safe. She stated, No, it's not. The Administrator was asked to define an unsafe area. She stated, If they are not accompanied by a staff member. The Administrator was asked if the alarm system was effective. The Administrator confirmed that, with the current alarm system, the door still opens immediately, and there is no delay in the door opening. She stated, .we feel the 15 second delay would enhance the ability to prevent actual elopement .it was determined in January that we would look into purchasing a system such as the Magnetic Locking System .it was discussed with Corporate who agreed this would be a helpful device . During a telephone interview on 7/22/2022 at 10:32 AM, the Social Services Director was asked to describe her role when a resident elopes. The Social Services Director stated, .If I feel like they are an elopement [risk], do a risk assessment, with a face sheet put all that information in the green book, let the nurses and staff know they are in the book for elopement risk .I document at least twice after an elopement . She was asked if she documented psychological or behavioral notes after Resident #45's elopement. The Social Services Director stated, I don't know if I wrote a note or not. The Social Services Director confirmed she had not documented psychological or behavioral notes after Resident #45's and Resident #87's elopement. During an interview on 7/22/2022 at 2:36 PM, the Administrator was asked if the facility should know where the residents are, when they exit the facility, and where they go. She stated, Yes. The Administrator was asked who was ultimately responsible for the safety and welfare of the residents. She stated, Everybody, all departments and every employee. Observation outside the New Hall South Exit Door on 7/24/2022 at 8:00 PM, revealed the Maintenance Director measured the distance from the area where Resident #87 was found to the parking lot. The distance measured using a walking wheel was approximately 61.2 feet from the parking lot. During an interview on 7/24/2022 at 8:14 PM, CNA #2 confirmed she had observed Resident #87 in his room approximately 10-15 minutes before hearing the exit door alarm. CNA #2 confirmed she was in the biohazard room with the door closed and did not hear the alarm until she exited the biohazard room and stated, I [had] just got done with rounds and throwing the trash away, when I come [came] out, we heard the door [alarm] go off. I go down .I go and open the door, and I seen [saw] him [Resident #87] right by the bushes .he was already out the door when we went down the hallway . During an interview on 7/25/2022 at 3:20 PM, the Maintenance Director was asked if he inspected the exit doors after each elopement. The Maintenance Director stated, .Not every door . The surveyors verified the removal plan by: 1. Staff education was initiated on 7/22/2022 on the following: a. Policies and procedures for Elopement, Incidents and Accidents, Allegations of Abuse, every 15-minute safety checks (24 hours/day, 7 days/week), b. Reporting to State Agencies no later than 2 hours after any reportable event. c. Safety checks every 15 minutes, 24 hours/day, 7 days/week, until new door alarms are installed and working properly. This was confirmed through review of the in-service sheets, in-service sign-in sheets, observation of the safety checks of the exit doors and residents, and interviews with staff on all shifts. 2. On 7/21/2022, a new Elopement Risk Assessment was completed on 100 percent (%) of the residents for risk and any resident found to score 4 or higher on Elopement Assessments had interventions implemented to prevent elopement from occurring. This was confirmed through review of the resident Elopement Risk Assessments and interviews. 3. On 7/22/2022, the facility initiated staff education on conducting risk assessments, recognizing if resident exhibits intention to leave, e.g. exit seeking, wandering, packing belongings, verbalizing the want to leave, reporting, and intervening to prevent elopement. This was confirmed through review of in-services and in-service sign-In sheets, and interviews with staff on all shifts. 4. Education was initiated for all staff on 7/22/2022, regarding the elopement book, Elopement Policy Procedures, Incidents & accidents. This was confirmed through review of the elopement book, review of in-services and in-service sign-In sheets, and interviews with staff on all shifts. 5. All previously mentioned education will be provided for any staff returning to work after being off or on leave prior to working their first shift back to work. This was confirmed through interview with the Staffing Development Coordinator and DON. 6. Staff education was initiated on 7/22/2022, on the following: a. Policies and procedures for Elopement, Incidents & Accidents, Allegations of Abuse 15-minute safety checks, 24 hours/day, 7 days/week b. Reporting to State Agencies no later than 2 hours after any reportable event. c. Safety checks every 15 minutes, 24 hours/day, 7 days/week, until new door alarms are installed and working properly. d. An Adhoc (Impromptu) Quality Assurance Performance Improvement (QAPI) committee met on 7/24/2022 at 10:00 AM to discuss the effectiveness of the safety check plan. The Team concluded continual presence with 15-minute documented checks, 24 hours/day, 7 days/week, until door alarm/magnetic locking system is installed and working properly will be most effective to ensure resident safety. This was confirmed through observation of the 15-minute safety checks and staff interviews. 7. All new admissions, readmission, residents exhibiting exit seeking behavior or expressing a desire to leave will have a Risk Assessment completed and needed interventions will be implemented and care planned. This was confirmed through medical record review and interview with the DON and Staff Development Coordinator. 8. DON or designee will audit records of all new admissions, readmissions, and residents exhibiting exit seeking behavior to verify all needed assessments have been completed and appropriate interventions implemented. This was confirmed through interview with the DON and the Administrator. 9. A Quality Assurance (QA) auditing tool will be implemented by 7/27/2022, to ensure compliance with this plan and will be completed daily by the Unit Manager or designee. Any changes to the schedule will be reported immediately to a Unit Manager by the scheduler or department manager to ensure no staff member works without receiving this in-service education. Audits will be double checked by the ADON daily. The Quality Auditing Tool will be utilized until agency staff is no longer working in the facility and 100% of facility employed staff have been in-serviced. All in-service education mentioned in this plan will immediately be included in facility new hire employee orientation to ensure continued compliance. This was confirmed through interviews with the DON, ADON, Staff Development Coordinator, and Administrator. 10. All investigations of elopement, incidents & accidents, allegations of abuse, and suggestions will be reported, reviewed, and discussed at the monthly QAPI meeting. This was confirmed through interview with the DON and Administrator. 11. Auditing tools will be implemented by 7/27/2022, to ensure compliance with this plan and will be monitored daily by the nursing Unit Managers and double checked for compliance by the ADON. This was confirmed through interviews with the ADON and the DON. 12. The DON and Administrator will audit daily for overall compliance of this plan. This was confirmed through interview with the DON and the Administrator. 13. All auditing will continue 2 times a week for 4 weeks. If substantial compliance is reached, auditing will continue weekly for 1 month, and then it will be 1 time a month thereafter. This will be reviewed in QAPI monthly or as needed. If concerns are identified, will re-evaluate the need to reinstate frequent monitoring. This was confirmed through interviews with the Administrator and the DON. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, Board of Examiners for Nursing Home Administrators (BENHA) review, job description review, and interview, the facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well-being of cognitively impaired residents with wandering behaviors. Administration failed to provide oversight to monitor and provide a safe resident environment for cognitively impaired residents with wandering behaviors, to report, and investigate incidents of elopement. These failures resulted in Immediate Jeopardy when Resident #45, a severely cognitively impaired resident with exit-seeking behaviors, exited the building without staff knowledge or supervision and was found approximately 94.6 feet from an exit door, standing in the parking lot on a cold January day, out of staff sight for five to ten minutes and when Resident #87, a moderately cognitively impaired resident exited the facility without staff knowledge or supervision and was found leaning against the building, outside an exit door at approximately midnight, out of sight of the staff for an undetermined amount of time. 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 to a resident. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager #1, and Staff Development Coordinator, were notified of the Immediate Jeopardy at F-609, F-610, and F-689 on 7/21/2022 at 7:18 PM, in the Conference Room. The Administrator and DON, were notified of the Immediate Jeopardy for F-835 and F-867 on 7/22/2022 at 6:20 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-609, F-610, F-689, F-835, and F-867. The facility was cited at F-609, F-610, and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 1/22/2022 through 7/24/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 7/25/2022 at 1:20 PM. The corrective actions were validated onsite by the surveyors on 7/25/2022 through observations, review of education records, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated Chief Executive Officer (CEO) (Administrator) Job Description, revealed .The CEO is responsible for the day to day operations and direction of the facility, and ensures that the facility complies with all policies and procedures set forth by the company, as well as those required by regulatory agencies. Also ensures that expectations of the corporation and our customers are met or exceeded on a continual basis .Ensures that the facility complies with all policies and procedures set forth by THE COMPANY, regulatory agencies, and other appropriate bodies .Ensures the provision of quality of services through the design and implementation of facility wide quality assurance and program evaluation plans .Ensures quality care .Demonstrates effective management/leadership skills .Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures .that are necessary for providing quality care and maintaining a sound operation .Must be able to communicate .regulations .to personnel .Makes decisions in a timely manner . Review of the BENHA form revealed the Administrator was hired 1/3/2020. Review of the facility's undated DON Job Description, revealed .The Director of Nursing ('DON') is responsible for effective overall management of the Nursing department and coordination with other disciplines to provide quality care to all patients/residents. She/he supports and practices the philosophy, objectives and standards of the Department of Nursing and participates in the revision of these as necessary to ensure quality care to all patients/residents. She/he also monitors the outcomes of nursing services activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, policies and procedures, coordinating facility committees .Ensure that nursing interventions meet the personal, physical, and cognitive needs of each patient/resident .Assumes full responsibility for the operation and management of the facility in the temporary absence of the Facility Administrator or as directed by the Administrator .Participates in the selection of patients/residents to be admitted by evaluating the level and amount of care required by prospective patients/residents in relation to exiting nursing capabilities .Meets with committee members to evaluate activities within the facility and to identify opportunities for continuous improvement in nursing operations . Review of the facility's undated policy titled, Quality Assurance and Performance Improvement (QAPI), revealed .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life . Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed .This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents .'Elopement' occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary .The administrator or designee should also notify the company's corporate office .Appropriate reporting requirements to the State Survey agency shall be conducted .A social services designee will re-assess the resident and make any referrals for counseling .Staff may be educated on the reason for elopement and possible strategies for avoiding such behavior . Review of the facility's undated policy titled, Incidents and Accidents, revealed .It is the policy of this facility for staff .to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident .The purpose of incident reporting can include .Meeting regulatory requirements for analysis and reporting of incidents and accidents .the following incidents/accidents require an incident/accident report .Elopement . Observation of the New Hall North exit door on 7/20/2022 at 3:13 PM, revealed the Maintenance Director used a walking wheel to measure the distance from the door to the area where Resident #45 was found. The distance measured approximately 94.6 feet. During a telephone interview on 7/20/2022 at 4:12 PM, Certified Nursing Assistant (CNA) #1 was asked to describe Resident #45's elopement. CNA #1 stated, .I was walking with [Named Resident #1] to put her to bed and I got to the room .I looked out the window and saw [Named Resident #45] standing on the sidewalk . CNA #1 was asked how far down the sidewalk was Resident #45. CNA #1 stated, An inch from the parking lot, I think she was by the white lines. CNA #1 was asked if she saw her exit the building. CNA #1 stated, No ma'am, I only saw her out the window . CNA #1 was asked if she heard the alarm sound. CNA #1 stated, .I heard the alarm going off as I was approaching the door. CNA #1 was asked how long the resident was out of the building. CNA #1 stated, About 5 or 10 minutes . During a telephone interview on 7/21/2022 at 11:30 AM, Licensed Practical Nurse (LPN) #6 was asked about the incident when Resident #87 was found outside the building. LPN #6 stated, .passed his room and noticed he wasn't there and then he was found by the techs [CNAs], just right outside the back door .I believe the alarm went off, and when we opened the door he was standing out to the side of the door. When we opened the door, the door swings out to the left, he was leaning against the right side of the building with a blanket over him . LPN #6 was asked if she saw him exit the door. LPN #6 stated, No. LPN #6 was asked if the CNA saw him exit the door. LPN #6 stated, I don't think so . Observation outside the New Hall South Exit Door on 7/24/2022 at 8:00 PM, revealed the Maintenance Supervisor used a walking wheel to measure the distance from the New Hall South Exit Door where Resident #87 was found to the parking lot. The distance measured approximately 61.2 feet. During an interview on 7/21/2022 at 2:30 PM, the Administrator and the Maintenance Director confirmed elopement drills should be conducted yearly and after an incident of elopement. The Administrator confirmed the last elopement drill was conducted 1/31/2022 and no elopement drills were conducted after Resident #87 eloped. During an interview on 7/21/2022 at 2:47 PM, the Staff Development Coordinator confirmed no in-services related to elopement were provided after Resident #87 eloped. During an interview on 7/21/2022 at 6:11 PM, the Administrator, DON, ADON, Unit Manager #1 and Staff Development Coordinator were asked to define elopement. The Administrator stated, When a resident leaves the premises, from safe area to unsafe area . The Administrator was asked what was considered a safe area. The Administrator stated, Inside the building. The Administrator was asked what an unsafe area was. The Administrator stated, .if they [residents] are not accompanied with a staff member. The Administrator was asked when an elopement should be reported. The Administrator stated, When a resident leaves the premises. The Administrator was asked to define premises. The Administrator stated, The property . When asked to define a thorough investigation, the Administrator stated, Interviewing and receiving statements from involved parties meaning staff members, residents, family members or vendors when applicable. The Administrator was asked when the investigation should be started after an incident. The Administrator stated, Immediately. The Administrator was asked how many elopement drills had been conducted in the facility since January, and the DON responded, I count 3 .Inside .the elopements you see a QA [Quality Assurance] tool in the investigation. We treat it like a drill . The Administrator stated, The actual elopement drill was conducted January 31, 2022 .an in-service was completed 1/22/2022 . The Administrator and DON were asked when an elopement drill should be conducted. The DON stated, An elopement drill should be conducted when a resident elopes. The Administrator stated, Yearly and as needed . The DON stated, We did a head count which is part of an elopement drill . The Administrator was asked when it was determined the facility needed a magnetic locking system and why one was necessary. The Administrator stated, .we feel the 15 second delay would enhance the ability to prevent actual elopement .it was determined in January 2022 that we would look into purchasing a system .it was discussed with corporate office who agreed this would be a helpful device, and are in support of purchasing and placement . The Administrator and DON were asked how the staff were educated after each elopement occurrence. The DON stated, We have done education before. When an elopement happens, we huddle and discuss it . The DON and Administrator were asked what should be reported to the state agency. The DON stated, .Elopements that are not care planned .that are not witnessed . During a telephone interview on 7/22/2022 at 10:32 AM, the Social Services Director confirmed Resident #45's elopement was not reported to the State Survey agency. The Social Services Director stated the elopement was not a reportable incident because the aides were with Resident #45, and she was in no danger (the resident exited the facility unsupervised). The Social Services Director was asked what the Social Services role was following an elopement. The Social Services Director stated, .I document at least twice after an elopement. I'm still checking progress notes and stuff like that .go sit and talk with them [residents] .a couple of days later check on them again and document that. The Social Services Director confirmed she did not do follow up documentation on Resident #45 and #87's behaviors and mental status following the incidents of elopement. During a telephone interview on 7/22/2022 at 11:30 AM, the Chief Nursing Officer (CNO) confirmed she was not aware of Resident #87's elopement. The CNO was asked if she felt this was something that should be immediately discussed with her. The CNO stated, Absolutely. During a telephone interview on 7/22/2022 at 2:18 PM, the Medical Director confirmed he was not aware of Resident #87's elopements. Refer to F-609, F-610, F-689, and F-867. The surveyor verified the Removal Plan by: 1. As of 7/21/2022, Resident #45 and #87 have been placed on 15-minute safety checks, 24 hours (hrs.) a day, 7 days a week until the new door safety alarm has been installed and working properly. The surveyors reviewed the documentation of the 15-minute checks and the order for the safety alarm. 2. Staff education was initiated on 7/22/2022 on the following: a. Policies and procedures for Elopement, Incidents & Accidents, Allegations of Abuse, 15-minute safety checks, 24 hours a day, 7 days a week, reporting to State Agencies no later than 2 hours after any reportable event. b. Safety checks every 15 minutes, 24 hours a day, 7 days a week until new door alarms are installed and working properly. c. An Adhoc (Impromptu) QAPI meeting was held on 7/24/2022 at 10:00 AM to discuss the effectiveness of the safety check plan. The team concluded continual presence with 15-minute documented checks 24 hours a day, 7 days a week until door alarm/magnetic locking system is installed and working properly to ensure resident safety. The surveyors reviewed the training, QAPI minutes, in-service sign-in sheets, and interviewed staff from all departments, on all shifts. 3. A Quality Assurance (QA) auditing tool will be implemented by 7/27/2022 to ensure compliance with this plan and will be completed daily by the Unit Manager or designee. Any changes to the schedule will be reported immediately to a Unit Manager by the scheduler or department manager to ensure no staff member works without this in-service education. Audits will be double checked by the ADON daily. The Quality Auditing Tool will be utilized until agency staff is no longer working in the building and 100 percent (%) of facility employed staff have been in-serviced. All in-service education mentioned in this plan will immediately be included in facility new hire employee orientation to ensure continued compliance. The surveyors interviewed nursing management, staff, and the Administrator. 4. The DON and the Administrator were educated on reporting requirements to State agencies regarding unusual incidents of abuse, neglect, or elopement by the Chief Nursing Officer (CNO) on 7/23/2022. The surveyors reviewed the training and interviewed the CNO, Administrator, and DON. 5. Follow up discussion about any new elopement, new elopement risk incident or accident or allegation of abuse will take place in the morning clinical meeting, morning stand up meeting, and afternoon stand down meeting. The surveyors reviewed the training, in-service sign in sheets, and interviewed members of the Interdisciplinary Team, the DON, and the Administrator. 6. All investigations of elopement, incidents & accidents, allegations of abuse, and suggestions will be reported and reviewed at the QAPI meeting. The surveyors interviewed members of the QAPI team, the DON, and the Administrator. 7. The DON will report the findings to QAPI committee monthly for at least 3 months or until resolved. The surveyors interviewed the DON. 8. All auditing will continue 2 times a week for 4 weeks, if substantial compliance is reached, auditing will continue weekly for 1 month and then it will be 1 time a month thereafter. This will be reviewed in QAPI monthly or as needed if concerns are identified to re-evaluate the need to reinstate frequent monitoring. The surveyors interviewed nursing management staff, members of the QAPI team, the DON, and the Administrator. 9. The Administrator received QAPI education with the expectations from the Corporate CNO, on 7/23/2022 regarding overall requirements and expectations related to the rules, guidelines, timely reporting to the appropriate state agency, timely reporting of incidents such as abuse/elopement/misappropriation, and all others, and complete oversight of the facilities QAPI program. The surveyors reviewed the education and interviewed the Administrator and the CNO. 10. The Administrator is responsible for ensuring compliance with QAPI within the facility. The surveyors interviewed the Administrator. 11. Oversight will be provided by the corporate Management, reports will be sent weekly, and review on a telephone call each Friday. The surveyors interviewed the Administrator, DON, and CNO. 12. Corporate will participate in monthly QAPI meetings with an invitation sent for the call by the Administrator. The surveyors interviewed the Administrator, DON, and CNO. 13. The Administrator was provided in-service training on Administration/Duties on 7/23/2022 by the CNO. A member of the corporate team will be on-site and in the facility on a weekly basis for 6 weeks or until compliance is achieved, then bi-weekly for 2 months, then ongoing at least monthly. The surveyors reviewed the education, and interviewed the Administrator, DON, and CNO. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job description review, Quality Assurance Performance Improvement (QAPI) reports, medical record review, observation, and interview, the QAPI committee failed to ensure systems and processes were in place that involved tracking/trending, evaluation/reevaluation of interventions, data, and trends to address quality concerns related to wandering and elopement behaviors. The QAPI committee failed to ensure a thorough investigation of a resident elopement, failed to identify quality deficiencies and effective interventions, failed to monitor the effectiveness of the interventions, and failed to assess staff knowledge of the care of residents with wandering/elopement behaviors in order to identify deviations and adverse events when residents exited the facility without staff knowledge. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #45, a cognitively impaired resident assessed as a risk for wandering/elopement left the facility unsupervised and was found in the back parking lot of the facility and when Resident #87, a cognitively impaired resident, exited the facility and was found outside the facility at approximately midnight. 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 to a resident. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager #1, and Staff Development Coordinator, were notified of the Immediate Jeopardy at F-609, F-610, and F-689 on 7/21/2022 at 7:18 PM, in the Conference Room. The Administrator and DON, were notified of the Immediate Jeopardy for F-835 and F-867 on 7/22/2022 at 6:20 PM, in the Conference Room. The facility was cited Immediate Jeopardy (IJ) at F-609, F-610, F-689, F-835, and F-867. The facility was cited at F-609, F-610, and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 1/22/2022 through 7/24/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 7/25/2022 at 11:43 AM. The corrective actions were validated onsite by the surveyors on 7/25/2022 through observations, review of education records, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated policy titled, Quality Assurance and Performance Improvement (QAPI), revealed .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life .The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan .Develop and implement appropriate plans of action to correct identified quality deficiencies .The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program .Systems and reports demonstrating systematic identification, reporting, investigating, analysis, and prevention of adverse events .The QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility . Review of the facility's undated Chief Executive Officer (CEO) (Administrator) Job Description, revealed, .The CEO is responsible for the day to day operations and direction of the facility, and ensures that the facility complies with all policies and procedures set forth by the company, as well as those required by regulatory agencies. Also ensures that expectations of the corporation and our customers are met or exceeded on a continual basis .Ensures the provision of quality of services through the design and implementation of facility wide quality assurance and program evaluation plans .Ensures quality care .Demonstrates effective management/leadership skills .Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objective, policies and procedures .that are necessary for providing quality care and maintaining a sound operation .Must be able to communicate .regulations .to personnel .Makes decisions in a timely manner . Review of the facility's undated DON Job Description, revealed .The Director of Nursing ('DON') is responsible for effective overall management of the Nursing department and coordination with other disciplines to provide quality care to all patients/residents. She/he supports and practices the philosophy, objectives and standards of the Department of Nursing and participates in the revision of these as necessary to ensure quality care to all patients/residents. She/he also monitors the outcomes of nursing services activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, policies and procedures, coordinating facility committees .Assumes full responsibility for the operation and management of the facility in the temporary absence of the Facility Administrator or as directed by the Administrator .Meets with committee members to evaluate activities within the facility and to identify opportunities for continuous improvement in nursing operations . Review of the medical record, revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Encephalopathy, Dementia, Anxiety, Depression, Hypertension, and Spinal Stenosis. Review of an Incident Report dated 1/22/2022, revealed .CNA [Certified Nursing Assistant] [#1] alerted nurse that while she was putting another resident to bed she saw resident [resident] [#45] ambulating down sidewalk and standing at the corner of the parking lot where the white lines are. Staff exited the building and assisted resident back in building .Resident was placed into a wheelchair and wheeled back into the building without difficulty. 15 minuee [minute] checks iknitiated [initiated] .No Injuries observed at time of incident .oriented to person .Oriented to Place .No Injuries observed Post Incident . During an interview on 7/20/2022 at 2:45 PM, Licensed Practical Nurse (LPN) #9 was asked where she was when Resident #45 eloped. LPN #9 stated, .I think I was at the Nurses' Station .I did not see [Named Resident #45] walk past the Nurses' Station or exit the door .[Named CNA #1] came and said [Named Resident #45] is outside in the parking lot .she [Resident #45] had her walker with her walking on the pavement . LPN #9 was asked if the alarm sounded. LPN #9 stated, I did not hear the alarm on the door .was still learning the alarm system I don't remember hearing the alarm to be honest . LPN #9 confirmed the doors were not checked by anyone after Resident #45's elopement. Observation with the Maintenance Director on 7/20/2022 at 3:13 PM of the New Wing North Hall exit door, revealed a Loud Mate Safety Alarm secured to the upper frame of the door with Velcro, with a string coming from the alarm box and secured/clipped to the upper part of the blind. The door was opened, and the alarm was activated. LPN #9 identified the location where Resident #45 was found in the parking lot at the white lines. The Maintenance Director measured the distance from the door to the area where LPN #9 indicated Resident #45 was found using a walking wheel. The distance measured from the door to the white lines was approximately 94.6 feet. During a telephone interview on 7/20/2022 at 4:12 PM, CNA #1 was asked to describe the incident of Resident #45's elopement. CNA #1 stated, .I was walking with [Named Resident #1] to put her to bed .I got to the room .I look up out the window and saw [Named Resident #45] standing on the sidewalk . CNA #1 confirmed she did not see the resident exit the building. CNA #1 stated, I only saw her out the window. CNA #1 was asked if an alarm was sounded. CNA #1 stated, .I heard the alarm going off as I was approaching the door . CNA #1 was asked how long Resident #45 was out of the building. CNA #1 stated, .About 5 or 10 minutes . During a telephone interview on 7/22/2022 at 10:32 AM, the Social Services Director confirmed Resident #45's elopement was not reported to the State Survey agency. The Social Services Director stated the elopement was not a reportable incident because the aides were with her, and she was in no danger (the resident exited the facility unsupervised and without staff). Review of the medical record, revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Encephalopathy, Heart Failure, Prostate Cancer, and Altered Mental Status. Review of the Behavior Charting dated 5/9/2022 at 4:28 AM, revealed .recently woke up from his sleep. res [resident] [#87] is slightly confused when found .res was in bed (passed by staff who was answering another res' call light) about 15min [15 minutes] before he triggered door alarm. res found standing right outside new wind [wing] south exit . During a telephone interview on 7/21/2022 at 11:30 AM, LPN #6 was asked about the incident when Resident #87 got outside the building. LPN #6 stated, .it was around late-night midnight .passed his room and noticed he wasn't there and then he was found by the techs [CNAs], just right outside the back door. I believe the alarm went off, and when we opened the door, he was standing out to the side of the door .he was leaning against the right side of the building with a blanket over him . LPN #6 was asked if she saw him exit the door. LPN #6 stated, No. LPN #6 was asked if the CNA saw him exit the door. LPN #6 stated, I don't think so .When we were looking for him we found him .and then the alarm went off . Observation outside the New Hall South Exit Door on 7/24/2022 at 8:00 PM, revealed the Maintenance Director measured the distance from the area where Resident #87 was found to the parking lot. The distance measured using a walking wheel was approximately 61.2 feet from the parking lot. The facility had an elopement drill on 1/31/2022 with the first shift staff members only. The facility was unable to provide the monthly QAPI committee Agenda/Minutes for 1/2022, 2/2022, 4/2022, and 6/2022. During an interview on 7/20/2022 at 6:36 PM, the Administrator confirmed the facility had QAPI meetings monthly. The Administrator was unable to provide QAPI meeting minutes for meetings in January, February, April, and June. During an interview on 7/21/2022 at 6:11 PM the Administrator, DON, ADON, Unit Manager #1, and Staff Development Coordinator were asked to define elopement. The Administrator stated, .when a resident leaves the premises from safe area to unsafe area . The Administrator was asked what was considered a safe area. The Administrator stated, Inside the building. The Administrator was asked what an unsafe area was. The Administrator stated, .if they [residents] are not accompanied with a staff member . The Administrator was asked when an elopement should be reported. The Administrator stated, When a resident leaves the premises. The Administrator was asked to define premises. The Administrator stated, The property . The Administrator confirmed the incidents of elopement for Resident #45 and Resident #87 were not reported to the State Survey Agency. Continuing the interview on 7/21/2022 at 6:11 PM, the DON and Administrator were asked what the facility did to identify the root cause of repeated elopements in the facility in the last 6 months. The DON stated, Wanting to go home and having problems adjusting to new facility .not used to being in Long Term Care and not being able to leave when they [residents] want to . The Administrator was asked when an Adhoc (impromptu) QAPI meeting should be held. The Administrator stated, When the facility identifies an incident or concern has been identified where improvements can be made to policies and procedures, an Adhoc will be held to educate, develop a root cause analysis. The DON stated, And possible need for a safer environment for the resident. The Administrator was asked since Resident #45 eloped in January, why was the Adhoc meeting not held until yesterday. The Administrator stated, The Adhoc meeting was not only for her, it was to review the facility's needs .educate staff . The Administrator confirmed there was no Adhoc meeting held after Resident #45 and #87 eloped. The Administrator stated, Through the process of providing documentation to the survey team it was apparent that we identified a more thorough investigation would be helpful . During a telephone interview on 7/24/2022 at 5:31 PM, the Regional Director of Clinical Services confirmed he was not aware of the 2 elopements that occurred in the facility. The Regional Director of Clinical Services confirmed he was not made aware of the elopement until the survey. The Regional Director of Clinical Services confirmed that during the facility's weekly meeting, the elopements were not discussed. The Regional Director of Clinical Services confirmed he did not attend the Adhoc meeting. Refer to F-609, F-610, F-689, and F-835. The surveyors verified the removal plan by: 1. On 7/23/2022, the Adhoc QAPI Committee reviewed the elopement assessments for the following residents to determine the root cause. a. Resident #45: Root cause, resident enjoys being outdoors. b. Resident #87: Acute mental status, unable to express his needs. d. These residents were assessed and found to be an elopement risk prior to their elopement. e. These residents had Care Plans for behaviors prior to their elopement. f. As of 7/21/2022, these residents were placed on 15-minute safety checks, 24 hours a day, 7 days a week until the new door alarm system is in place and working properly. This was confirmed through observations, record review, and interviews. 2. Resident #45 goes outside with supervision of staff as warranted. Resident #87 is monitored for any acute mental status episodes that may increase his risk of elopement. The Interdisciplinary team identified the following root causes for the above elopements: a. The 15 second release after holding the door allows the resident to get out when the door releases. b. The tone loudness is not at the highest capacity for staff to hear if in resident room with residents. c. The black box door alarm could be removed easily by resident is not the best system to alert for an elopement. d. Lack of understanding of reporting requirements and the term on or off the premise deemed as an elopement. e. Lack of staff education regarding warning signs and triggers. f. The need for a new door alarm system to prevent elopements. g. Increase in agency staff requires the need for more education input from the team. h. Staff reporting changes in residents' behavior or medical condition that may place them at higher elopement risk. i. Identified the need for improved communication of residents at risk for elopement. j. Current Elopement Policy to be reviewed for any needed changes. This was confirmed through observations, record review, and interviews. 3. Staff education was initiated on 7/22/2022 on the following: a. Policies and procedures for Elopement, Incidents & Accidents, Allegations of Abuse, b. 15-minute safety checks, 24 hours a day, 7 days a week, c. Reporting to State Agencies no later than 2 hours after any reportable event. d. Safety checks every 15 minutes, 24 hours a day, 7 days a week until new door alarms are installed and working properly, e. An adhoc QAPI meeting was held on 7/24/2022 at 10:00 AM to discuss the effectiveness of the safety check plan. The team concluded continual presence with 15-minute documented checks 24 hours a day, 7 days a week until door alarm/magnetic locking system is installed and working properly to ensure resident safety. This was confirmed through observations, record review, review of QAPI minutes, review of education and in-service sign in sheets, and interviews with staff on all shifts. 4. The DON and Administrator were educated on reporting requirements to State agencies regarding unusual incidents of abuse, neglect, or elopement by the Chief Nursing Officer (CNO) on 7/23/2022. This was confirmed through interviews. 5. A new Magnetic Lock alarm system is scheduled to be installed by 8/8/2022. This was confirmed through record review and interviews. 6. Staff were educated on 7/23/2022 on monitoring the doors every 30 minutes, 24 hours per day, 7 days a week until the new alarming Magnetic Lock system is installed. 7. The QAPI committee will convene and review any new elopement or abuse allegation within 72 hours of occurrence to ensure a thorough investigation is conducted, root cause is correctly identified, and corrective action plan is implemented. This will be conducted weekly for 4 weeks, assessed for effectiveness, then monthly thereafter. This was confirmed through observations, record review, and interviews. 8. The Administrator and DON will monitor this plan daily for compliance. This was confirmed through interviews with the Administrator and DON. 9. All auditing will continue 2 times a week for 4 weeks. If substantial compliance is reached, auditing will continue weekly for 1 month and then it will be 1 time a month thereafter. This will be reviewed in QAPI monthly or as needed. If concerns are identified with the auditing, QAPI will re-evaluate the need to reinstate frequent monitoring. This was confirmed through observations, record review, and interviews. 10. Education was initiated by the Administrator on 7/24/2022 and again on 7/25/2022 for all QAPI members, the Department Managers, and the Interdisciplinary Team (IDT) members regarding the QAPI process with handouts provided. Any member not available on the above dates will be educated prior to working their next scheduled shift. This was confirmed through observations, record review, and interviews. 11. The Administrator is responsible for the overall QAPI program in the facility and will be monitored for compliance by Corporate Management weekly through report submission ensuring compliance and by a follow up call 1 time weekly on Friday. This was confirmed through interviews. The facility's noncompliance at F-867 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.