**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, National Weather Service record, medical record review, observation, and interview, the facility failed to ensure adequate supervision and monitoring for 4 of 4 (Resident #38, #44, #272, and #422) cognitively impaired, vulnerable residents who had wandering and exit seeking behaviors. The failure of the facility to ensure a safe environment and adequately supervise residents placed Resident #38 in Immediate Jeopardy. Resident #38 was a cognitively impaired resident with prior wandering and exit seeking behaviors, who was missing for approximately 15 minutes before staff saw the resident outside the facility unsupervised and realized he had eloped from the facility. Resident #38 was found by a staff member in his wheelchair on a heavily traveled street beside the facility. Immediate Jeopardy 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 and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 8/27/19 at 7:21 PM, in the Assistant Director of Nursing (ADON) Office. F-689 was cited at a scope and severity of J. F-689 is Substandard Quality of Care. An extended survey was conducted on 8/28/19 through 8/29/19. An acceptable Allegation of Compliance (AOC), which removed the immediacy of the jeopardy, was received on 8/29/19 at 1:50 PM and the AOC was validated onsite by the surveyor on 8/29/19 through review of assessments, policies related to exit seeking behavior, in-service training records, and staff interviews. The IJ was effective from 8/20/19 to 8/28/19. The findings include: 1. The facility's Elopement policy, revised November 2017, documented, .Elopement occurs when a resident leaves the premise [premises] or a safe area without authorization .and/or any necessary supervision to do so .For residents requiring increased monitoring of wandering, the Licensed Nurse will initiate, 'Elopement / Wandering' supervision for a specific period of time identified in the care plan or physician orders .New wandering behavior or attempted elopement will be noted .documented in the Nurses Notes as to effect of interventions . The facility's Wandering, Unsafe Resident policy, revised November 2017, documented, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . The facility's Safety and Supervision of Residents policy, revised December 2007 documented, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease, Dementia, Hypertension, Atrial Fibrillation, and Cerebrovascular Accident. Medical record review of a Wandering and Elopement Evaluation dated 6/28/19 revealed Resident #38 was assessed as low risk for wandering and elopement. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was assessed to have a Brief Interview of Mental Status (BIMS) of 3, which indicated severe cognitive impairment. The resident was visually impaired and had delusional behaviors. He was not assessed to have wandering behaviors. Medical record review of a Nurses' Note dated 8/15/19 revealed Resident #38 was anxious and agitated and was exhibiting exit-seeking behaviors such as lingering around exit doors and trying to push the doors open. A physician's order dated 8/15/19 documented, .Wanderguard r/t [related to] elopement risk . Medical record review of a Wandering and Elopement Evaluation dated 8/15/19 (the day his exit seeking behaviors began) revealed Resident #38 was reassessed as a low risk for wandering. Medical record review of the Comprehensive Care Plan revised 8/15/19 revealed Resident #38 was an elopement risk and had wandering tendencies due to impaired safety awareness. The interventions included to distract the resident from wandering by offering diversional activities, to document wandering behaviors and attempted diversional activities, and to check placement of wanderguard per protocol. The facility was unable to provide a protocol for wanderguards. A Nurses' Note dated 8/20/19 at 3:30 PM documented, .staff reported resident was observed outside. therapy [Therapy] and nursing staff obtained resident from road next to parking lot entrance. Resident was in his w/c [wheelchair], self propelling to road. resident [Resident #38] exited facility from exit door near chapel that exits to parking lot .wander guard remains in place to right ankle . Review of a Wandering and Elopement Evaluation dated 8/20/19, after Resident #38 eloped from the facility, revealed moderate risk for wandering and elopement. The National Weather Service records revealed the recorded high temperature for the facility area on 8/20/19 (the day of the elopement from the facility) was 95 degrees Fahrenheit. The facility is located near a school on a hill. The road is heavily traveled by traffic and has limited visibility. Medical record review revealed after Resident #38 exhibited exit seeking behaviors, there was no nursing documentation in the progress notes between 8/15/19 and 8/20/19 related to any type of exit seeking behaviors. Observations in the Dining Room on 8/25/19 at 10:15 AM, revealed Resident #38 was sitting in a wheelchair, wearing glasses, and had a wanderguard on his right ankle. Interview with Licensed Occupational Therapist (OT) on 8/26/19 at 11:18 AM, in the ADON Office, the OT was asked to review her written statement and sign and date it if there were no changes. The statement dated 8/20/19 read as follows, At approximately 3:30 PM I was sitting in my car in the parking lot talking with my ride .I looked out to see [Named Resident #38] self-propelling his wheelchair in the road . At this time the OT changed her statement to read, .[Named Resident #38] was seen self-propelling toward the road, not in the road . The OT wrote this statement at the bottom of her previous written statement. The OT was asked where Resident #38 was when she found him. The OT stated, Where the parking lot and road meet . The OT was asked what the weather conditions were outside at the time. The OT stated, Hot. Observation and interview with the OT on 8/26/19 at 11:45 AM, in the facility's parking lot, the OT stated, We were parked in the 3rd parking spot and there were no cars beside us so we could see where he [Resident #38] was . The OT was asked to clarify why she stated Resident #38 was in the road on her original statement. The OT stated, Because I thought he [Resident #38] was in the road when I first saw him .his wheelchair was literally sitting right here [pointed with her toe to the line where the pavement of the facility's parking lot met the pavement of the heavily traveled city street] . Observations in the East Hall on 8/26/19 at 2:36 PM, revealed Resident #38 was self-propelling in a wheelchair and had a wanderguard on his right ankle. Interview with CNA #5 on 8/26/19 at 3:01 PM, in the ADON Office, CNA #5 confirmed she was working the East Hall the day Resident #38 eloped from the facility. CNA #5 was asked if she observed the incident. CNA #5 stated, No ma'am .heard them [staff] yelling and running toward the front door .saw them [staff] bringing him [Resident #38] back from the road and a school bus had stopped. Telephone interview with Licensed Practical Nurse (LPN) #2 on 8/26/19 at 4:13 PM, LPN #2 confirmed that she was Resident #38's assigned nurse that day (8/20/19) and Resident #38 was beside her at the Nurses' Station at 3:15 PM. LPN #2 was asked if Resident #38 had tried to get out of the facility before this incident. LPN #2 stated, He [Resident #38] wanders around a lot and will push on the doors . LPN #2 was asked when Resident #38 first began exhibiting exit-seeking behaviors. LPN #2 stated, Maybe a few weeks ago. LPN #2 was asked the outcome of the facility's investigation of the incident. LPN #2 stated, We found out he had gotten out that back door [East Hall exit door]. LPN #2 was asked if the door was unlocked when she checked it after Resident #38 eloped from the facility. LPN #2 stated, Yes .the Administrator was the one who first discovered it [East Hall exit door] was unlocked and he told me .I put the key in .locked it .checked it. Interview with the Administrator on 8/26/19 at 4:42 PM, in the ADON Office, the Administrator confirmed that he was in his office when Resident #38 eloped from the facility and once the resident was back in the facility, he began checking exit doors. He stated, .it had rained .and it was easy to see there were wheelchair tracks from the exit door to the left of therapy [East Hall exit door], opposite the smoking entrance. When I pushed on the door, it opened without the delayed egress. I looked up and the light was green indicating .mag [magnet] lock was unlocked . The Administrator stated, [Named LPN #2] .remembers that a coroner took a body out that door [on 8/14/19] and that's the only time she remembered it being unlocked . The Administrator was asked if the East Hall exit door could have been left unlocked for 6 days. The Administrator stated, .the likely thing that should happen, is if someone takes a key and unlocks it, they should relock it . Interview with the Maintenance Director on 8/26/19 at 5:09 PM, in the ADON Office, the Maintenance Director was asked about the incident where Resident #38 eloped from the building. The Maintenance Director stated, I was notified by [Named Administrator]. He called me and asked who had keys to the door .I check the doors every week .I have all week to do the [Named maintenance documentation system] but basically, I check them every morning. The Maintenance Director was asked how he could tell the door was locked. The Maintenance Director explained the locking mechanism and stated, It makes a noise, you turn it all the way to the right to the green then back to the center and the light turns to red and that resets it. The Maintenance Director confirmed he locked the door per this procedure on 8/14/19. Per the Maintenance Director's documentation the door was checked and documented as locked on 8/14/19. There was no other documentation of a door checks on the exit doors until 8/21/19. Telephone interview with CNA #4 on 8/27/19 at 9:23 AM, CNA #4 confirmed she was working when Resident #38 eloped from the building. CNA #4 stated, I'm not sure what happened .was walking down North Hall, looked out the windows .saw a man in a wheelchair .realized who it was [Resident #38] .I saw the bus through the window and adrenaline kicked in .one of the therapists had already seen him [Resident #38] and was bringing him back from the road to the parking lot . Observations in the Dining Room on 8/27/19 at 11:38 AM, revealed Resident #38 slowly rolled his wheelchair backward and forward using his feet and had a wanderguard on his right ankle. Observations from facility's parking lot on 8/27/19 from 3:00 PM to 3:55 PM, revealed several school buses and a heavy flow of traffic on the road. Telephone interview with [Named School Bus Driver] on 8/28/19 at 5:02 PM, [Named School Bus Driver] was asked if she saw a person in a wheelchair beside the road close to the facility on the afternoon of 8/20/19. [Named School Bus Driver] stated, Yes Ma'am. He [Resident #38] was in the road .I stopped pretty far back and put my signs out and my light on so that nobody would pass me or my bus . Observations in the hallway by the Rehabilitation (Rehab) Department on 8/29/19 at 9:05 AM, revealed Resident #38 attempted to reach the East Hall exit door on the parking lot side of the hallway. Staff were between the door and Resident #38, and were redirecting Resident #38. Observations outside of the facility on 8/29/19 at 2:08 PM, revealed the Rehabilitation Director measured the distance in linear feet from the exit door where Resident #38 eloped to the heavily traveled street. The distance was 146 linear feet to the road. 3. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Anxiety Disorder, Psychosis, Dementia, History of Falls, Disorientation, and Alcohol Abuse. The Care Plan revised 7/7/19 documented, [Named Resident #44] is an elopement risk/wanderer .wanders aimlessly .Interventions .Placement of wanderguard per protocol. Monitor for placement and in working order. Date Initiated: 10/18/2017 Medical record review of a Wandering and Elopement Evaluation dated 7/8/19 revealed Resident #44 was assessed as low risk for wandering and elopement. Medical record review of the quarterly MDS for Resident #44 dated 7/11/19 revealed a BIMS of 1 which indicated severe cognitive impairment. The physician's orders dated 8/7/19 documented, .Monitor placement and function of wanderguard two times day . Medical record review of Resident #44's July and August 2019 Activity of Daily Living (ADL) task list revealed there was no documentation of monitoring wanderguard equipment checks for the day shift on 7/7/19, 8/11/19, 8/12/19, or 8/25/19, and there was no documentation for either shift on 8/13/19 through 8/24/19. Observations in the Dining Room on 8/26/19 at 9:30 PM, revealed Resident #44 walking around in the Dining Room. Observations in the North hallway on 8/28/19 at 8:49 AM, revealed Resident #44 walking up and down the hallway. Interview with the DON on 8/29/19 at 12:04 PM, in the ADON Office, the DON was asked how often should the wanderguards be checked. The DON stated, Every shift .we did not realize it [the checks] had dropped off [from the electronic documentation record] until we started looking for stuff for you all on the 25th of August .they should have done paper charting when the task was dropped off . 4. Medical record review revealed Resident #272 was admitted to the facility on [DATE] with diagnoses of Dementia, Hypertensive Chronic Kidney Disease, Dysphagia, and History of Malignant Neoplasm of Kidney and Breast. The physician's orders dated 8/15/19 documented, .Wander guard [wanderguard] in place to left ankle . Medical record review of a Wandering and Elopement Evaluation dated 8/15/19 revealed Resident #272 was assessed as low risk for wandering and elopement. Medical record review of the Baseline Care Plan dated 8/16/19 documented, .Minimize Risk of Elopement .Wander Bracelet [wanderguard] . Medical record review of Resident #272's ADL task list documented, .August 2019 .MONITORING Wandering [monitor for wandering behaviors] .Q [every] shift . There was no documentation of wander monitoring for the day shift for 8/16/19, 8/17/19, 8/19/19, 8/20/19, 8/25/19, or 8/26/19, and for the night shift for 8/23/19 and 8/25/19. Medical record review of Resident #272's ADL facility task list for August 2019 revealed there was no documentation of monitoring wanderguard equipment checks for the day shift for 8/16/19, 8/17/19, 8/22/19, 8/23/19, 8/25/19, and 8/26/19. Observations in the North hallway on 8/26/19 at 10:00 AM, revealed Resident #272 had a wanderguard to her left ankle walking to Activities with a staff member. Interview with CNA #1 on 8/26/19 at 1:11 PM, in the ADON Office, CNA #1 was asked if she was assigned to Resident #272 for the day. CNA #1 stated, Yes. CNA #1 was asked if Resident #272 had a wanderguard. CNA #1 stated, I don't know . CNA #1 was asked who was responsible to check the wanderguards. CNA #1 stated, I don't know. I would have to find that out . CNA #1 was asked how she would know if a resident had a wanderguard. CNA #1 stated, I just see it when I am getting her dressed. It is not a structured thing. Interview with LPN #1 on 8/26/19 at 3:23 PM, at the North Hall Nurses' Station, LPN #1 was asked if the CNAs should know if a resident had a wanderguard. LPN #1 stated, Absolutely. LPN #1 was asked when should CNAs look at the [NAME] [CNA Plan of Care for the resident] to know how to take care of the residents. LPN #1 stated, Daily, at the beginning of the shift to see if anything has changed. LPN #1 was asked if there would be a reason for a CNA who had taken care of a resident for 5 hours not to know a resident was a wanderer with a wanderguard in place. LPN #1 stated, Absolutely not. Interview with CNA #2 on 8/26/19 at 4:52 PM, at the North Hall Nurses' Station, CNA #2 was asked if she had reported to CNA #1 that Resident #272 had a wanderguard when she arrived to work on the North Hall to take care of the resident. CNA #2 stated, I did not. Interview with the DON on 8/27/19 at 6:20 PM, in the ADON Office, the DON was asked when was the wanderguard ordered for Resident #272. The DON stated, 8/15/19. The DON was asked when the wanderguard was placed on Resident #272. The DON stated, On 8/16 [19] . The DON confirmed there was no documentation the wanderguard was placed on 8/15/19. The DON was asked if Resident #272 was exit seeking. The DON stated, Sometimes she is. The DON confirmed the wanderguard functioning tests and wanderguard checks had not been performed. The DON was asked if she expected the CNAs to review a resident's [NAME] to know if a resident was exit seeking and if the resident had a wanderguard in place. The DON stated, Yes. 5. Medical record review revealed Resident #422 was admitted to the facility on [DATE] with diagnoses of Encephalopathy, Dementia, Repeated Falls, Hypertension, and Altered Mental Status. Medical record review of a Nursing: Wandering & Elopement Evaluation dated 8/16/19 documented, .New admission .Current Evaluation .Lacks safety awareness of current situation .Immediate interventions .wanderguard .Low Risk . Medical record review of a Baseline Care Plan for Resident #422 dated 8/17/19 documented, .Goal: Minimize Risk of Elopement .Interventions .Wander Bracelet [checked] . Medical record review of a Nurses' Note dated 8/20/19 documented, .Resident was standing at the front entrance and pushing on the door handle. She was very agitated and requesting to go outside as this nurse was attempting to leave for the day. Resident states she wants to 'get out of here.' Attempted to determine why she wanted to leave/go outside. She declined to answer questions stating that it was 'none of your business . Medical record review of a Nursing: Wandering & Elopement Evaluation for Resident #422 dated 8/25/19 documented, .Low Risk . Observations on 8/25/19 at 9:30 AM and 11:23 AM, revealed Resident #422 wandered the halls throughout the facility. Observations in the East hallway on 8/26/19 at 8:01 AM, revealed Resident #422 ambulated in the hallway with a staff member and held an ink pen and clipboard in her hand, Resident #38 was overheard telling staff member that she badly needs to find someone. A physician's order dated 8/26/19 documented, .Wander guard [wanderguard] in place to right ankle . Interview with the DON on 8/27/19 at 6:30 PM, in the ADON Office, the DON was asked if a wanderguard was placed on Resident #422 on 8/20/19, when the resident was documented as exit-seeking. The DON stated, .I think it was on there before that but the [nursing] documentation says the 25th [8/25/19] .I honestly can't answer that question. It shouldn't have happened . The DON was asked if an elopement risk evaluation should have been completed when the resident was actively exit seeking on 8/20/19. The DON stated, Yes. Telephone interview with LPN #2 on 8/28/19 at 9:05 AM, LPN #2 was asked if she placed a wanderguard on Resident #422 after she assessed her on 8/20/19. LPN #2 confirmed Resident #422 did not have a wanderguard in place on 8/20/19 and stated, .I know I didn't place the wanderguard on the resident. Interview with the DON and the Administrator on 8/27/19 at 7:06 PM, in the ADON Office, the DON and Administrator were asked why a resident would have a wanderguard. The DON stated, .Exit seeking, wandering . The DON was asked how staff would know how to check wanderguards per protocol if the facility did not have a protocol. The DON stated, I know that the protocol was asked for and we don't have one . Interview with the Administrator on 8/28/19 at 5:25 PM, in the ADON Office, the Administrator was asked who was responsible to ensure care plan interventions, elopement evaluation forms, charting, and staff education were completed. The Administrator stated, The DON. The Administrator was asked who was responsible to ensure the residents were safe. The Administrator stated, The Administrator and the team. Every employee here . The failure of the facility to ensure a safe environment, the failure to provide adequate supervision and monitoring of residents with wandering and exit seeking behaviors resulted in Immediate Jeopardy for Resident #38, #44, #272, and #422. Resident #38 exited the facility through an unsecured exit door without staff knowledge and was found on a heavily traveled city street. The survey team verified the AOC by: 1. Education was initiated with the Interdisciplinary Team (IDT) members on 8/27/19 by Administrator. All staff were re-educated regarding policies including Elopement; Safety and Supervision of Residents, and the Wanderguard Protocol on 8/27/19 by the DON, ADON, and/or designee. Education of staff will occur upon entering the facility for their scheduled shift. The survey team reviewed the in-service sign in sheets and interviews with staff on all shifts confirmed this. 2. Beginning on 8/27/19 the charge nurse will monitor Plan of Care (POC) documentation by the CNAs at the end of every shift to ensure POC documentation is completed, for ongoing compliance. Any behaviors will be documented and a POC alert will be sent to the Licensed Nursing Staff on the dashboard. Interviews with the DON, nurses, and CNAs on all shifts confirmed this. 3. Beginning on 8/28/19 the DON, ADON, and/or Designee will audit clinical alerts in (Named electronic charting for documentation) for compliance daily, in morning clinical meeting. Interviews with the DON and ADON confirmed this and the survey team reviewed the audit forms. 4. Beginning 8/27/19 if wandering or any behavior occurs during a shift, staff will follow current interventions, and place resident on 72 hour alert charting which monitors for effectiveness of interventions, followed by documentation in (Named electronic charting for documentation). Licensed Nurses will update Care Plan interventions as deemed appropriate. Interviews with the DON and Nursing staff on all shifts confirmed this. 5. Exit doors will be checked beginning 8/28/19 by the Maintenance Director and/or Housekeeping Supervisor hourly for proper operation/locking during normal shift hours Monday - Friday for two weeks, then decrease to twice daily for two weeks, then daily ongoing. After hour door checks will be completed hourly by the RN Supervisor, Charge Nurse, and/or designee. Checks will be placed on a log verifying that door checks were completed hourly. Audit log for exit doors was reviewed by the survey team. Interviews with the Maintenance Director, Housekeeping Supervisor, and Nursing staff on all shifts confirmed this. 6. Beginning 8/28/19 Daily rounds will be completed by Administration/Department Managers to include monitoring of door alarms for four weeks, then monthly. Interviews with the Administrator and Department Managers confirmed this. 7. On 8/28/19 the [NAME] (CNA Care Plan) and daily tasks were reviewed and updated as necessary for wandering residents. Interviews with the Nursing and CNA staff on all shifts confirmed this. 8. Beginning 8/28/19 doors will not be unlocked without notification/consent from the Administrator. Interviews with the Administrator and staff on all shifts confirmed this. 9. Beginning 8/28/19 an Elopement Binder, which includes policies & procedures regarding Wandering Residents, is located at both Nurses' Stations. The survey team reviewed the Elopement Binder and interviews with Nursing staff on all shifts confirmed this. 10. Beginning 8/28/19 Licensed Nursing Staff will monitor wanderguards, document on the Treatment Administration Record (TAR), communicate with the DON and Social Worker regarding residents who display behaviors, and update the [NAME] and Nursing Care Plan to reflect new interventions, as needed. The survey team reviewed the TARS, [NAME], and care plans, and interviews with the DON and Nursing staff on all shifts confirmed this. 11. Beginning 8/27/19 Licensed Nursing Staff will implement appropriate interventions such as 1:1 or 15 minute checks when residents listed at risk for wandering display behaviors. Interview with the DON and Nursing staff on all shifts confirmed this. 12. Beginning 8/27/19 documentation of monitoring residents at risk for wandering is a Task in the CNA POC. Interviews with the DON and CNA staff on all shifts confirmed this. Noncompliance of F-689 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.

Based on the Administrator Job Description, Director of Nursing (DON) Job Description, medical record review, and interview, the Administrator failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of residents. Administration failed to ensure staff to were monitoring doors to prevent a cognitively impaired, vulnerable resident from eloping from the facility. Resident #38 exited the East Hall Exit Door out into the parking lot and continued toward a heavily traveled street next to the facility. The Administrator's failure to ensure resident safety placed Resident #38 in Immediate Jeopardy when staff failed to supervise and monitor residents with elopement risks and exit seeking behaviors. An 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 and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 8/27/19 at 7:21 PM, in the Assistant Director of Nursing (ADON) Office. F-689, F-835, and F-867 were cited at a scope and severity of J. F-689 is Substandard Quality of Care. A extended survey was conducted on 8/28/19 through 8/29/19. An acceptable Allegation of Compliance (AOC), which removed the immediacy of the jeopardy, was received on 8/29/19 at 1:50 PM, and the AOC was validated onsite by the surveyors on 8/29/19 through review of assessments, policies related to active exit seeking behavior, in-service training records, and staff interviews. The IJ was effective from 8/20/19 to 8/28/19. The findings include: The facility's Administrator Job Description with a revision date of 8/2018 documented.Meet with personnel as scheduled, to assist in identifying and correcting problems, and or the improvement of services .Direct various committees of the facility, such as care plan .quality assessment and assurance .Monitor procedures to assure compliance with the guidelines of state and federal regulations and facility policy .Audit documentation for errors to inconsistencies and make necessary corrections or document reasons for corrections not made . The facility's Director of Nursing Job Description with a revision date of 8/2018 documented, .Coordinates all departments relating to nursing. Accountable for all functions, activities, training, and education of all nursing employees .Evaluates resident records to assure accuracy, care plans are current and complete and residents are receiving optimal nursing care .Responsible for supervising direction of resident care . Interview with the Administrator on 8/26/19 at 4:42 PM, in the Assistant Director of Nursing (ADON) Office, the Administrator was asked about the incident when Resident #38 eloped from the building. The Administrator stated, .I saw him [Resident #38] at least 30 minutes before .it was reported to me they [staff] were getting him [Resident #38] back in the building .we [Administrative staff] started asking questions found out it was the Licensed Occupational Therapist that had actually intervened to get the patient [Resident #38] out by the road to return to the facility .upon interviewing Licensed Occupational Therapist .she reported that while outside .he [Resident #38] was heading toward the road .she [Occupational Therapist] took a dash toward him [Resident #38] turned around and brought him [Resident #38] to the facility .at that time once he [Resident #38] was back in the facility I started checking the exit doors because it had rained .it was easy to see where the wheel chair tracks from the exit door to the left of the therapy opposite the smoking entrance .when I pushed on the door it opened without the delay egress .I looked up and the light was green indicating the mag [magnetic] lock was unlocked . The Administrator was asked if the alarm sounded. The Administrator stated, No. The Administrator was asked if he was aware a school bus had stopped traffic on the road. The Administrator stated, No. Administration failed to ensure staff supervised and monitored Resident #38 who had wandering and exit seeking behaviors and failed to ensure staff were monitoring exit doors. Refer to F689. Administration failed to ensure staff followed care plan interventions for residents with exit-seeking and wandering behaviors. Refer to F656. The surveyor verified the AOC by: 1. The Administrator will provide ongoing monitoring by reviewing audit sheets for exit doors daily beginning on 8/29/19. The survey team reviewed the audit forms. 2. Administrator will make walking rounds daily Monday-Friday to check exit doors to ensure they are secure beginning 8/29/19. Interview with the Administrator confirmed this. 3. Administrator will complete walking rounds twice daily Monday-Friday. As well as monitoring staff activity to ensure supervision of residents beginning 8/29/19. Interview with the Administrator confirmed this. 4. Beginning 8/29/19 the Administrator will audit POC (Plan of Care) documentation in PCC (facility's electronic medical record) in regards to Behaviors/Wandering for Four Weeks. Weekly ongoing to ensure staff is monitoring behaviors. Interview with the Administrator confirmed this. 5. Beginning 8/29/19 the Administrator will audit TAR's for residents who are at risk for wandering to ensure that licensed nurses are checking wanderguards daily. Audits will be daily Monday-Friday for Four Weeks, then weekly thereafter, until substantial compliance is achieved. Interview with the Administrator confirmed this and the survey team reviewed the audit forms. 6. Beginning 8/29/19 the Administrator will conduct walking rounds daily to interview staff to ensure staff has retained education pertaining to residents with exit seeking/ wandering behaviors, regarding elopement, safety of wandering residents. Rounds will be twice daily, this measure will be ongoing. Interview with the Administrator confirmed this. 7. Starting 8/29/19 any negative findings will be presented in monthly Quality Assurance meeting to identify any trends or patterns and plans will be reviewed/revised as necessary. Interview with the Administrator confirmed this. 8. If findings indicate non-compliance from 8/29/19, audits will resume to the initial schedule and plan will be reviewed and revised as needed. Interview with the Administrator confirmed this. Noncompliance of F-835 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Administrator job description, Quality Assessment and Quality Assessment and Performance Improvement Committee review, policy review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to completion of elopement assessments, developing plans of action and interventions for exit seeking behaviors, failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns, and failed to ensure the facility was administrated in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI Committee to ensure the facility staff ensured a safe environment for residents placed Resident #38 in Immediate Jeopardy when Resident #38, a cognitively impaired resident with known exit-seeking behaviors, exited the building. 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 and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 8/27/19 at 7:21 PM in the Assistant Director of Nursing (ADON) Office. F-689, F-835, and F-867 were cited at a scope and severity of J. F-689 is Substandard Quality of Care. An extended survey was conducted on 8/28/19 through 8/29/19. An acceptable Allegation of Compliance (AOC), which removed the immediacy of the jeopardy, was received on 8/29/19 at 1:50 PM and the AOC was validated onsite by the survey team on 8/29/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 8/20/19 to 8/28/19. The findings include: The facility's Quality Assessment and Performance Improvement Committee policy revised November 2017 documented, .This facility shall establish and maintain a .(QAPI) that oversees the identification and handling of quality issues .Adverse Event: an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk there of, which includes, near misses .To coordinate the development, implementation, monitoring, and evaluation of action plans to achieve specified quality goals . The facility's Quality Assessment and Performance Improvement Program policy revised November 2017 documented, .This facility shall develop, implement, and maintain an ongoing, facility-wide .program (QAPI), designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems .Individual departments or services shall develop quality indicators for programs and services in which they are involved and which affect their function . The facility's Safety and Supervision of Residents policy revised December 2007 documented, .Facility-Oriented Approach to Safety .Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA&A [Quality Assessment and Assurance] reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization .When accident hazards are identified, the QA&A/Safety Committee shall evaluate and analyze to the extent possible . The facility's Administrator Job Description with a revision date of 8/2018 documented, .Meet with personnel as scheduled, to assist in identifying and correcting problems, and or the improvement of services .Direct various committees of the facility, such as care plan .quality assessment and assurance . Interview with the Administrator on 8/27/19 at 7:05 PM, in the ADON Office, the Administrator was asked if they had a QAPI meeting since the incident of the elopement on 8/20/19. The Administrator stated, No .we discussed it in daily stand-up meeting .use morning meeting as part of QA [Quality Assessment and Improvement] . The Administrator was asked if the Medical Director had been invited to a daily stand up meeting to discuss the elopement of 8/20/19. The Administrator stated, No, ma'am . Interview with the Administrator on 8/28/19 at 8:32 AM, in the Administrator Office, the Administrator was asked to provide a wanderguard protocol. The Administrator stated, .We do have a Wanderguard Protocol .they [policies] were not located on the shared drive where they should have been, we could not retrieve them because it [policies] had been deleted . Interview with the DON on 8/28/19 at 3:34 PM, in the ADON Office, the DON was asked when were the medical records of wandering residents QA'd. The DON stated, .We just did the QA today . 1. The facility's QA committee failed to identify areas of improvement related to active exit seeking behaviors. Refer to F689 and F835 2. The facility's QA committee failed to identify appropriate plans of action, and failed to ensure new interventions related to elopement risk and supervision of residents were followed. Refer to F656, F689, F835 3. The facility's QA committee failed to identify that elopement risk assessments were not current and updated for the residents with wandering behaviors. Refer to F842 The surveyor verified the AOC by: 1. Education was provided to the current staff regarding policies including Elopement; Safety and Supervision of Residents and the Wander Guard Protocol were initiated on 8/27/19 by the Director of Nursing and Assistant Director of Nursing and/or designee. Education included but was not limited to; list of at risk wandering residents, if behavior occurred appropriate intervention was put in place by Licensed Nurse including 1:1 or 15 minute checks. Documentation of monitoring residents at risk for wandering is a TASK in POC (facility's electronic medical record for CNA documentation) for CNA's (Certified Nursing Assistants). Monitoring with documentation on TAR (Treatment Administration Record) for Licensed Nurses. Communications to DON, SW (Social Worker) regarding residents who display behaviors and updating [NAME] (CNA care plan) and the care plan to reflect new interventions as needed. Doors are not to be unlocked without the notification/consent from the Administrator. Documentation of hourly monitoring of doors and documentation of function on audit log. Location of Elopement binder at both nurse's station which include policies and procedure regarding wandering residents. The survey team reviewed the in-service sign in sheets and interviewed staff on all shifts. 2. Beginning 8/27/19 education of staff will occur upon entering facility for their scheduled shift. The survey team reviewed the in-service sign in sheets and interviewed staff on all shifts. 3. Beginning 8/27/19, the charge nurse will monitor the POC documentation by the CNAs at the end of every shift to ensure POC documentation was completed including behaviors for ongoing compliance. Any behaviors are documented and a POC alert will be sent to nursing on the dashboard. The survey team reviewed the audit forms. 4. Beginning 8/28/19, in clinical morning meeting DON, ADON and/or Designee will audit clinical alerts in PCC (facility's electronic medical record) for documentation for compliance daily. The survey team reviewed the audit forms. 5. Beginning 8/27/19, if wandering or any behavior occurs during shift staff will follow current intervention and place resident on 72 hour alert charting which monitor for effectiveness of intervention followed by documentation in PCC. The nurse will update care plan interventions when necessary. The survey team reviewed the charting and interviewed staff on all shifts. 6. Beginning 8/28/19, the Maintenance Director or Housekeeping Supervisor will check the exit doors hourly for two weeks, then decrease to twice daily for two weeks, then daily ongoing. After hour door checks will be completed by RN [Registered Nurse] Supervisor, Charge Nurse, or designee. Checks will be placed on a log verifying that door checks were completed hourly. The survey team reviewed the audit forms and interviewed staff on all shifts. 7. Beginning 8/28/19, daily rounds will be completed by Administration/Department Managers to include monitoring of door alarms for four weeks, then monthly for 3 months. The survey team reviewed the audit forms. 8. On 8/28/19, the [NAME] and tasks were reviewed and updated as necessary for wandering residents. The survey team reviewed the [NAME] and Tasks. 9. Beginning 8/28/19, wander Guard/door/exit audits will be reviewed by Administration in morning meetings Monday through Friday for two weeks. Audits completed on Saturday and Sunday will be reviewed on Monday morning in morning meetings. Wander Guard/Door/Exit audits review will reduce to weekly for four weeks, then monthly ongoing until substantial compliance is achieved. Negative findings will be presented in monthly Quality Assurance meeting to identify any trends or patterns and plans will be reviewed/revised as necessary. If findings indicate non-compliance, audits will resume to the initial schedule and plan will be reviewed and revised as needed. The survey team reviewed the audit forms Noncompliance of F-867 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.