**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of the facility investigation, weather reports, satellite data, observations and interviews, the facility failed to maintain secure exits (functional door alarms or magnetic locking mechanisms) on 2 of 5 units (C Wing and East Wing) which resulted in the elopement of 1 resident, (Resident #1), an ambulatory, cognitively impaired resident with a history of wandering, of 5 residents reviewed for elopement risks. The facility's failure placed Resident #1 in Immediate Jeopardy (IJ, a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when on 5/8/2023 around 7:30 AM, Resident #1 exited the C Wing clinical unit via an alarmed door in which the alarm malfunctioned and did not sound and entered the unoccupied East Wing undetected to a delayed egress door whose magnetic locking mechanism malfunctioned, and exited to the outside of the building. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J, which is Substandard Quality of Care (SQC). The Director of Nursing (DON) and the Corporate Nurse were notified of the Immediate Jeopardy on 5/23/2023 at 1:19 PM in the conference room. The IJ was effective 5/8/2023. A corrective action plan was implemented and the IJ was removed on 5/9/2023. The corrective actions were validated onsite by the surveyor on 5/18/2023 to 5/23/2023. The IJ was cited as past noncompliance and the facility is not required to submit a Plan of Correction (POC). The findings included: Review of the facility policy Emergency Procedure, Missing Resident (undated) revealed .Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure safety . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Major Depression, Unspecified Hallucinations, Insomnia, Unspecified Anxiety Disorder, Pseudobulbar Affect, and Hypertension. Medical record review of an annual Minimum Data Set (MDS) dated [DATE] showed Resident #1 was ambulatory, severely cognitively impaired with altered thought processes, moderate signs of depression, impaired communication, and a history of wandering. Resident #1 was dependent upon one person for all activities of daily living (ADLs). Resident #1 was care planned as at risk for elopement due to wandering, impaired safety awareness and packing her suitcase on 5/1/2020 with interventions implemented. Review of the facility investigation dated 5/8/2023 showed Resident #1 was last seen wandering about in her customary fashion on the [NAME] Wing A hallway around 7:20 AM on 5/8/2023. Around 7:30 AM, Resident #1 was spotted outside the rear of the facility, by staff members who were located near an exit door in the centrally located dining room, adjacent to the centrally located nursing station. Staff members called for assistance as they immediately went outside, retrieved Resident #1, then escorted her back inside the building through the rear entrance of the dining hall, where she was then escorted to her room and assessed by the attending nurse, as an investigation was launched. Review of the facility staffing data, cross referenced against the time sheets and punch reports, showed at the time of Resident #1's elopement, 2 Certified Nurse Assistants (CNAs) and 3 Licensed Nurses were on duty, assigned to care for 39 residents. Review of National Weather Service (NWS) online data compiled by the weather underground online database (www.weatherchannel.com) showed at the time of the elopement, weather conditions in the facility's area were as follows: Temperature, 62 degrees Fahrenheit, with 6 mile per hour (MPH) winds from the south, scattered clouds, with scattered light rain. Review of satellite imaging of the facility and surrounding terrain, cross referenced to its physical address and Global Positioning System (GPS) Coordinates as compiled from Google Earth (www.googleearth.com) showed the facility was situated between Highway 382 ( a heavily traveled 2 lane state highway) to the west and [NAME] Bar Lake (a large Tennessee Valley Authority managed reservoir) located between 583 and 630 feet to the east, behind the building. The facility was bordered by a small condominium complex situated approximately 166 feet east to the rear of the facility, between the facility property and the lake. The area beyond the condominium complex was bordered by heavily wooded and rolling terrain extending in a north by northwesterly direction bordered by the lake, as well as a wood line which extended north/ northeasterly and south/southeasterly along the lake bank. Continued review showed the facility was also bordered by an access road (Jonelle Court) which ran west to east, parallel to and behind the facility, directly beside the building, a few feet away, which led to the condominium complex entrance. Across the access road, up a small vegetation covered embankment, approximately 34 feet away from the exit door where Resident #1 left the building, was a large tract of mowed pastureland with a heavily wooded border which measured 638 feet from its northwestern edge nearest the facility, which extended [NAME] towards a local college baseball field and athletic complex several acres in size. The pasture also extended westward parallel to the facility, ending with its border with highway 382, situated approximately 810 feet away from the elopement site, and northward to the wood line bordering the lakebed, 720 feet away from the location where Resident #1 exited the building. Continued review of the satellite data, cross referenced to the facility layout, facility investigation, and witness interviews, revealed on 5/8/2023 sometime around 7:20 AM Resident #1 ambulated from her last known location inside the building, roughly 143 feet to the junction of the East Wing hallway and the C Wing clinical unit, where she passed through an audibly alarmed door. The alarm malfunctioned and did not sound. Resident #1 exited the clinical unit undetected into the East Wing hallway to the rear of the facility, which was not in use. Resident #1 then turned right, (eastward) and ambulated another 189 feet to a delayed egress door located at the end of the East Wing. Resident #1 then exited the facility undetected, through the delayed egress door, which also malfunctioned and was not locked as a result. Once outside, Resident #1 turned right again, this time in a westward direction. Resident #1 followed the sidewalk around the rear corner of the building, bore right again and wandered approximately 100 feet from the exit point, down the sidewalk to an area behind the building, which was situated close to the central courtyard enclosed by a chain link fence, an adjacent grassy area, the employee parking lot, and access road. Resident #1 was spotted by staff inside, who intercepted her and escorted her back inside. Interview with Licensed Practical Nurse (LPN) #1 on 5/18/2023 at 11:48 AM in the conference room, revealed LPN #1 reported Resident #1's elopement was due to multiple door malfunctions which occurred simultaneously. LPN #1 reported the facility investigation of the incident initially focused on the failed audible alarm on the doorway between the C Wing hallway and East Wing which staff suspected but could not prove had been switched off/ deactivated by a resident, who by then, had discharged back home. LPN #1 reported the facility investigation determined the alarm was intact and working on the prior night shift, but no definitive cause of the mechanical failure was identified on the morning the incident occurred. LPN #1 reported the faulty audible alarm was replaced. Continued interview revealed LPN #1 reported the East Wing delayed egress door system malfunctioned due to a bent door hinge which prevented it from locking closed and arming the exit alarm and that was discovered minutes later during a systematic search of the facility after Resident #1 was returned inside, in which the door was found ajar and alarm silent. LPN #1 reported facility staff were aware Resident #1 wandered about the facility as part of her normal routine but were surprised she had exited the facility, as she did not usually exit seek, and on the morning of the occurrence had not exhibited unusual behaviors. LPN #1 confirmed facility staff were not aware Resident #1 had eloped both the clinical unit and the building until she was found outside. LPN #1 reported the facility Quality Assurance (QA) team evaluated the incident. LPN #1 reported the QA committee considered the incident a critical occurrence which placed Resident #1 at risk of serious injury, harm or worse, and multiple interventions were put in place afterwards to address the situation. Interview with the Maintenance Director on 5/18/2023 at 12:12 PM in the East Wing hallway, revealed on 5/8/2023, examination of the C Wing door alarm which malfunctioned showed the sliding power switch was not in the on position when examined by staff as they conducted door checks throughout the facility after Resident #1 was brought back inside. The Maintenance Director reported though no definitive evidence the unit had been manually turned off by someone was found, it was suspected that had occurred, as when the unit's sliding switch was moved back to the proper position fully engaged, it functioned as designed. Continued interview revealed the Maintenance Director reported nevertheless, he replaced the alarm with a new unit, with the sliding switch superglued into place in the on position to prevent any inadvertent dislodgements and performed the same modification to all other identical devices in use on other doors throughout the facility the same day. The Maintenance Director reported no other malfunctioning units were identified. Continued interview revealed the Maintenance Director reported the East Wing delayed egress door had malfunctioned due to misalignment of its magnetic locking mechanism, which had been caused by a sagging upper door hinge, which was not noted when the door was last checked on 5/4/2023, during routine weekly alarm checks. The Maintenance Director reported the defective hinge prevented the door from locking securely, allowing Resident #1 to open it without pushing on the release bar in the center of the door, which would have triggered an alarm. This was discovered on 5/8/2023, during the facility investigation, which began immediately after Resident #1's elopement occurred. The Maintenance Director reported staff determined Resident #1 eloped through the East Wing door as it was slightly opened and the alarm silent, when observed a few minutes after the incident. Interview with the Administrator on 5/18/2023 at 12:40 PM in the conference room, revealed the Administrator corroborated LPN #1's interview as related to the East Wing delayed egress door malfunction which led to Resident #1's elopement. The Administrator reported there was no conclusive evidence the malfunctioning audible alarm on the C Wing exit door inside the facility leading to the East Wing hallway had been deliberately manually deactivated by anyone as reported by LPN #1. He confirmed the unit was replaced. The Administrator confirmed staff inside the facility failed to detect Resident #1's elopement from the clinical area and confirmed her eventual exit from the East Wing also went undetected. The Administrator acknowledged Resident #1 was discovered outside, around 7:30 AM, 10 minutes after she was last seen inside, by a staff nurse, who had elected to take a break. The Administrator confirmed given the terrain around the facility and the fact Resident #1 was severely cognitively impaired those factors placed Resident #1 at risk of severe harm, injury, impairment, or death under the circumstances, despite the short duration of the incident. Interview with CNA #1 on 5/22/2023 at 1:35 PM in the conference room, revealed CNA #1 and CNA #2, along with three nurses LPN #1, LPN #2, and Registered Nurse (RN) #1, were assigned to the floor on the day Resident #1 eloped from the facility. CNA #1 reported the incident occurred near the conclusion of the morning tray pass/breakfast meal which usually began around 6:30 AM and ended by 7:30 AM. CNA #1 reported at the time she and CNA #2 were engaged in resident care, nursing staff were also active on the floor, as they passed morning medications and assisted the CNAs. CNA #1 reported at the time of the incident she was located near the A Wing kiosk charting on a resident. CNA #1 reported the staff on duty were familiar with Resident #1 and her routine of wandering about or briefly socializing in the halls near the nursing station after breakfast. CNA #1 stated she did not recall seeing Resident #1 approach any exits or testing doors that morning. CNA #1 reported that morning she did not recall hearing the C Wing door alarm sound. CNA #1 stated she last saw Resident #1 inside sometime between 6:30 AM and 7:00 AM on the B Wing where she lived, eating breakfast. CNA #1 stated she was aware LPN #1 was at the nursing station charting when Resident #1 was found. CNA #1 reported the facility usually staffed 5 persons in the morning for around 40 residents, and usually 3 of those personnel were CNAs, but on the day of the elopement, only 2 CNAs were present with 3 nurses instead. CNA #1 reported at the time of the incident Resident #1 was clothed but was not wearing shoes. CNA #1 reported Resident #1 usually wore socks instead. CNA #1 reported none of the floor staff were aware Resident #1 eloped until she was found outside by LPN #2. Interview with CNA #2 on 5/22/2023 at 2:00 PM in the conference room revealed she was also very familiar with Resident #1. CNA #2 recalled on the morning of the incident, she and CNA #1 were performing tray returns or tending to 4 or 5 of the facility's residents who were dependent for feeding. CNA #2 reported that morning all 3 nurses present were also assisting the CNAs while they performed their morning assessments and medication passes. CNA #2 stated around 7:30 AM, LPN #2 took a short break, but on her way to the break area saw Resident #1 outside, called for help, and went to recover the resident. CNA #2 reported it was raining lightly that morning, the sky was overcast, and the temperature was cool. CNA #2 reported when Resident #1 was returned inside, her hair was damp, she did not wear shoes normally, and her nonskid socks and the bottoms of her pajama pant legs were wet. CNA #2 stated she noted Resident #1 was shivering slightly when taken back to her room, where she was examined by RN #1 and changed into warm, dry clothing. CNA #2 reported afterwards, Resident #1 took a nap. CNA #2 reported she last observed Resident #1 in her room on the B Wing sometime between 6:30 AM and 7:00 AM during tray pass. CNA #2 also reported she did not recall hearing the audible alarm on the C Wing hall activate that morning and confirmed she too was unaware Resident #1 eloped until the resident was found outside by the nurse. Interview with RN #1 on 5/22/2023 at 4:00 PM in the conference room, revealed she was the nurse assigned to Resident #1 on the day she eloped. RN #1 reported she observed Resident #1 around 6:30 AM and again shortly after 7:00 AM on the B Wing hallway during medication pass. RN #1 reported Resident #1 did not appear anxious or agitated and was walking about the unit consistent with her usual daily routine. RN #1 reported LPN #2 found Resident #1 outside the rear of the facility around 7:25 AM and brought her back inside. RN #1 reported she was certain of the time, as she noted the time on her watch while the resident was brought back inside. RN #1 reported she assessed Resident #1 in her room immediately after she was returned to the facility. RN #1 reported the resident was not wearing shoes (as was customary), was dressed, but was damp. RN #1 stated she did not detect signs of injury or any evidence Resident #1 had fallen. RN #1 reported she did not recall hearing any door alarms sound that morning before the elopement. RN #1 reported a facility investigation was immediately launched and staff discovered the malfunctioning audible alarm on the door leading to the East Wing, which cued them to follow into the empty East Wing where they discovered the malfunctioning delayed egress door at the far end of the hall near where Resident #1 was found. RN #1 reported the delayed egress door was ajar, and no alarm was sounding there as well. RN #1 confirmed none of the clinical staff on duty that morning was aware Resident #1 had gotten outside until she was spotted by LPN #2 and brought back inside. Interview with the DON on 5/23/2023 at 1:00 PM in the conference room revealed the DON confirmed the facility investigation determined Resident #1 eloped due to door malfunctions at 2 different locations and staff on duty at the time were unaware Resident #1 was outside until she was located by LPN #2 around 7:30 AM. The DON reported she arrived at the facility as the incident was unfolding and initiated an investigation within minutes of Resident #1's recovery. The DON confirmed the C Wing door switch was in the off position and was immediately switched back on, but the facility could not conclude as to how that had occurred after interviewing all the night shift nurses from the previous shifts and the day shift staff on duty at the time. The DON reported there was no conclusive evidence a resident had deactivated the alarm. The DON reported she interviewed all alert and oriented residents on the C Wing who denied they had manipulated the alarm switch or heard it go off that morning. The DON also confirmed she observed the delayed egress door on the East Wing could be opened by simply pushing on the door, and it appeared the magnetic locking system there had also malfunctioned. The DON confirmed the facility investigation determined Resident #1 eloped from the facility via the East Wing delayed egress door to the rear of the building undetected by staff and the facility failed to ensure doors were secured. The DON confirmed Resident #1's elopement placed the cognitively impaired resident at risk of serious harm, injury, or death. Interview with LPN #2 on 5/23/2023 at 2:45 PM in the conference room, revealed LPN #2 reported on the day of the incident, she had completed her medication pass early and stated she usually never took her break early in the shift, but on 5/8/2023, decided to take a brief break to smoke, in the central courtyard, beneath a gazebo located outside the main dining area side doors. Continued interview revealed LPN #2 reported as she approached the dining area exit, she saw Resident #1 outside, as Resident #1 wandered on the sidewalk behind the closed East Wing, outside the chain link fenced in central courtyard, near the East Wing patio white wooden fence, adjacent to the parking lot. LPN #2 stated she and an orientee called out for assistance (missing resident code W), the orientee went inside to summon staff, she went outside, through a gate in the courtyard chain link fence, intercepted Resident #1 on the sidewalk, then held hands with her and conversed with the resident, as she escorted Resident #1 back inside, through the parking area, to the rear door of the main dining area. LPN #2 reported Resident #1 was profoundly confused as was her baseline, was shoeless, wore nonskid socks, was damp from drizzle, but returned inside without incident. LPN #2 acknowledged though Resident #1 was severely cognitively impaired, she was very mobile and may have traveled considerable distance from the facility in a short time span, had she not been intercepted. LPN #2 confirmed she had not heard an alarm sound that morning on the clinical unit, and nobody inside the facility was aware Resident #1 had eloped. The facility corrective actions included: 1. Corrective actions for the impacted resident: A. Resident #1 was immediately assessed by the RN upon return to the building on 5/8/2023 with no injuries noted. The responsible party, physician, psychiatric nurse practitioner and Administrator were advised of her status within minutes of the incident. No changes to Resident #1's medical regimen were required. Medical record review confirmed all notifications were made and Resident #1 was assessed for injury, with no injury noted. B. Resident #1 was placed on 1 to 1 observation after return to the building. She was transitioned to every 15- minute checks for 3 days upon order of the physician on 5/8/2023. Every 15-minute checks were completed until the morning of 5/11/2023. Review of facility documentation and interviews with staff confirmed Resident #1 was monitored as documented by the facility. C. Resident #1's path of egress was identified on 5/8/2023 at 7:40 AM. The doors were secured. Checks of all other exits were performed with no irregularities noted. The Maintenance Director assessed all doors and alarms at 8:00 AM, then replaced the defective alarm on the C Wing, and implemented temporary repairs to the East Wing door to correct misalignment (door shims) which were completed by 12:00 PM. A secondary alarm was added to the East Wing door as well. The door contractor was called to assess the East Wing door on 5/8/2023 after it was temporarily re-secured. Observations conducted during the survey confirmed all alarms were functioning and doors were secure. D. An ad hoc Quality Assurance (QA) meeting which involved all department heads and facility leadership was held at 8:15 AM on 5/8/2023. A root cause analysis of the incident was initiated by the DON. Additional interventions to address all persons potentially impacted by the incident were initiated. Corporate leadership was notified of the incident. Mandated reporting procedures were initiated. Interviews of involved staff were completed by the DON/designee. Review of facility documentation and interviews with staff confirmed the ad hoc QA was held as documented by the facility. E. Resident #1 was already care planned as at risk for elopement at the time of the incident. The elopement risk assessment was updated. The care plan was enhanced with additional interventions for wandering added on 5/8/2023 shortly after the incident occurred. Review of the elopement risk assessment and Resident #1's care plan confirmed the updates and interventions. Observations conducted of Resident #1 during the survey confirmed all care planned interventions were in place. F. Staff education related to the new care plan interventions specific to Resident #1 began on 5/8/2023 and were completed for all clinical employees by 5/11/2023. Interviews conducted with CNAs, LPNs and RNs during the survey showed all employees were knowledgeable of the care planned interventions for Resident #1. G. Reassessment of Resident #1's medications and medical regimen was completed by 9:30 AM on 5/8/2023. Review of the medical record confirmed Resident #1 was assessed by the provider. H. The facility began elopement drills and in-service retraining of all staff related to the missing resident procedure (Code W) across all shifts on 5/8/2023. Training related to the door alarms, recent door failures, and twice per shift door and alarm checks with corresponding logs were implemented. Review of facility documentation confirmed elopement drills were conducted on all shifts, including evenings and weekends. Interviews conducted with facility staff confirmed staff's understanding of the education provided. Review of facility documentation confirmed twice per shift door and alarm checks were performed and continued to be performed. I. Resident #1 was re-examined by the Medical Director on 5/10/2023 with no changes to her medications or medical regimen required. Review of the medical record confirmed Resident #1 was assessed by the Medical Director. 2. Interventions for other residents potentially impacted by the deficient practice: A. The facility performed elopement risk reassessments for all residents which began on 5/8/2023 and were completed on 5/11/2023. Any residents with new identified risks were added to the facility elopement risk book and additional care plan modifications were initiated consistent with facility policy. Review of facility documentation and medical record reviews confirmed elopement risks and care plans were updated for those residents identified as at risk. B. All residents identified as at risk for elopement had their identification bands checked on 5/8/2023 to ensure yellow bands were in place per the facility policy. No irregularities were noted. The elopement risk book was evaluated and found to be in order and up to date on 5/8/2023. Observations of Resident #1 and other residents identified as at risk confirmed the presence of yellow identification bands to alert staff of residents at increased risk of elopement. Review of the elopement risk book showed the book to be up to date. C. Elopement drills continued on all shifts 5/9/2023-5/13/2023 and included evening/night/weekend shift drills with continued training on the facility policy and procedures for missing persons and alarm checks/door checks twice per shift and prevention of elopements/identification of at- risk behaviors. Elopement drills were then randomized and continued at least once daily through 5/17/2023. The facility continued to perform spot check elopement drills on random shifts/intervals. Review of facility documentation confirmed elopement drills were performed, door and door alarm checks continued. Interviews conducted with the staff responsible for completing the door and door alarm checks confirmed their understanding of the checks. Interviews conducted with facility staff confirmed understanding and knowledge of elopement procedures. D. A second ad hoc QA meeting was held on 5/9/2023 to review progress of corrective actions to date and additional interventions identified for implementation going forward. 3. Systemic Measures Implemented: A. The door contractor visited the facility on 5/8/2023 and plans to replace the East Wing delayed egress door assembly were arranged. Corporate officials were advised, and the repair authorized. The necessary door assembly and hardware were ordered directly from the manufacturer by the contractor. A timeline for installation was made. The contractor evaluated temporary repairs made by the facility and deemed them sufficient to keep the East Wing door secure until a new replacement was installed. Multiple observations by the surveyor of the East Wing door during the survey confirmed the door was secure and alarm was functional. B. The offices for activities therapy department and Admissions Coordinator were moved from the front of the building to the East Wing to increase monitoring/visibility of the unoccupied section of the building on 5/8/2023. Observation by the surveyor confirmed the relocation of the offices to the East Wing. C. The QA committee reviewed the incident, findings to date and additional interventions moving forward on 5/13/2023. Convex mirrors were installed near the nursing station on the B/C Wing hallway to improve visibility of the impacted C Wing door. A convex mirror for the A/D Wing hall was also ordered and was installed immediately upon its receipt. The QA committee added review of the incident and corresponding interventions to the monthly agenda for 3 months through August 2023, and to re-evaluate the need for continued monitoring afterwards. Observation of the B/C Wing hallway confirmed the installation of the convex mirror to aid in visibility. D. The facility equipped all staff with walkie talkies on 5/16/2023. Appropriate charging stations and back up units were also acquired. Staff were trained on their use which was completed by 5/17/2023. Observation and interviews with staff during the survey confirmed the use of the walkie talkies and education provided on the use of the walkie talkies. E. Stop signs and secondary audible alarms were added to all facility exit doors as an added layer of security by 5/17/2023. Door checks twice per shift continued with no additional irregularities noted. The DON was responsible for monitoring alarm and door checks twice per shift were conducted. Observations of all egress doors confirmed the presence of the stop signs and secondary alarms. Review of facility documentation confirmed door and door alarm checks were conducted twice per shift. F. The facility altered its employee entrance/exit procedures and prohibited use of doors on the East Wing to be used to access the facility. All staff were notified via memo and oral instructions to department heads and daily morning meetings they were to enter the building at the front entrance or rear entrance by the dining hall only (for those who parked in the rear lot) on 5/10/2023. Compliance monitoring by Department Heads was ongoing. Observation by the surveyor during the survey showed no staff entering the facility through the East Wing door.