**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide a safe environment and ensure supervision to prevent neglect for 1 of 3 sampled residents (Resident #36) reviewed for elopement risk. The facility's failure to provide care and services necessary to prevent neglect resulted in Immediate Jeopardy when Resident #36, a vulnerable resident with severe cognitive impairment was found 0.9 miles from the facility on a warm summer day. The facility was unaware of the resident's location for approximately 30-45 minutes. Resident #36 was located on the corner of a busy street in an [NAME] area by a facility staff member driving on her lunch break. 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 Administrative staff were notified of the Immediate Jeopardy on 7/14/2022 at 9:43 PM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-600. The facility was cited at F-600 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed on 6/2/2022 through 6/7/2022. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyors on 7/11/2022 through 7/14/2022. The IJ was cited as past noncompliance and the facility is not required to submit a Plan of Correction for F-600. The findings include: Review of the facility's policy titled, Abuse Prohibition Plan, revised 6/10/2021, revealed .This facility has a zero-tolerance policy for abuse .'Neglect' means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Review of the medical record, revealed Resident #36 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Altered Mental Status, Alcohol Abuse, Nicotine Dependence, and Dysarthria. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 0, which indicated Resident #36 had severe cognitive impairment. Review of the Care Plan dated 1/18/2022, revealed Resident #36 had a self-care deficit related to ambulation due to weakness. The interventions implemented included the resident was to call for assistance before ambulating. Resident #36 has an alteration in thought process and was difficult to understand. The intervention included to re-orient the resident to location and time as needed. Review of a Nurse's Progress Note dated 3/11/2022, revealed .I [Licensed Practical Nurse (LPN) #6] observed resident go to side door and held door until it open [opened]. Resident is slightly confused and wanders the hall. I redirected the resident to his room. Resident may benefit from wander guard [a monitoring device to alert staff of a resident attempting to exit the facility unattended] . Review of a Nurses' Progress Note dated 3/14/2022, revealed .Res [Resident] with some increased wondering [wandering] . Review of a Nurses' Progress Note dated 4/23/2022, revealed .Resident refused nicotine patch this AM [morning] and said that he does not want it anymore .tried to go out the outside door today. I could make out [understand] that he was trying to go somewhere but majority of his words are unintelligible . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 0, which indicated Resident #36 had severe cognitive impairment. Review of the Nurses Event Note dated 6/2/2022 at 12:30 PM, revealed Resident #36 left the building without an escort. Review of the Physician Order revealed, .Start Date .6/4/2022 .Wander Guard . Observation in the Smoke Shack on 7/11/2022 at 9:27 AM, revealed Resident #36 was seated in a wheelchair with other residents smoking a cigarette and was supervised by staff. Observation in the resident's room on 7/12/2022 at 8:22 AM, revealed Resident #36 was dressed, standing in the doorway, and his speech was garbled. During an interview on 7/12/2022 at 2:21 PM, the Activity Assistant Coordinator stated, .he [Resident #36] was standing to go smoke .by the door . never known him to be a smoker .this was around 10 or 11 [o'clock] [on 6/2/2022] around smoke time .around 3-4 [o'clock] [LPN #5] asked me if I heard about [Resident #36] I said I hadn't heard anything about elopement at all .she [LPN #5] said [Named Resident #36] had eloped .she [LPN #5] had picked him up and brought him back .said she [LPN #5] reported it to her supervisor .the next morning [Named the previous Director of Nursing (DON)] talked about it that he had eloped to the smoke shack and she wanted him placed on side 4 [Secure Unit] normally put people over there that wander or elope .which I felt was strange .it didn't add up to me .[LPN #5] wasn't here .she had called [the previous DON] told everything. [Named previous DON] told her [LPN #5] not to tell what happened .after that I guess they [Corporate] come [came] in and investigated .and found out [Named Previous DON] had lied about it .I said it had to be something deeper .he eloped on 6/2 [2022] .and they fired her the next day . During an interview on 7/12/2022 at 2:34 PM, the Administrative Specialist confirmed she was seated at the Receptionist Desk in the Front Lobby and stated, .he [Resident #36] came up and pushed his chair under the window .he walked outside .if he had wander guard he couldn't have got out it wouldn't opened .when he would come up .would let him outside and he would sit in the rocking chair .I didn't notice him coming back in . The Administrative Specialist confirmed she was unaware that Resident #36 had exit seeking behaviors. During an interview on 7/12/2022 at 2:44 PM, Dietary Aide #1 confirmed she saw Resident #36 exit the Breakroom door. Earlier in the day on 6/2/2022 Housekeeper #1 was outside by the Smoke Shack and assisted Resident #36 back into the facility. During an interview on 7/12/2022 at 3:05 PM, the Assistant Director of Nursing (ADON) confirmed the first time Resident #36 started to leave the facility by the Breakroom door, Dietary Aide #1 was in the Breakroom. The ADON confirmed he did not have a wander guard at that time and stated, maybe an hour or so [later] me and [Named previous DON] .went out to smoke .and she [previous DON] had told me that [Resident #36] had walked away from the facility .she [previous DON] was talking about the time he [Resident #36] actually eloped that day and that [LPN #5] had seen him on her lunch break and picked him up .didn't say what time it was .I didn't know he [Resident #36] had left and gotten out .my understanding that .[LPN #5] had called her [previous DON] and had seen him walking on the sidewalk and she [LPN #5] was picking him up and bringing him back to the facility .I told her we had to report it .told her thought we had 2 hours . she [previous DON] made the comment didn't want to do all that paperwork and I told her that he [Resident #36] had walked away from the facility .that he was gone .she [previous DON] was just laughing and joking and said we wouldn't have to report it .he [Resident #36] walked right in front of EMS [Emergency Medical Service] and down by the roundabout .by the gas station .she [previous DON] made the comment that we have family members that walk there and that if they saw him [Resident #36] they wouldn't think he was a resident .God was with him that day .she [previous DON] never reported it .she [previous DON] said you are going to have to help with the calls [to staff members] .it was the same day .at this point I'm thinking we are on the same page .nothing else was ever said about it . The ADON confirmed she did not make any calls that day and stated, The next morning .we had morning meeting and she [previous DON] didn't say anything about it .after the meeting she was like .[Named Regional Director of Operation] .had called her and had questioned her about it .and she [previous DON] was telling him about the incident with the time clock [at the Breakroom door] .and that's how I know she didn't report it .[previous DON] told him about the first incident .not the second and that's when Corporate came in and that's when I told them [Corporate] .I should have followed up and made sure .it just never crossed my mind I was dumb founded I should have went [gone] straight to the Administrator . The ADON confirmed that Resident #36 did not have a wander guard on at that time and that his exit seeking behaviors and wandering were never discussed in the morning meetings. During an interview on 7/12/2022 at 3:49 PM, LPN #5 stated, .I was on my lunch break .I was driving down the road .and saw [Resident #36] .walking down the sidewalk .not a whole mile .I turned around .I pulled off the road .I asked him [Resident #36] what was he doing .he mumbled the words out he wanted a beer and cigarettes .he seemed frustrated .I immediately notified my DON .sent her text message and she [previous DON] said bring him back to the facility .told her he [Resident #36] was wanting some cigarettes .and I asked her if that would be ok and she said yes .got him some cigarettes .when I brought him back here .checked him out .we went to his room .then I took him outside to smoke .and I stayed out there with him .he seemed to be ok .it was very hot and he walked quite a distance .it was around lunch time [12:00 PM] .after he was done smoking took him back to his room .I told his nurse to keep an eye on him .didn't tell her [his nurse] what happened was waiting for [previous DON] .to tell me what to do .went and saw her [previous DON] after that and she told me to leave it alone that she will handle it and told me to make a statement to give to her .this all happened on a Thursday .Friday I was scheduled to be off .I told [Activity Assistant Coordinator] .I think he [Activity Assistant Coordinator] saw me pull up in the parking lot .that was it .when all the other unfolded .[Previous DON] called me first and asked me did I tell anybody about the elopement and I told her I hadn't at that time .she said as you know it was not reported in a timely manner .she was just really trying to figure out if I had told anybody .[Regional Director of Operations] called me and told him exactly what had happened . LPN #5 confirmed Resident #36 had tried to get out of the facility and go smoke earlier that morning. During a telephone interview on 7/13/2022 at 8:30 AM, LPN #6 stated, .the door on side 3 .the one by the walk-way .he [Resident #36] went to the door and held the door [on 3/11/2022] .he is kinda [kind of] confused .and I said hold up .I did let someone know that he may need a wander guard .don't remember who .I may have even wrote [written] it on the 23 hour report . During an interview on 7/13/2022 at 8:46 AM, the Regional Nurse Manager confirmed no one had followed up on Resident #36's exit seeking behaviors on 3/11/2022 (when Resident #36 went to the door and held it open) and these behaviors should have been discussed in their morning meetings and stated, .that's one of the reasons the Director of Nursing was terminated . The Regional Nurse Manager confirmed that on 6/2/2022, Resident #36 had gotten outside that morning going to the Smoke Shack, and stated, .Should have investigated more .the Director of Nursing was told that he [Resident #36] went outside .said he was trying to go smoke .it happened at 10:30 [AM] and he was told they would take him out to smoke at 11:00 [AM]. The Regional Nurse Manager confirmed no one took him out to smoke. The Regional Nurse Manager was asked about Resident #36's elopement through the front door of the facility. The Regional Nurse Manager stated, .11:30-11:45 [AM] [Named Administrative Specialist] doesn't remember the time .a little before lunch she [Administrative Specialist] saw him [Resident #36] park his wheel chair in front the Receptionist window .and saw him go out the door .like he normally does .he sat down on the front porch .then they [LPN #5] found him on the sidewalk .this sounds horrible .when I found out .we could have prevented it .the Risk Manager [LPN #5] saw him on the sidewalk at 12:15 [PM] .he went through 3 red lights .got on the main highway on the sidewalk .she brought him back and assessed him for injuries .she [LPN #5] called the DON when she saw him on the highway . The Regional Nurse Manager also confirmed Resident #36 should have been assessed for a wander guard on the first incident and stated, He wasn't .I was off the day all this happened I was floored .the DON told the ADON that [Resident #36] had walked off the property and [LPN #5] brought him back .she [ADON] told her [the previous DON] to report it .and thought she [previous DON] was going to report it .she [ADON] didn't know she didn't .and because she [ADON] didn't follow up with .no one did anything till [until] the next day .no one addressed the elopement issue on the 2nd .she should have reported . During an interview on 7/13/2022 at 1:02 PM, the Regional Director of Operations stated, .I had gotten a phone call from an employee that we had elopement .didn't know anything about elopement .called the DON .the morning after the event .asked her [previous DON] about elopement she said she wasn't aware of any elopement .told her [previous DON] what I had heard .said she hadn't heard anything about that .but was an incident related to him [Resident #36] going out that morning .but they brought him right back in .later after that .I wasn't getting all the truth .and that's when we [Corporate] all came in .at first I thought we were ok if it was related to the first incident but then we became aware that there was another event that had taken place other than him going out the back door .there were 2 stories .heard patient [Resident #36] was picked up walking down the street .we started doing investigation and quickly discovered that she [previous DON] hadn't been truthful .then it was evident to us that she [previous DON] tried to sweep it under the rug .she knew it was a reportable .she told me that she made a mistake .and should have been honest with us . The Regional Director of Operations was asked what should have been done on 3/2022 when the nurse recognized Resident #36 had wandering behaviors. The Regional Director of Operations stated, .that note .should have triggered an elopement risk assessment . The Regional Director of Operations stated, .should have had an elopement risk assessment done .that's an exit seeking behavior .would have liked to have something implemented .because there wasn't an intervention set up .no implementation was done over here . The Regional Director of Operations confirmed if there had been an intervention in place, it may have stopped the elopement from happening the first time. During an interview on 7/13/2022 at 3:45 PM, Physician #2 confirmed she was not aware of Resident #36's wandering and exit seeking behaviors and stated, If someone had brought that to our attention .wanted to smoke and drink .could have called the family and got him some cigarettes and beer .shouldn't have been swept under the rug . Observations of the surrounding area on 7/14/2022 at 8:36 AM, revealed the facility is located on a dead-end side street along with an Ambulance Service nearby. Resident #36 had to walk past the Ambulance service to a busy two-lane street, walked through 2 red-lights. There were no sidewalks on the two-lane street, until he reached the 3rd red-light. He then turned right on a busy 4-lane street and walked on the sidewalk. Resident #36 had walked approximate 0.9 miles away from the facility and was out of the facility between 30-45 minutes. During an interview on 7/14/2022 at 6:32 PM, the Administrator was asked when an intervention should have been implemented when a resident had exit seeking/wandering behaviors. The Administrator stated, .immediately or as soon as possible . The Administrator was asked if an intervention should have been implemented to prevent elopement when the Resident #36 exhibited exiting seeking behaviors on 3/11/2022 (when Resident #36 held the door until it opened]. The Administrator stated, Yes ma'am. Anybody that has exit seeking behaviors should be assessed for interventions . The Administrator was asked if an intervention should have been implemented on 6/2/2022 when the resident exited the back door and was immediately brought back inside. The Administrator stated, . if a resident is exhibiting exit seeking behavior should have done an assessment and put an intervention in place to keep him from eloping .to see why .he is having a behavior and try to come up with interventions to keep it from happening . The facility's corrective action plan included the following: A. On 6/2/2022, Resident #36 left the facility without staff notification. Upon returning to the facility the resident was assessed by the Risk Manager and on 6/3/2022, the Physician, Responsible Party, Adult Protective Services, and State Regulatory Agency were notified. This was verified through review of the documentation and interviews with administration. B. On 6/2/2022, a Smoking Assessment was completed for Resident #36, and he was added to the smoking list for scheduled smoke breaks. The surveyor verified this through observations, review of the smoking list, and interviews with Administration and facility staff. C. On 6/3/2022, a head count was completed on all residents to ensure their locations. The surveyors verified this through review of the count sheet and interviews with Administration and facility staff. D. On 6/3/2022, visual signs were posted at the front entrance to remind staff, family members, and visitors not to assist residents outside the facility before checking with the nurse. The front door was locked to ensure all entrance and exits were monitored by employees. The surveyors verified this through observations of the signage on the facility doors, validation the doors were secured, locked, and being monitored, and staff interviews. E. A Resident head count was conducted for 48 hours. The surveyors verified this through review of the count sheet and interviews with Administration and facility staff. F. From 6/3/2022 through 6/6/2022, Elopement Risk Assessments were reviewed and updated on 100% (percent) of the residents. The surveyors verified this through review of the audit sheets and medical record review of the sampled residents. G. From 6/3/2022 through 6/6/2022, Smoking Assessments were reviewed and updated on 100% of residents. The surveyors verified this through review of the audit sheets and medical record review of sampled residents. H. On 6/3/2022, in-services began on the elopement policy/procedure: When resident exhibits exit seeking behaviors, staff are to determine why they are exit seeking. If a door alarms and you are unsure of the reason why, staff are to do a 100% resident audit to assure residents are in the facility, and staff must go outside immediately to see if a resident has exited the facility. Elopements must be reported within 2 hours of the incident. A staff member can report to their supervisor, then follow up with the Administrator to ensure reporting to the state agency was completed. Staff are to report to at least 2 supervisors. Staff that are off duty will be educated upon return to work or start of their shift on the Elopement and Wandering Patients policy, steps to take in responding to alarms, steps to take when a resident is exhibiting exit seeking behavior, and the reporting requirements for an elopement. The Nurse Manager that is on call will educate agency staff that have not already received the in-service. The surveyors verified this through a review of the in-service documentation and interviews with facility staff on all shifts. I. Residents were encouraged to sit outside in the Courtyard instead of the front porch. Staff are to go out to the Courtyard and frequently check on the residents. The surveyors verified this through observations and staff interviews. J. On 6/7/2022, all residents were educated by the Social Services Director/designee on proper Leave of Absence (LOA) and personal outing procedure. The surveyors verified this through a review of the in-service documentation and interviews with facility staff. K. On 6/7/2022, Resident representatives were educated by the Social Services Director/designee by text messaging, telephone calls and visual alerts on Leave of Absence personal outing process. The surveyors verified this through interviews with Administration and Social Services. L. All newly hired personnel will be educated during orientation on Elopements and Wandering Patient Policy for responding to alarms, residents with exit seeking behaviors, reporting requirements and head in the bed check. The surveyors verified this through interviews with recently hired staff and with Administration. M. An elopement drill was completed on 6/3/2022 and will continue 2 times a week on all shifts for two weeks. The results will be given to the Interdisciplinary Team (IDT) and drills may continue until substantial compliance is reached. The surveyors verified this through review of the elopement drill signature sheet and interviews with staff on all shifts. N. On 6/3/2022, a 100% door audit was completed to ensure proper functioning of all doors, to include the doorbell in place and functioning at the front door, for families, friends and visitors and the telephone number for entrance to the facility. The surveyors verified this through review of the door audits, signage on the facility doors, and interview with Administration. O. On 6/6/2022, the Regional Nurse Manger and the Regional Director of Operation educated facility administration and management on ensuring patient safety by monitoring elopement risks, concerns and reporting requirements. A policy review was conducted by the Regional Nurse Manger and the Regional Director of Operations with no new recommendations. The surveyors verified this through in-service documentation and interviews with Administration. P. On 6/7/2022, a Quality Assurance Performance Improvement (QAPI) meeting was held to discuss the incident, the interventions that had been implemented for the individual resident and preventive measures for all residents. The surveyors verified this through review of the QAPI sign in sheet and interviews with Administration and the Medical Director. Q. On 6/7/2022, the Regional Director of Operations updated the Physician and the Medical Director on the action plan. The surveyors verified this through interviews with the Regional Director of Operations, the Physician, and the Medical Director. R. On 6/7/2022, the facility held a telephone conference with the Governing Body to review and approve the action plan to provide supervision to prevent residents assessed for elopement from leaving the facility without staff knowledge. It was also discussed to offer the individual resident alcohol during the day or night. The surveyors verified this through Administration interviews. S. On 6/7/2022, placement options were discussed again for Resident #36 and agreed that the current interventions that were in place were sufficient to allow him to stay at the facility and to discontinue 1 on 1 surveillance. Every 1-hour checks had been continued for 24 hours to see if he was an active elopement risk. There were no elopement attempts and the 1-hour checks were discontinued. The family was made aware. The surveyors verified this through review of the documentation of the 1 hour checks for 24 hours and interviews with staff and Administration. T. On 6/8/2022, the Physician gave a verbal order for the individual resident to have 2 beers a day as needed. The surveyors verified this through review of the Physician Orders, documentation of the beer given to the resident, and interviews with staff and Administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, weather website review, medical record review, observation, and interview, the facility failed to ensure a safe, secure environment for 1 of 3 sampled residents (Resident #36) reviewed for elopement/wandering. The facility's failure to ensure a safe, secure environment resulted in Immediate Jeopardy when Resident #36, a vulnerable cognitively impaired resident, exited the facility unsupervised through an unlocked door. Resident #36 was found by a facility staff member driving on her lunch break approximately 0.9 miles from the facility, approximately 30-45 minutes later. 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 and impairment or death to a resident. The Administrator and the Administrative staff were notified of the Immediate Jeopardy (IJ) on 7/14/2022 at 9:43 PM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed from 6/2/2022 through 6/7/2022. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyors on 7/11/2022 through 7/14/2022. The IJ was cited as past noncompliance and the facility is not required to submit a Plan of Correction for F-689. The findings include: Review of the facility's policy titled, Elopements and Wandering Patients, revised 6/21/2021, revealed .This facility ensures that residents who exhibit wandering behavior .receive adequate supervision .Elopement occurs when a resident leaves the premise or a safe area without authorization .and/or necessary supervision to do so . Review of the medical record, revealed Resident #36 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Altered Mental Status, Alcohol Abuse, Nicotine Dependence, and Dysarthria. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 0, which indicated Resident #36 had severe cognitive impairment. Review of the Care Plan dated 1/18/2022, revealed Resident #36 had a self-care deficit related to ambulation due to weakness. The interventions included to call for assistance before ambulation. Resident #36 had an alteration in thought process and was hard to understand. The intervention included re-orient to location and time as needed. Review of the Progress Note dated 3/11/2022, revealed Licensed Practical Nurse (LPN) #6 observed Resident #36 go to the side door and Resident #36 held the door until it opened. The resident was slightly confused and wandered the hall. LPN #6 redirected Resident #36 to his room and determined the resident might benefit from the use of a wander guard (a monitoring device to alert staff of a resident attempting to exit the facility unattended). Review of the Progress Note dated 3/14/2022, revealed Resident #36 had demonstrated increased wandering. Review of the Elopement Risk assessment dated [DATE], Resident #36 was assessed as not being at risk for wandering. Review of the Progress Note dated 4/23/2022, revealed .[Resident #36] tried to go out the outside door today. I could make out [understand] that he was trying to go somewhere but majority of his words are unintelligible . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 0, which indicated Resident #36 had severe cognitive impairment. Review of the Nurses' Event Note dated 6/2/2022 at 12:30 PM, revealed Resident #36 left the building without an escort. Review of weather.com, revealed the high temperature for this area on 6/2/2022 was 81 degrees. Observation in the Smoke Shack on 7/11/2022 at 9:27 AM, revealed Resident #36 was seated in a wheelchair with other residents smoking a cigarette and was supervised by staff. Observation in the resident's room on 7/12/2022 at 8:22 AM, revealed Resident #36 was dressed appropriately, standing in the doorway, and his speech was garbled. During an interview on 7/12/2022 at 2:15 PM, Housekeeper #1 stated, .saw him [Resident #36] walking out the door .and I knew it wasn't smoke time .I turned him round .brought him back in . Housekeeper #1 stated this incident occurred earlier the same day he eloped through the front door, and he had reported it to the previous Director of Nursing (DON). During an interview on 7/12/2022 at 2:44 PM, Dietary Aide #1 stated, .he [Resident #36] was sitting in the Breakroom by himself by the time clock .he wasn't in the wheelchair .I walked in the Breakroom .just me and him .the door alarm went off .he [Resident #36] jumped up .he walked towards the door .the alarm was still going off .he [Resident #36] was outside .[Housekeeper #1] was bringing him back in and asked me why did I let him out .I said I didn't let him out .it wasn't smoke time . Dietary Aide #1 confirmed this incident occurred before the elopement on 6/2/2022. During an interview on 7/12/2022 at 2:44 PM, the Administrative Specialist stated, .[Resident #36] came up and pushed his chair under the window .he walked outside .I didn't notice him coming back in . During an interview on 7/12/2022 at 3:05 PM, the Assistant Director of Nursing (ADON) stated, .he [Resident #36] went to go out the first time by the time clock door [in the Breakroom] .Dietary Aide [#1] had gotten up and answered the door alarm .he was pushing to get out of it .the door opened and [Housekeeper #1] was standing right outside the door .he had walked out door .[Housekeeper #1] brought him right back in .that was right around lunch time . The ADON confirmed he did not have a wander guard at that time and stated, .later on maybe an hour or so [later] me and [Named previous DON] .went out to smoke .and she [previous DON] had told me that [Resident #36] had walked away from the facility .she [previous DON] was talking about the time he [Resident #36] actually eloped that day and that [LPN #5] had seen him on her lunch break and picked him up .didn't say what time it was .I didn't know he [Resident #36] had left and gotten out .my understanding that .[LPN #5] had called her [previous DON] and had seen him walking on the sidewalk and she [LPN #5] was picking him up and bringing him back to the facility .I told her we had to report it .told her thought we had 2 hours . she [previous DON] made the comment didn't want to do all that paperwork and I told her that he [Resident #36] had walked away from the facility .that he was gone .she [previous DON] was just laughing and joking and said we wouldn't have to report it .he [Resident #36] walked right in front of EMS [Emergency Medical Service] and down by the roundabout .by the gas station .she [previous DON] made the comment that we have family members that walk there and that if they saw him [Resident #36] they wouldn't think he was a resident .God was with him that day .she [previous DON] never reported it .she [previous DON] said you are going to have to help with the calls [to staff members] .it was the same day .at this point I'm thinking we are on the same page .nothing else was ever said about it . The ADON confirmed she did not make any calls that day and stated, The next morning .we had morning meeting and she [previous DON] didn't say anything about it .after the meeting she was like .[Named Regional Director of Operation] .had called her and had questioned her about it .and she [previous DON] was telling him about the incident with the time clock [at the Breakroom door] .and that's how I know she didn't report it .[previous DON] told him about the first incident .not the second and that's when Corporate came in and that's when I told them [Corporate] .I should have followed up and made sure .it just never crossed my mind I was dumb founded I should have went [gone] straight to the Administrator . The ADON confirmed that Resident #36 did not have a wander guard on at that time and that his exit seeking behaviors and wandering were never discussed in the morning meetings. During an interview on 7/12/2022 at 3:49 PM, LPN #5 stated, .I was on my lunch break .I was driving down the road .and saw [Resident #36] walking down the sidewalk .not a whole mile .I turned around .pulled off the road .it was him [Resident #36] .I asked him what was he was doing .he mumbled the words out he wanted a beer and cigarettes .he seemed frustrated .I immediately notified my DON .I sent her a text message and she [previous DON] said bring him back to the facility .told her he was wanting some cigarettes .I asked her if that would be ok .she said yes and .got him some cigarettes .I got him a cheeseburger and sprite .I brought him back here .then I took him outside to smoke .and I stayed out there with him .he seemed to be ok .it was very hot and he walked quite a distance .it was around lunch time [12:00 PM] . During an interview on 7/13/2022 at 8:46 AM, the Regional Nurse Manager stated, .on 3/16/2022 .had another elopement assessment and [Resident #36] was not considered an elopement risk .6/3/2022 .risk assessment .because of the elopement .he does not have exit seeking behaviors now .he is at risk for elopement because he has history of exit seeking behaviors .think we have resolved his issues .we have put him on the smoking list .he was on a nicotine patch on admission .he started refusing those in March [2022] .nobody let him out .he just walked out the front door . The Regional Nurse Manager confirmed no one followed up with the 3/11/2022 incident when Resident #36 attempted to get out the door, and stated, .that should have been talked about in the morning meeting .Resident #36 had got outside that morning on 6/2/2022 by the Smoke Shack .saw him go out and brought him right back in .should have investigated more .the previous DON was told that he went outside .he was trying to go smoke . The Regional Nurse Manager confirmed no one took him out to smoke and that the previous DON should have placed Resident #36 on the smoking list. The Regional Nurse Manager stated, .between 11:30-11:45 [AM] [Named Administrative Specialist] doesn't remember the time .a little before lunch she [Administrative Specialist] saw him [Resident #36] park his wheelchair in front of the Receptionist window .like he normally does .and saw him go out the door .like he normally does .he sat down on the front porch .then they [LPN #5] found him on the sidewalk .this sounds horrible .when I found out .we could have prevented it .the Risk Manager [LPN #5] saw him on the sidewalk at 12:15 [PM] .he went through 3 red lights .got on the main highway on the sidewalk .she got him in the car . The Regional Nurse Manager confirmed Resident #36 should have been assessed and given a wander guard on the first incident on 6/2/2022, and stated, .he wasn't . During a telephone interview on 7/13/2022 at 3:11 PM, the Associate Medical Director stated, .got a phone call from [Regional Director of Operations] what had happened .fortunately [LPN #5] had seen him [Resident #36] walking down the street, Thank God .got him back in the building .something like that is serious . Observation in the hallway on 7/14/2022 at 8:18 AM, revealed Resident #36 dressed and propelling himself in a wheelchair. Observations of the surrounding area on 7/14/2022 at 8:36 AM, revealed the facility is located on a dead-end side street with an Ambulance service nearby. Resident #36 had to walk past the Ambulance service to a busy two-lane street, had to walk through 2 red-lights, and there were no sidewalks on the two-lane street until he reached the 3rd red-light. He then turned right on a busy 4-lane street and walked on the sidewalk. Resident #36 had walked approximately 0.9 miles from the facility and was gone from the facility between 30-45 minutes. The facility's corrective action plan included the following: A. On 6/2/2022, Resident #36 left the building without staff notification. Upon returning to the facility, he was assessed by the Risk Manager and on 6/3/2022, the Physician, Responsible Party, Adult Protective Services, and State Regulatory Agency were notified. B. On 6/2/2022, a Smoking Assessment was completed for Resident #36, and he was added to the smoking list for scheduled smoke breaks. The surveyor verified this through observations, review of the smoking list, and interviews with Administration and facility staff. C. On 6/3/2022, a head count was completed on all residents to ensure their location. The surveyors verified this through review of the head count sheet and interviews with Administration and facility staff. D. On 6/3/2022, visual signs were posted at the front entrance to remind staff, family members, and visitors not to assist residents outside before checking with the nurse. The front door was locked to ensure notification all entrance and exits were monitored by employees. The surveyors verified this through observations of the signage on the facility doors, observation the doors were secured and locked and being monitored, and staff interviews. E. A resident head count was conducted for 48 hours. The surveyors verified this through review of the count sheet and interviews with Administration and facility staff. F. From 6/3/2022 through 6/6/2022, Elopement Risk Assessments were reviewed and updated on 100% of the residents. The surveyors verified this through review of the audit sheets and medical record review of sampled residents. G. From 6/3/2022 through 6/6/2022, Smoking Assessments were reviewed and updated on 100% of the residents. The surveyors verified this through review of the audit sheets and medical record review of sampled residents. H. On 6/3/2022, in-services began on the elopement policy/procedure which included when a resident exhibits exit seeking behaviors, determine why they are exit seeking. If a door alarms and you are unsure of the reason why, do a 100% resident audit to assure that residents are in the facility, and staff must go outside immediately to see if a resident has exited the facility. Elopements must be reported within 2 hours of the incident. The elopement can be reported to their supervisor, and then follow up with the Administrator to ensure the incident was reported to the state agency. Staff are to report to at least 2 supervisors. Staff that are off duty will be educated upon return to work or start of their shift on the Elopement and Wandering Patients policy, steps to take responding to alarms, when a resident is exhibiting exit seeking behaviors and reporting requirements for an elopement. The Nurse Manager that is on call will educate agency staff that had not already received the in-service. The surveyors verified this through a review of the in-service documentation and interviews with facility staff on all shifts. I. Residents were encouraged to sit outside in the Courtyard instead of on the front porch. Staff are to go out to the Courtyard and frequently check on the residents. The surveyors verified this through observations and staff interviews. J. On 6/7/2022, all residents were educated by the Social Services Director/designee on proper Leave of Absence (LOA) and personal outing procedure. The surveyors verified this through a review of the in-service documentation and interviews with facility staff. K. On 6/7/2022, the resident's representatives were educated by the Social Services Director/designee by text messaging, telephone calls and visual alerts on the LOA personal outing process. The surveyors verified this through interviews with Administration. L. All newly hired personnel will be educated during orientation on Elopements and Wandering Patient Policy for responding to alarms, residents with exit seeking behaviors, reporting requirements and head in the bed check. The surveyors verified this through interviews with newly hired staff and with Administration. M. An elopement drill was completed on 6/3/2022 and will continue 2 times a week on all shifts for two weeks. The results will be given to the Interdisciplinary Team ( IDT) and drills may continue until substantial compliance is reached. The surveyors verified this through review of the elopement drill signature sheet and interviews with staff on all shifts. N. On 6/3/2022, a 100% door audit was completed to ensure proper functioning of all doors, to include doorbells in place and functioning at the front door, for families, friends and visitors and the telephone number for entrance to the facility. The surveyors verified this through review of the door audits, signage on the facility doors, and interview with Administration. O. On 6/6/2022, the Regional Nurse Manger and the Regional Director of Operation educated facility administration and management on ensuring patient safety by monitoring elopement risks, concerns, and reporting requirements. A policy review was conducted by the Regional Nurse Manger and the Regional Director of Operations with no new recommendations. The surveyors verified this through in-service documentation and interviews with Administration. P. On 6/7/2022, a Quality Assurance Performance Improvement (QAPI) meeting was held to discuss the incident, the interventions that had been implemented for the individual resident and preventative measures for all residents. The surveyors verified this through review of the QAPI sign in sheet and interviews with Administration and the Medical Director. Q. On 6/7/2022, the Regional Director of Operations updated the Physician and the Medical Director on the action plan. The surveyors verified this through interviews with the Regional Director of Operations, the Physician, and the Medical Director. R. On 6/7/2022, the facility held a telephone conference with the Governing Body to review and approve the action plan to provide supervision to prevent residents assessed for elopement from leaving the facility without staff knowledge. It was also discussed to offer the individual resident alcohol during the day or night. The surveyors verified this through Administration interviews. S. On 6/7/2022, placement options were discussed again for Resident #36 and agreed that the current interventions that were implemented were sufficient to allow him to remain at the facility and to discontinue 1 on 1 surveillance. Every 1-hour checks had been continued for 24 hours to see if he was an active elopement risk. No elopement attempts were made, and the 1-hour checks were discontinued. The family was made aware. The surveyors verified this through documentation of the 1-hour check for 24 hours and interviews with staff and Administration. T. On 6/8/2022, the Physician gave a verbal order for the individual resident to have 2 beers a day as needed. The surveyors verified this through review of the Physician Orders, documentation of the beer given, and interviews with staff and Administration.