**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, facility investigation review, weather website review, surveillance camera video footage review, medical record review, and interview, the facility failed to provide adequate supervision and ensure a safe and secure environment to prevent an incident of elopement for 1 of 4 (Resident #1) sampled residents reviewed for elopement. The facility's failure to ensure a safe environment to prevent an elopement resulted in Immediate Jeopardy (IJ) when Resident #1 exited the facility without staff knowledge or supervision from the Staffing Coordinator's unlocked office door, that did not have a working alarm system in place on 12/17/2022. Resident #1 was discovered approximately 20 minutes later in an unlocked car with the ignition on and the engine running in the parking lot. 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 Interim Administrator, Director of Nurses, Regional Director of Operations, Regional Nurse Manager, and Director of Regional Nurses were notified of the Immediate Jeopardy at F-689 on 12/20/2022 at 5:02 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed 12/17/2022 - 12/22/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/21/2022 and was validated onsite by the surveyors on 12/22/2022 by policy review, medical record review, observation, review of education records, auditing tools, and staff and resident interviews. The findings include: 1. Review of the facility's policy titled, Elopements and Wandering Patients, with a revision date of 6/21/2022, revealed .The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and care .unique factors contributing to wandering or elopement risk .facility is equipped with door/alarms to help avoid elopements .establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions .monitoring for effectiveness .residents will be assessed for risk of elopement and unsafe wandering upon admission .adequate supervision will be provided to help prevent accidents or elopements .review physical plant to be sure alarms are working and that unauthorized areas are properly locked to prevent resident entry . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnosis of Metabolic Encephalopathy, Dementia, Behavioral Disturbance, Acute Kidney Failure, Pain, and Insomnia. Review of the facility's undated and unsigned ADMISSION/BASELINE CARE PLAN revealed, .ELOPEMENT RISK .PROBLEM .At risk for elopement . Review of a Care Plan dated 12/19/2022 revealed, .(Resident #1) has exhibited Wandering Behavior .12/17/2022 Patient exited building .Wanderguard was placed 12/17/2022 . Review of the medical record revealed no Minimum Data Set assessment was available due to Resident #1's admission date of 12/16/2022. Review of the medical record confirmed the facility failed to complete an Elopement Risk Assessment for Resident #1 upon his admission on [DATE]. Review of a Clinical Note dated 12/17/2022 at 3:01 PM revealed, .has severe dementia and confusion .does not use words appropriately and difficulty following simple commands .restless, wandering .ambulatory .has required 1:1 [one on one] care for most of the shift, unable to redirect .then began to wonder [wander] again. Review of a Nurses Event Note dated 12/17/2022 revealed, .At approximately 1805 [6:05 PM] I was notified that pt [patient - Resident #1] in [Resident #1's room number] was noted outside on the building in a parked vehicle near the kitchen door. Kitchen staff escorted the pt back into the building and notified me. At that time I Notified the DON [Director of Nursing] .The last time I saw the pt he was ambulating on the 100 hall with the staff as they were passing trays. This was at approximately 1745-1750 [5:45 PM - 5:50 PM] .skin tear noted on his anterior left lower leg . Review of an Initial Skin Injury Note dated 12/17/2022 revealed, .6.4 x (by) 2.7 x 0.2 skin tear to lower leg . 3. During observation of the surveillance camera video footage dated 12/17/2022 starting at 17:24, with the actual time being 5:44 PM (the Regional Director of Operations had stated during an interview on 12/19/2022 at 11:55 AM that the surveillance camera video footage was 20 minutes behind at all times), revealed Resident #1 was seen in the hallway outside of the main dining room wearing a gown and socks. At approximately 17:25 (actual time was 5:45 PM) the resident was seen at the corner of the Staffing Coordinator's door entrance, and then was no longer in sight on the surveillance camera video footage until 17:44 (actual time was 6:04 PM), when Dietary Staff brought Resident #1 back into the building from outside through the kitchen door. Resident #1 was outside unattended and unsupervised for approximately 20 minutes without staff knowledge. 4. Review of The Weather Channel.com Internet resource revealed the weather on 12/17/2022 at approximately 5:00 PM, was 39 degrees. 5. During an interview on 12/19/2022 at 12:38 PM, Dietary Staff #1 confirmed she went outside on 12/17/2022 at approximately 5:50 PM, saw an elderly man sitting in the passenger seat of Dietary Staff #2's car, and went back inside to notify Dietary Staff #2. Dietary Staff #1 and #2 went back outside to Dietary Staff #2's vehicle, found Resident #1 sitting in the vehicle, and brought him back inside the facility. Dietary Staff #1 confirmed it was cold outside, and Resident #1 was wearing non-skid socks and 2 gowns. During an interview on 12/19/2022 at 4:14 PM, Dietary Staff #1 confirmed that the ignition was on and the car was running while Resident #1 was sitting inside the vehicle. During an interview on 12/19/2022 at 12:55 PM, Dietary Staff #2 confirmed Resident #1 was found sitting inside her vehicle with the engine running. Dietary Staff #2 stated, [Resident #1] seemed very lost. He didn't know where he was. He was confused. Dietary Staff #2 confirmed it was a cold night and Resident #1 had socks and a gown on when he was found outside sitting in her car. During a telephone interview on 12/19/2022 at 4:20 PM, Dietary Staff #2 was asked if her car was running when Resident #1 was found sitting inside her car. Dietary Staff #2 stated, Yes, I went outside earlier to heat it . During an interview on 12/19/2022 at 2:13 PM, the DON confirmed Licensed Practical Nurse (LPN) #1 called her to inform her of the elopement by Resident #1. The DON confirmed she watched the surveillance camera video footage to learn from which door Resident #1 exited the facility. The DON confirmed she went to the area that he was last seen on the video and noticed the Staffing Coordinator's office door was unlocked, and the emergency exit door was ajar. The DON confirmed there was no alarm sounding when she entered the Staffing Coordinator's office. The DON was asked if an admission wandering/elopement assessment was completed when Resident #1 was admitted on [DATE]. The DON confirmed a wandering/elopement assessment was not completed on the night of Resident #1's admission. The DON confirmed that Resident #1 was wearing only a gown and non-skid socks on the night he eloped and stated, It was a little chilly that night . The DON confirmed Resident #1 should not have been left alone or unsupervised for almost 21 minutes. During an interview on 12/19/2022 at 2:44 PM, LPN #1 confirmed that Resident #1 wandered constantly. LPN #1 confirmed Resident #1 was found outside of the facility unattended, and stated it was very cold outside. LPN #1 confirmed Resident #1 sustained a skin tear to his left shin. During an interview on 12/19/2022 at 3:54 PM, Certified Nurse Assistant (CNA) #1 confirmed Resident #1 constantly wandered and was hard to redirect. CNA #1 stated, .his attention span was very short .he had a skin tear .after he was brought inside . During an interview on 12/20/2022 at 12:55 PM, the Maintenance Director confirmed and verified with a rolling meter measuring device that Resident #1 wandered from the Staffing Coordinators door inside of the facility, through the Staffing Coordinator's office and through the emergency exit door, into the staff parking lot where Resident #1 was found sitting inside a parked vehicle. The measured distance was approximately 145 feet. During observation and interview on 12/20/2022 at 9:50 AM, the Interim Administrator confirmed the door to the Staffing Coordinator's office should always be locked unless she was in her office. The Interim Administrator confirmed the alarm did not sound when the emergency exit door to go outside was opened. The Interim Administrator confirmed the emergency exit door in the Staffing Coordinator's office was not functioning properly. During an interview on 12/20/2022 at 12:38 PM, the Maintenance Director confirmed he did not check the emergency exit door in the Staffing Coordinator's office on a routine basis and stated, .because that was not a door we usually exited from . During an interview on 12/21/2022 at 11:18 AM, the Interim Administrator confirmed Resident #1 exited the facility unattended, unsupervised and without staff knowledge, was outside for approximately 20 minutes on a cold evening, and was found in a parked car with the engine running. The Interim Administrator confirmed this was unacceptable. 6. The surveyors verified the Allegation of Compliance (AOC) Removal Plan through record review, audit review, review of education and sign-in sheets, and interviews for the immediate corrective actions listed below. A. Resident #1 was assessed by Charge Nurse immediately on 12/17/2022 upon return to the facility with an abrasion to anterior left lower leg. Charge Nurse cleaned the abrasion and initiated an initial skin injury assessment. Fifteen minutes checks implemented immediately for Resident #1. Family of Resident #1 was notified on 12/17/2022 of the event by the Charge Nurse. The surveyor confirmed through interviews, and medical record review. B. 100% head count completed to determine location of all residents on 12/17/2022. Residents were accounted for. The Surveyor validated by review of the census count sheet to determine location of all residents on 12/17/2022. All Residents were accounted for. C. Door leading into the Staffing Coordinator's office from hallway and the door in the Staffing Coordinator's office were locked immediately on 12/17/2022. 100% audit completed by Director of Maintenance and Director of Nursing on 12/17/2022 to ensure proper functioning of all doors within facility. The Surveyor validated and confirmed through observation, interview and review of the documentation. D. Residents with wanderguards (4 total) were verified for placement and functionality by Nurse Management on 12/18/2022. The Surveyor validated the Residents with wander -guards (4 total) were verified for placement and functionality by Nurse Management on 12/18/2022 by interview, observation of Wanderguards on residents, and review of the provided documentation. E. Elopement risk assessments were reviewed and updated on 100% of facility residents by Nurse Management on 12/19/2022. Facility residents identified as high risk for elopement had care plans reviewed and revised as needed between 12/18/2022 and 12/19/2022. The Surveyor validated through interview and Care Plan review. F. The Interdisciplinary Team (IDT) team will review new admissions for completion of elopement risk assessments and implemented plans of care for resident's identified as high risk for elopement/wandering in the morning Quality Assurance (QA) meeting. The Surveyor validated through interviews with the DON. G. The facility's Elopement and Wandering Patients Policy was reviewed to reflect procedure for responding to alarms beginning on 12/17/2022. Procedures for responding to alarms include: a. Employees should identify location and respond to alarm timely b. Upon arrival to location of alarm, observe the physical environment both inside and outside for wandering residents. c. Complete a head count on wandering/exit seeking residents to determine location. d. If unable to locate a resident initiate the procedure for Locating a Missing Resident. The surveyor validated through interviews with the DON and staff. H. On duty personnel education initiated by Director of Nursing, Nurse managers and designees on 12/17/2022 on the steps to take when a resident exhibits behavior indicating exit seeking behaviors, the procedure for responding to alarms including checking the physical environment after responding to alarms and performing a head count of physical location of residents determined to be at risk for elopement/wandering. The Surveyor validated and confirmed through interview and review of the documentation. I. Off duty personnel upon return to work will be educated by Administrator, Nurse Managers, or designee on steps to take when a resident exhibits behavior indicating exit seeking, the procedure for responding to alarms to include checking the physical environment after responding to alarms and performing a head count of physical location of patients determined to be at risk for elopement/wandering, initiated on 12/17/2022. The Surveyor validated and confirmed through interview and review of the documentation. J. Newly hired personnel will be educated during orientation on identifying residents assessed to be high risk for elopement, on the elopement/wandering patient policy and procedure, the procedure for responding to alarms to include checking the physical environment after responding to alarms and performing a head count of physical location of patients determined to be at risk for elopement/wandering. The Surveyor validated and confirmed through review of the documentation in the facility onboarding orientation process. K. Staffing Agency personnel will be educated on identifying residents assessed to be high risk for elopement and elopement/wandering patient policy and procedure, the procedure for responding to alarms to include checking the physical environment after responding to alarms and performing a head count of physical location of patients determined to be at risk for elopement/wandering. The Surveyor validated and confirmed through interview and review of the in-service documentation. L. An elopement drill was initiated by Nurse Management on 12/18/2022. An elopement drill will take place on each shift 2 times per week for two weeks. If concerns are identified, the information will be communicated to the IDT and drills will continue until substantial compliance is achieved. If no concerns are identified at the end of two weeks, the information will be communicated to the IDT and facility will return to the previous auditing schedule. The surveyor validated through interview and review of documentation of elopement drills. M. Social Services Director interviewed resident on 12/18/2022 and the resident was found to have no psychosocial harm resulting from event. Social Services will continue to make daily assessments for 72 hours to ensure no psychosocial harm results. The surveyor validated through interview with the Social Services Director and medical record review. N. Door alarms were installed on 12/18/2022 on the fire doors leading to resident units by the Director of Maintenance and Director of Nursing. Fire doors will remain closed, and the alarm will alert staff if anyone is coming onto or is leaving the unit. The Surveyor validated through interviews and observation. O. A policy review was conducted on 12/19/2022 by the Regional Director of Operations and the Regional Nurse Manger with no new recommendations. The Regional Director of Operations and Regional Nurse Manager educated facility Administration and Nurse Managers on ensuring patient safety through monitoring elopement risks/concerns on 12/19/2022. The Surveyor validated through interview, review of policy, and review of in-service documentation. P. The Medical Director was notified by the Director of Nursing of the elopement on 12/19/2022. Members of the IDT (including Administrator, Director of Nursing, Regional Nurse Manager, Regional Director of Operations and Director of Regional Nurses) met with Medical Director. On 12/19/22 a QAPI review was conducted to discuss the incident and the interventions put in place for the individual resident and preventative measures going forward for all residents. Members of the IDT and Medical Director are in agreement with the protocols and interventions that were put in place to include; initiating every 15 minute checks on resident #1, locking the staffing coordinator office door, assessing residents for high risk for elopement, verifying wanderguards in use for placement and functionality, verifying proper functioning of all doors within facility, review of facility Policies and procedures to provide adequate supervision of residents, and closing firedoors on the hall and placing an alarm on the door to alert staff when the door is opened. The Surveyor validated through interview of the Medical Director. Q. The office door leading from the main hallway into the Staffing Office, the Staffing office door leading from the office to the outside, and the office door leading from the main dining room into the staffing office were locked on 12/17/22. Starting on 12/17/22, Maintenance Director to check exit door functionality daily x 5 days, and weekly thereafter. No adverse findings were noted. Any future adverse findings will be reported to the QA&A committee. The Surveyor confirmed through interview with the Maintenance Director and review of the maintenance log. R. The facility held a Governing Body meeting via phone conference on 12/18/22 and 12/20/22 to review and approve the facility's action plans. The surveyor validated by interview of the Assistant [NAME] President of Clinical Operations. The facility's noncompliance of F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.