**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation, facility policy review, medical record review, and interview, the facility failed to revise a wandering/elopement care plan for 1 of 2 sampled residents (Resident #39) reviewed for wandering and elopement risk (Residents who have a history of leaving or trying to leave the facility, or have wandered or have potential to wander into unsafe areas), placing the resident in an Immediate Jeopardy (IJ) (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 facility failed to update Resident #39's care plan with new interventions which resulted in an elopement from the facility on 5/23/2022 with a fall with major injury, a Right Femoral neck fracture (hip fracture). The Administrator was notified of the Immediate Jeopardy on 7/12/2022 at 12:47 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-657. The facility was cited a F-657 at a scope and severity of J. The Immediate Jeopardy was removed onsite and was effective from 4/23/2022 to 7/12/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 7/12/2022 at 7:29 PM. The corrective actions were validated on site by surveyors on 7/12/2022. The facility's noncompliance at F-657 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The findings include: Review of the facility's undated policy titled, Policy for Care Plan Updates and Review, revealed, .Review for your department, initial assessment, current (last) update, and any mini assessments (assessments for identifying residents at risk or any other tool utilized as a supplement to the MDS [Minimum Data Set]) and discipline specific assessment tools completed on admission .Update the assessment so that it describes the functional and dysfunctional changes since the last assessment .Review the most recent care plan .Modify or re-write problems/goals/approaches for the department based upon future needs of the resident described in your progress note. Confer with other pertinent departments if appropriate .At care plan conference, integrate your input with other departments . Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses which included Dementia with Behavioral Disturbances and Chronic Obstructive Pulmonary Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Continued review revealed Resident #39 required a wander guard daily because she exhibited behaviors of wandering. Continued review revealed the resident required supervision with walking in the room, in corridor and with locomotion on/off the unit. Review of Resident #39's care plan dated 3/21/2022 revealed .CODE ALERT BRACELET R/T [RELATED TO] ELOPEMENT RISK .Alert staff to resident's wandering behavior .If resident elopes from facility protocol for locating resident .Monitor and document resident behavior at least twice daily .Report increase in negative findings to physician . Review of Resident #39's physician notes dated 3/9/2022 revealed Resident #39 was prescribed a Code Alert Bracelet related to a history of elopement at another facility. Review of Resident #39's Progress Notes dated 4/23/2022 revealed .RES. [Resident] WENT OUT BACK DOOR AND DOWN THE RAMP, WAS RE-DIRECTED BACK IN PER STAFF. RES. HAS BEEN WALKING ALL OVER THE FACILITY TODAY. GETS VERY AGITATED WHEN STAFF RE-DIRECTS. AT THIS TIME RES. IS SITTING IN HER RECLINER . Review of Resident #39's Progress Notes dated 4/24/2022 revealed .RES. WENT OUT FRONT DOOR WITH RW [Rolling Walker] ALARM SOUNDED D/T [due to] WANDER GUARD. RE-DIRECTED BACK IN . Review of Resident #39's Progress Notes dated 5/6/2022 revealed .DOOR ALARM SOUNDED AND TECHS WENT TO FRONT DOOR. RESIDENT WAS FOUND ABOUT 100 FEET OUTSIDE FACILITY . Review of Resident #39's Progress Notes dated 5/20/2022 revealed .RES. ELOPED OUT THE DOOR ON THE WARDS HALL, WAS RE-DIRECTED BACK IN. RES. NOW SITTING IN DR [dining room] FOR SUPPER . Review of Resident 39's Progress Notes dated 5/21/2022 revealed .RES. HAS BEEN WANDERING AROUND FACILITY ALL DAY AT A FAST PACE. DID ELOPE OUT THE PATIO DOOR. RES. DID REFUSE TO COME BACK IN FOR CNA [Certified Nursing Assistant], BUT NURSE RE-DIRECTED RES. BACK IN. RES. VERY AGITATED WHEN RE-DIRECTED FOR ANY REASON. RES. AT THIS TIME SITTING IN THE BIRD ROOM . Review of Resident #39's Progress Notes dated 5/22/2022 revealed .RES. FOLLOWED STAFF OUT BACK DOOR, WAS RE-DIRECTED BACK IN AND ENCOURAGED TO SIT IN HER RECLINER. RES. HAS STAYED IN HER ROOM FOR A WHILE . Review of Resident #39's Progress Notes dated 5/23/2022 revealed .FOR APPROX 6:30 PM RESIDENT CODE ALERT ALARM WAS HEARD SOUNDING TO ALERT STAFF OF EXIT OUTWARD HALL BACK DOOR. CNA TO BACK DOOR AND RESIDENT OBSERVED WALKING ACROSS BACK PARKING LOT. WHEN CNA CALLED FOR RESIDENT TO STOP SHE TOOK OFF RUNNING, SHE THEN TRIPPED OVER CONCRETE CAR STOP AND STRUCK HER HEAD ON HANDICAPPED PARKING SIGN ON THE WAY DOWN. SHE THEN LANDED ON HER RIGHT-SIDE HIP AREA AND WHEN NURSES STAFF GOT TO HER FOR ASSESSMENT SHE COMPLAINED OF RIGHT LEG AND HIP PAIN AND COULD NOT STRAIGHTEN HER RIGHT LEG. SHE WAS KEPT IN THE POSITION SHE WAS FOUND IN UNTIL EMS [Emergency Medical Service] ARRIVED FOR TRANSPORT. SON WAS CONTACTED BY [named nurse] TO NOTIFY OF FALL AND THEN AGAIN BY [named nurse] TO CONFIRM AS TO WHICH HOSPITAL FAMILY WOULD PREFER TRANSPORT TO THEY CHOSE [named hospital]. SHE DID NOT APPEAR TO HAVE ANY OTHER INJURY NOTED INCLUDING NO INJURY NOTED TO HEAD DESPITE STRIKING HEAD. WILL AWAIT FURTHER REPORT FROM HOSPITAL . Review of Resident #39's Progress Notes dated 5/24/2022 revealed .REPORT RECEIVED FROM NURSE [named nurse] FROM ED [Emergency Department][named hospital]. RESIDENT NOTED BROKEN RT [right]. HIP. SX [surgery] SCHEDULED TOMORROW 5/24/22 AT [named hospital]. FAMILY PRESENT AT [named resident] AND AWARE OF ALL FINDINGS PER [named nurse] . Review of the History and Physical dated 5/23/2022 revealed, XXX[AGE] year-old female presents to clinic today from the Emergency Department for right hip pain. She stated that yesterday evening while walking outside she tripped and fell and landed on right hip. She had immediate pain and swelling to the area and was transported via EMS [emergency medical services] to [named hospital] for she was seen in the emergency department and received x-rays. X-rays revealed a fracture of the right femoral neck .Patient reports decreased range of motion secondary to pain as well as a palpable deformity along the lateral hip at the proximal femur area . During an interview on 7/12/2022 at 11:19 AM, the MDS Coordinator confirmed Resident #39's care plan had not been updated after each elopement since 3/21/2022 when she was admitted to the facility. Continued interview she confirmed there should be new interventions in place after each elopement event. The surveyors verified acceptable Immediate Action Removal Plan on 7/12/2022 by: 1.) The surveyors verified through review of the education completed on 7/12/2022 and interviews with various Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Housekeeping, and Maintenance regarding verifying elopement, missing person, policies, and procedures. 2). The surveyors verified through review of the care plans completed on 7/12/2022 residents were identified as risk for wandering and elopement and interventions were put in place or updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation review, facility policy review, medical record review, and interview, the facility failed to provide adequate supervision to prevent elopement for 1 of 2 sampled residents (Resident #39) reviewed for wandering and elopement risk (Residents who have a history of leaving or trying to leave the facility, or have wandered or have potential to wander into unsafe areas), placing the resident in an Immediate Jeopardy (IJ) (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 facility's failure to supervise Resident #39 resulted in an elopement from the facility on 5/23/2022 and a fall with major injury resulting in a Right Femoral neck fracture (hip fracture). The facility also failed to prevent a fall for 1 of 7 sampled residents (Resident #16) which resulted in a major injury, a left Femoral Neck fracture (hip fracture), which caused an actual harm but did not rise to the level of IJ. The Administrator was notified of the Immediate Jeopardy on 7/12/2022 at 12:47 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-689. The facility was cited a F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 4/23/2022 to 7/12/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 7/12/2022 at 7:29 PM. The corrective actions were validated on site by surveyors on 7/12/2022. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The findings include: Review of the facility documentation 9/2017 revealed .Upon discovery of a missing resident: Alert all staff on the unit. Conduct a quick but thorough search of the unit and logical places where resident may have gone. If a resident cannot be located, the Nurse in charge of the area shall be responsible for notifying the Administrator and page overhead. This will alert all staff that a resident is missing. Immediate attempts shall be made to determine where the resident was last seen and what the resident was wearing . Review of the undated facility policy titled, Wandering/Eloping Patients revealed .Patients shall be assessed upon admission to determine the possibility of the patient trying to leave the facility. If there is a concern, a Code Alert Bracelet shall be placed on the patient, the patient walker, or the patient wheelchair as per the determined need. The Code Alert Bracelet will set off the Alarm should the patient go out any exit door. If a patient should exit the building without the knowledge of staff and it is discovered, a facility-wide search shall be made for the patient, both inside the facility and the area of the entire campus grounds. If the patient is not found within 15 minutes, the police shall be called, and the Administrator notified if not on the premises. The patient's family shall be notified . Review of the facility undated policy titled, Fall Prevention Policy, revealed, .[Named Facility] wants to provide a safe environment for all residents. And therefore utilizes different steps to prevent harm .A fall risk assessment shall be done on any resident who is considered at risk for falls .The Director of Nursing shall do an investigation following each fall to determine if proper interventions have been implemented; to ensure the care plan has been updated; and to monitor the results of the planned interventions .Incident reports shall be completed upon any incidental fall and charge nurses shall monitor patient for any sign of injury. Family member/responsible party shall be notified regarding the incident; the patient physician; the pharmacy consultant; and the therapy department .Resident-centered interventions shall be implemented following each fall to try to reduce the resident's risk of future falls .Falls shall be reviewed by the QA Committee during each meeting to monitor the number of falls, the effectiveness of the interventions, and to review and assess for any patterns that might be pertinent to the cause of any of the falls . Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses which included Dementia with Behavioral Disturbances and Chronic Obstructive Pulmonary Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Continued review revealed Resident #39 required a wander guard daily because she exhibited behaviors of wandering. Continued review revealed the resident required supervision with walking in the room, in corridor and with locomotion on/off the unit. Review of Resident #39's care plan dated 3/21/2022, revealed .CODE ALERT BRACELET R/T [RELATED TO] ELOPEMENT RISK .Alert staff to resident's wandering behavior .If resident elopes from facility protocol for locating resident .Monitor and document resident behavior at least twice daily .Report increase in negative findings to physician . Review of Resident #39's physician notes dated 3/9/2022, revealed Resident #39 was prescribed a Code Alert Bracelet related to a history of elopement at a previous facility. Review of Resident #39's Progress Notes dated 4/23/2022, revealed .RES. [Resident] WENT OUT BACK DOOR AND DOWN THE RAMP, WAS RE-DIRECTED BACK IN PER STAFF. RES. HAS BEEN WALKING ALL OVER THE FACILITY TODAY. GETS VERY AGITATED WHEN STAFF RE-DIRECTS. AT THIS TIME RES. IS SITTING IN HER RECLINER . Review of Resident #39's Progress Notes dated 4/24/2022, revealed .RES. WENT OUT FRONT DOOR WITH RW [Rolling Walker] ALARM SOUNDED D/T [due to] WANDER GUARD. RE-DIRECTED BACK IN . Review of Resident #39's Progress Notes dated 5/6/2022, revealed .DOOR ALARM SOUNDED AND TECHS WENT TO FRONT DOOR. RESIDENT WAS FOUND ABOUT 100 FEET OUTSIDE FACILITY . Review of Resident #39's Progress Notes dated 5/20/2022, revealed .RES. ELOPED OUT THE DOOR ON THE WARDS HALL, WAS RE-DIRECTED BACK IN. RES. NOW SITTING IN DR [dining room] FOR SUPPER . Review of Resident 39's Progress Notes dated 5/21/2022, revealed .RES. HAS BEEN WANDERING AROUND FACILITY ALL DAY AT A FAST PACE. DID ELOPE OUT THE PATIO DOOR. RES. DID REFUSE TO COME BACK IN FOR CNA [Certified Nursing Assistant], BUT NURSE RE-DIRECTED RES. BACK IN. RES. VERY AGITATED WHEN RE-DIRECTED FOR ANY REASON. RES. AT THIS TIME SITTING IN THE BIRD ROOM . Review of Resident #39's Progress Notes dated 5/22/2022, revealed .RES. FOLLOWED STAFF OUT BACK DOOR, WAS RE-DIRECTED BACK IN AND ENCOURAGED TO SIT IN HER RECLINER. RES. HAS STAYED IN HER ROOM FOR A WHILE . Review of Resident #39's Progress Notes dated 5/23/2022, revealed .FOR APPROX 6:30 PM RESIDENT CODE ALERT ALARM WAS HEARD SOUNDING TO ALERT STAFF OF EXIT OUTWARD HALL BACK DOOR. CNA TO BACK DOOR AND RESIDENT OBSERVED WALKING ACROSS BACK PARKING LOT. WHEN CNA CALLED FOR RESIDENT TO STOP SHE TOOK OFF RUNNING, SHE THEN TRIPPED OVER CONCRETE CAR STOP AND STRUCK HER HEAD ON HANDICAPPED PARKING SIGN ON THE WAY DOWN. SHE THEN LANDED ON HER RIGHT-SIDE HIP AREA AND WHEN NURSES STAFF GOT TO HER FOR ASSESSMENT SHE COMPLAINED OF RIGHT LEG AND HIP PAIN AND COULD NOT STRAIGHTEN HER RIGHT LEG. SHE WAS KEPT IN THE POSITION SHE WAS FOUND IN UNTIL EMS [Emergency Medical Services] ARRIVED FOR TRANSPORT. SON WAS CONTACTED BY [named nurse] TO NOTIFY OF FALL AND THEN AGAIN BY [named nurse] TO CONFIRM AS TO WHICH HOSPITAL FAMILY WOULD PREFER TRANSPORT TO THEY CHOSE [named hospital]. SHE DID NOT APPEAR TO HAVE ANY OTHER INJURY NOTED INCLUDING NO INJURY NOTED TO HEAD DESPITE STRIKING HEAD. WILL AWAIT FURTHER REPORT FROM HOSPITAL . Review of Resident #39's Progress Notes dated 5/24/2022, revealed .REPORT RECEIVED FROM NURSE [named nurse] FROM ED [Emergency Department][named hospital]. RESIDENT NOTED BROKEN RT [right]. HIP. SX [surgery] SCHEDULED TOMORROW 5/24/22 AT [named hospital]. FAMILY PRESENT AT [named resident] AND AWARE OF ALL FINDINGS PER [named nurse] . Review of the History and Physical dated 5/23/2022, revealed XXX[AGE] year-old female presents to clinic today from the Emergency Department for right hip pain. She stated that yesterday evening while walking outside she tripped and fell and landed on right hip. She had immediate pain and swelling to the area and was transported via EMS to [named hospital] for she was seen in the emergency department and received x-rays. X-rays revealed a fracture of the right femoral neck .Patient reports decreased range of motion secondary to pain as well as a palpable deformity along the lateral hip at the proximal femur area . During an interview 7/12/2022 at 2:36 PM, CNA #5 stated Resident #39 did wander the building because she was confused and there were times she would go to the exit door and staff would redirect or she would exit the building and staff would have to go after her and bring her back in. Resident #39 had a wander guard. It would go off if a resident tried to open the door; if they were near the door; if it was opened; and if they went outside. Continued interview revealed the alarm was heard throughout the building. During an interview on 7/12/2022 at 4:10 PM, CNA #4 stated Resident #39 was not assigned to her but had heard the alarm and was the one who arrived at the door where Resident #39 eloped. Resident #39 had gone out the door on the ward side in the middle hall in the evening. When CNA #4 heard the alarm she went to the box at the round station to figure out which door was alarming. Once CNA #4 figured out which door it was CNA #4 went down the hall and saw Resident #39 outside and opened the exit door and called Resident #39's name. Resident #39 started running towards the adjacent building and tripped over a concrete parking block which caused her to fall and hit her head on the handicap sign. Resident #39 had left the building on occasions but staff had brought her back inside the building without injuries. During an interview on 7/12/2022 at 6:43 PM, LPN #3 stated on the day she fell Resident #39 was wandering in the building. Resident #39 did not like redirection. LPN #3 did not see her leave the facility but heard the alarm go off. CNA #4 told LPN #3 when she got to the door she saw Resident #39 outside and yelled her name and the resident started running and then tripped over the parking medium and fell. LPN #3 stated she had assessed Resident #39 and called EMS. During an interview on 7/12/2022 at 2:26 PM, the Director Of Nursing (DON) stated she had known Resident #39 was a wanderer. The DON was not at the facility as she had already gone home for the day. The DON stated, Typically, if the alarm goes off we are out the door. I'm sure we had conversations about the wandering. Talked to son about psych services. He refused and said she [Resident #39] was at her baseline. The DON was unaware Resident #39 was leaving the facility unattended and thought staff was redirecting her. When asked if she had reviewed the nurses notes explaining Resident #39's exit seeking behaviors and elopements, the DON stated, I do not come to work during the day and have time to read the nurses notes. The DON confirmed Resident #39's leaving the building was considered elopement from the facility. During an interview on 7/13/2022 at 4:30 PM, the Administrator confirmed Resident #39 went out of the building on the ward door on the middle hall without supervision. The surveyors verified acceptable Immediate Action Removal Plan on 7/12/2022 by: 1.) The surveyors verified through review of the education completed for staff on duty on 7/12/2022, and interviews with various Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Housekeeping, and Maintenance regarding verifying elopement, missing person, policies, and procedures. 2). The surveyors verified through observation and interview the exit doors at the end of the ward hall alarmed when a wander guard was within 3 feet of the exit door while opened, and when the surveyor walked through the exit door. 3.) The surveyors verified the facility's updated list of wandering/elopement residents dated 7/12/2022. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behavioral Disturbances and History of Falls. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #16 had a BIMS score of 0, which indicated severe cognitive impairment. Review of Resident #16's medication administration record (MAR) dated 7/2021 revealed .Non-Skid Pad to Recliner at all times for risk of fall .Non-skid Mat in front of recliner at all times . Review of Resident #16's care plan dated 7/7/2021 .Fall: I WILL HAVE A DECREASE IN THE NUMBER OF FALLS X 90 DAYS .1 NON-SKID SOCKS AT ALL TIMES .NON-SKID MESH TO RECLINER OR WHEELCHAIR R/T FALL RISK . Review of the fall investigation dated 7/26/2022 revealed Resident #16 did not have the ordered non-slip mat on the recliner or the non-skid mats on the floor in front of the recliner at the time of the fall. Review of Resident #16's progress notes dated 7/26/2021, revealed .CALLED FOR ASSISTANCE TO room [ROOM NUMBER][Resident #16's room], RESIDENT FOUND IN LEFT SIDE LYING POSITION. RESIDENT ASSESSED PRIOR TO STANDING STATES NO PAIN. NO OBVIOUS INJURY NO REDNESS OR BRUSING NOTED. ASSISTED TO STANDING POSITION .DID COMPLAIN OF MILD PAIN LEFT KNEE/LEG UPON STANDING NO DEFORMITIES NOTED. [named family member] NOTIFIED. DOES NOT WISH FOR PATIENT TO GO TO ER [emergency room]. STATES IF X-RAY HAS TO BE DONE PLEASE CALL MOBILE X-RAY . Review of Resident #16's progress notes dated 7/26/2021 revealed .@ [at] 8:56 PM - WHILE ASSISTING RESIDENT TO BED, RESIDENT NOTED TO BE UNABLE TO BEND LT. [left] KNEE TO TRANSFER NORMALLY TO STANDING POSITION. RESIDENT VERBALLY STATED, I CANT STAND UP. RESIDENT ASSISTED TO STANDING POSITION AND RESIDENT RETAINED THE POSTURE OF A STRAIGHT LEG BILATERALLY THE ENTIRE TRANSFER. RESIDENT NOTED TO HAVE A LIMP DURING AMBULATION. RESIDENT UNABLE TO PUT WEIGHT ON LT. LEG. MOBILE IMAGES CALLED AND STAT 5-VIEW BILATERAL HIP INCLUDING PELVIS WITH BILATERAL TIBULA/FIBULA X-RAYS ORDERED TO RULE OUT INJURY. [named family member] NOTIFIED OF ORDERS. DAUGHTER EXPRESSED THAT IF THERE WERE ANY INJURIES TO CALL HER BACK REGARDLESS OF TIME AND NOTIFY HER. THIS LPN VOICED UNDERSTANDING OF TEACHING . Review of Resident #16's progress notes dated 7/27/2021 revealed .THIS LPN CALLED [named hospital] AND GAVE VERBAL REPORT TO [named nurse] REGARDING RESIDENTS STATUS. FLOOR NURSE VERBALIZED UNDERSTANDING . Review of the Mobile Images dated 7/27/2021 revealed .Pelvis, and bilateral hip 5 view .There is acute fracture involving left femoral neck . During an interview on 7/12/2022 at 6:35 PM, LPN #3 immediately went into the room and saw her (Resident #16) lying on the floor. LPN #3 did not recall seeing a non-skid mat on the floor in front of the recliner or a non-skid mats in the recliner. During an interview on 7/12/2022 at 5:44 PM, the DON confirmed there were no non-skid mats in front of the recliner or a non-skid mat in the recliner at the time of the fall. The DON stated, Staff did not follow the care plan. The DON also confirmed the intervention after the fall was to re-educate the staff of the fall precautions for Resident #16. The DON stated if the staff had followed the care plan interventions it would have prevented the fall which caused Resident #16's injury. During an interview on 7/14/2022 at 8:00 AM, LPN #4 stated he had observed LPN #3 in Resident #16's room while the resident was on the floor. LPN #3 was already conducting an assessment of Resident #16 and she did not find any acute injuries. After two hours LPN #4 with a CNA, was helping Resident #16 and noticed she could not bend her left leg or bear weight on it. Mobile x-ray was notified and it was discovered she had a left hip fracture. LPN #4 stated he did not see any non-skid mats in front of the recliner or on the recliner at the time of the resident's fall.

Based on medical record review and interview, the Administrator failed to administer the facility in a manner to ensure resident care plans were revised and to provide adequate supervision to prevent unsafe wandering and elopement from the facility for 1 of 1 resident (Resident #39) who was an elopement risk. The administrator's failure to ensure resident care plans were revised and to provide supervision and keep residents safe placed the residents in Immediate Jeopardy (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 findings include: Review of the medical record revealed Resident #39 eloped from the facility a total of 7 times from 4/23/2022 through 5//23/2022. There was no evidence that the facility systematically examined all possible root causes, or came to a determination as to why the facility's supervision had not been adequate to prevent the elopement. Continued review revealed Resident #39's care plan was not updated after each elopement attempt to reflect the resident's current needs. The Administrator was notified of the Immediate Jeopardy on 7/12/2022 at 12:47 PM in the Administrator's office. The facility was cited an Immediate Jeopardy IJ at F-835. The Immediate Jeopardy was removed onsite and was effective from 4/23/2022 to 7/12/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 7/12/2022 at 7:29 PM. The corrective actions were validated on site by surveyors on 7/12/2022. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The findings include: During an interview on 7/13/2022 at 4:30 PM, the Administrator confirmed Resident #39 went out of the building without supervision. She stated she was aware of her history of successful elopement attempts at a previous facility. The surveyors verified acceptable Immediate Action Removal Plan on 7/12/2022 by: 1.) The surveyors verified through review of the education that began on 7/12/2022 and interviews with various Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Housekeeping, and Maintenance regarding verifying elopement, missing person, policies, and procedures. 2). The surveyors verified through observation and interview the exit doors at the end of the ward hall alarmed when a wander guard was within 3 feet of the exit door while opened and when the surveyor walked through the exit door. 3.) The surveyors verified through review of the list of wandering/elopement residents dated 7/12/2022. 4). The surveyors verified the care plans for residents at risk for elopement were updated with current interventions. 5). The surveyors verified the facility conducted an ad hoc QAPI meeting on 7/12/2022.