**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility document review, observation, and interview, the facility failed to implement a care plan for risk of elopement for 1 of 13 sampled residents (Resident #2) reviewed for risk of wandering and/or elopement with a diagnosis of Dementia. The facility's failure to implement the care plan and interventions for Resident #2 placed the resident in 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 implement an elopement care plan with interventions for Resident #2 which resulted in an elopement from the facility on 8/2/2022. The Administrator was notified of the Immediate Jeopardy on 11/15/2022 at 3:04 PM in the Administrator's Office. The facility was cited Immediate Jeopardy at F-656. The facility was cited at F-656 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 8/2/2022 to 11/15/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 11/15/2022 at 7:18 PM. The corrective actions were validated onsite by the surveyors on 11/15/2022 at 7:30 PM. The facility's noncompliance at F-656 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. The findings include: Review of the facility's policy titled, Elopement and Wandering Residents, revised 5/1/2020, revealed, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff .TIPS FOR PREVENTION OF ELOPEMENTS .React to statements such as I want to go home. Observe for aimless wandering .Consider use of a personal alarm for the resident . Review of the facility's policy titled Comprehensive Care Plans, revised 5/1/2020, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record . Review of the facility's policy titled Care Plan Revisions Upon Status Change, revised 5/1/2020, revealed, .The purpose of this procedure is to provide a consistent process for reviewing and revising for those residents experiencing a status change .The comprehensive care plan will be reviewed and revised as necessary, when a resident experiences a status change .Upon identification of a change in status the nurse will notify the MDS [Minimum Data Set] Coordinator, the physician .MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options .The care plan will be updated with the new or modified interventions .Care plans will be modified as needed .The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs . Review of medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia with Behavioral Disturbance. Review of admission Minimum Data Set (MDS) dated [DATE], revealed Resident #2 scored 13 on the BIMS Assessment (indicating cognitively intact), limited assistance with bed mobility, transfer, dressing, toileting, and personal hygiene, supervision with walking and locomotion on unit, mobility devices of walker and wheelchair, and Non-Alzheimer's Dementia. Review of the Comprehensive Care Plan for Resident #2 initiated 7/12/2022, revealed, a care plan with goals and interventions for .At risk for Cardiac Complications .I have an ADL self-care performance deficit .I am at risk for falls .I have potential for pain .The resident has impaired cognitive function or impaired thought processes . and a care plan created on 8/3/2022 .I am at risk for elopement positive Wandering/Elopement assessment . There was no documentation provided by the facility of a Care Plan for wandering or elopement prior to Resident #2's elopement on 8/2/2022. Review of Resident #2's Social Services Notes revealed, .7/13/2022 .Resident is pleasantly confused .7/20/2022 .Resident came out of her room with all her belongings on rollator [wheeled walker]. SW [social worker] asked Resident where she was going. Resident stated that she would like to go to front office to sign out and go home .7/21/2022 .Resident came out of her room with all of her belongings and with her purse on her shoulder ready to go home .She is pleasantly confused . The SW notes from 7/13/2022 - 7/21/2022 confirmed Resident #2 was at risk for elopement. Review of a Behavior Note dated 7/27/2022 for Resident #2 revealed, Patient is currently becoming increasingly anxious and confused .Patient believes she is supposed to go work at [named hospital] as a nurse and she says she is running late for work. Patient has purse, jacket, and car keys in hand currently. I reoriented patient, but this has been an ongoing pattern throughout the day . Review of a Nurses Note dated 7/27/2022 for Resident #2 revealed, .AT BEDTIME RESIDENT REDIRECTED MULTIPLE TIMES FOR WANDERING, EXIT SEEKING, RESIDENT STATED THAT SHE WANTS TO GET HOME TO HER HUSBAND WHO IS HOME ALONE . Review of a Wandering Elopement assessment dated [DATE] for Resident #2 revealed .Wandering pattern .Objects to living away from own home .Wandering during disoriented period is common .At risk to wander or elope the facility .RESIDENT WANDERING ON UNIT, PURSE AND CAR KEYS WITH HER ON ROLLATOR, RESIDENT STATES NEED TO GET HOME TO HUSBAND WHO SHE SAYS IS HOME ALONE .Proceed to Care Plan as needed . Review of Facility's Reported Incident (FRI) #202282213039 dated 8/2/2022 confirmed Resident #2 eloped from the facility to an unsafe environment. During an interview in the conference room on 11/15/2022 at 11:00 AM, Assistant Director of Nursing (ADON) confirmed Resident #2's documented wandering/exiting behaviors exhibited should have been brought to the interdisciplinary teams attention to review plan of care and initiate increased monitoring interventions as appropriate. During an interview in the conference room on 11/15/2022 at 3:30 PM, the Director of Nursing (DON) confirmed the expectation was when a resident has a history of/or identified as a wander/elopement risk, nursing should contact the physician to obtain an order for a WanderGuard and initiate a care plan for wandering/elopement for the resident. The surveyors verified the acceptable Immediate Action Removal Plan on 11/15/2022 at by: 1. On 11/15/2022 surveyors revealed that Resident #2 who eloped from the facilty on 8/2/2022 did not have a care plan to reflect the risk for elopement. The nurse notes, social notes, and elopement risk assessment revealed prior to the elopement she was at high risk. 2. The surveyors verified that after the elopement on 8/2/2022 Resident #2 received a wanderguard and Elopement Plan of Care was put in place on 8/3/2022. 3. The facility will review nursing's notes and elopement risk assessments daily in morning meeting. Discuss the findings at daily Interdisciplinary Team (IDT) meetings to ensure that measures are put in place to ensure safety and the care plans are updated accordingly to reflect any changes in care. 4. The surveyors verified the facility educated all staff on care planning and crafting of care plans on 11/15/2022 and 11/16/2022. 5. The surveyor verified IDT Note on 8/3/2022 reviewed Resident #2's plan of care and interventions. 6. The surveyor verified Facility Elopement Books located at nurse's stations on each hall of facility were up to date with current of Walk and Talk Residents including pictures and WanderGuard battery expiration dates. 7. The surveyors verified the facility held an Elopement Assessment Changes Inservice on 8/3/2022. The facility implemented elopement assessments to be done on admission and again in 48 hours. The nurse would obtain an order for a WanderGuard for residents determined at risk for exiting the facility. Every ambulatory resident admitted will have WanderGuard placed X 7 days then re-evaluated. 8. The facility will report to the weekly at-risk meeting regarding nursing notes and elopement risk assessment to ensure that all in need of a care plan was completed. Weekly reporting to at-risk IDT meeting will continued for 3 months and then monthly for 3 months. Report findings and progress to quarterly Quality Assurance (QA). The facility is required to submit a Plan of Correction for F-(Tag).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility's policy review, medical record review, facility documentation review, observation, and interview, the facility failed to provide adequate supervision to prevent elopement for 1 of 13 sampled residents (Resident #2) reviewed for risk of wandering and/or elopement with a diagnosis of Dementia. The facility's failure to provide adequate supervision and implement interventions to prevent elopement for Resident #2 who eloped from the facility on 8/2/2022 on a hot summer day. This placed 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 Administrator was notified of the Immediate Jeopardy on 11/15/2022 at 1:39 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 Immediate Jeopardy was removed onsite and was effective from 8/2/2022 to 11/15/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 11/15/2022 at 7:18 PM. The corrective actions were validated onsite by the surveyors on 11/15/2022 at 7:30 PM. 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 facility is required to submit a Plan of Correction. Review of the facility's policy titled, Accidents and Incidents-Investigating and Reporting, revised 3/7/2022, revealed, .All accidents or incidents involving residents, employees, visitors, vendors, etc. (similar items included), occurring on our premises must be investigated and reported to the Administrator .All incidents are to be reported timely and appropriate interventions implemented .The Nurse Supervisor and/or Charge Nurse shall: a. Examine all accident/incident victims .b. Notify the Medical Director or the victim's personal or Attending Physician, and inform the physician of the accident or incident .c. If necessary, transfer the injured person to the emergency room, medical treatment center, hospital . Review of the facility's policy titled, Elopement and Wandering Residents, revised 5/1/2020, revealed, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff .TIPS FOR PREVENTION OF ELOPEMENTS .React to statements such as I want to go home. Observe for aimless wandering .Consider use of a personal alarm for the resident . Review of the facility's policy titled Comprehensive Care Plans, revised 5/1/2020, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record . Review of the facility's policy titled Care Plan Revisions Upon Status Change, revised 5/1/2020, revealed, .The purpose of this procedure is to provide a consistent process for reviewing and revising for those residents experiencing a status change .The comprehensive care plan will be reviewed and revised as necessary, when a resident experiences a status change .Upon identification of a change in status the nurse will notify the MDS [Minimum Data Set] Coordinator, the physician .MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options .The care plan will be updated with the new or modified interventions .Care plans will be modified as needed .The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs . Review of medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Polyarthritis, Unspecified, Hypertensive Heart Disease with Heart Failure, and Unspecified Dementia with Behavioral Disturbance. Resident #2 was discharged on 08/20/2022. Review of Brief Interview of Mental Status (BIMS) assessment dated [DATE], revealed, a score of 7 for Resident #2 indicating severe cognitive impairment. Review of the Comprehensive Care Plan for Resident #2 initiated 7/12/2022, revealed, a care plan with goals and interventions for .At risk for Cardiac Complications .I have an ADL self-care performance deficit .I am at risk for falls .I have potential for pain .The resident has impaired cognitive function or impaired thought processes . and a care plan created on 8/3/2022 .I am at risk for elopement positive Wandering/Elopement assessment . There was no documentation provided by the facility of a Care Plan for wandering or elopement prior to Resident #2's elopement on 8/2/2022. Review of a Social Services Progress Note dated, 7/13/2022 for Resident #2 revealed, .Resident is pleasantly confused . Review of History and Physical dated 7/15/2022 for Resident #2 revealed, .Past Medical History .Delirium, Dementia .Psychiatric: Forgetful Oriented to self, confused . Review of a Skilled Nursing Note dated, 7/16/2022 for Resident #2, revealed, .Patient is very confused. She doesn't know where she is .She thinks she is on vacation . Review of admission MDS dated [DATE], revealed Resident #2 scored 13 on the BIMS Assessment indicating cognitively intact, limited assistance with bed mobility, transfer, dressing, toileting, and personal hygiene, supervision with walking and locomotion on unit, mobility devices of walker and wheelchair, and Non-Alzheimer's Dementia. The previous BIMS score for 7/12/2022 which was 7 indicating severe cognitive impairment and 7/17/2022 BIMS score of 13 (intact cognition) confirmed Resident #2's cognitive abilities varied at different times during her stay at the facility. Review of a Physical Therapy (PT) Progress Report dated 7/18/20/22, for Resident #2 revealed a functional skill assessment of .transfers .independent .Ambulation Walk 10 feet independent, Walk 50 feet with Two Turns .Reason for Skilled Services: Continued PT services are necessary in order to promote safety awareness, increase LE [lower extremity] ROM [range of motion] and strength, minimize falls, improve dynamic balance, facilitate independence with all functional mobility Review of a Social Services Note dated 7/19/2022 for Resident #2 revealed, .She is alert with some confusion noted . Review of a Social Services Noted dated 7/20/2022 for Resident #2 revealed, .Resident came out of her room with all her belongings on rollator [wheeled walker]. Social Worker [SW] asked Resident where she was going. Resident stated that she would like to go to front office to sign out and go home . Review of a Social Services Note dated 7/21/2022 for Resident #2 revealed, .Resident came out of her room with all of her belongings and with her purse on her shoulder ready to go home .She is pleasantly confused . Review of a Social Services Noted dated 7/27/2022 for Resident #2 revealed, .SW called [Family Member #1] about Resident d/c [discharge] plans. She is alert with confusion and requires redirection by Staff. She is able to use rollator. She is a fall risk . The Social Service notes from 7/13/2022 - 7/27/2022, confirmed Resident #2 was an elopement risk prior to 8/2/2022. Review of a Physical Therapy (PT) Treatment Encounter note dated 7/27/2022 for Resident #2 revealed, .Pt [patient] ambulated throughout F hall today for 3 laps, completing directional changes at supervision. Gait training completed for ~500 ' [500 feet] with pt presenting with no fatigue . Review of Medical Administration Record (MAR) note dated 7/27/2022 for Resident #2 revealed, .Patient exhibited confusion while lying in bed this afternoon .Patient stated she was here to play with friends and to make friends. Patient continued on to ask about when she could go home . Review of a Behavior Note dated 7/27/2022 for Resident #2 revealed, Patient is currently becoming increasingly anxious and confused .Patient believes she is supposed to go work at [named hospital] as a nurse and she says she is running late for work. Patient has purse, jacket, and car keys in hand currently. I reoriented patient, but this has been an ongoing pattern throughout the day . Review of a Nurses Note dated 7/27/2022 for Resident #2 revealed, AT BEDTIME RESIDENT REDIRECTED MULTIPLE TIMES FOR WANDERING, EXIT SEEKING, RESIDENT STATED THAT SHE WANTS TO GET HOME TO HER HUSBAND WHO IS HOME ALONE . Review of the MAR note dated 7/28/2022 for Resident #2 revealed, .Behavior Monitoring .resident wandering throughout unit, exit seeking . Review of Wandering Elopement Assessment dated 07/28/2022 for Resident #2 revealed .Wandering pattern .Purposeless wandering .Objects to living away from own home .Sensory dependent; searches for things/persons .At risk to wander or elope the facility .RESIDENT WANDERING ON UNIT, PURSE AND CAR KEYS WITH HER ON ROLLATOR, RESIDENT STATES NEED TO GET HOME TO HUSBAND WHO SHE SAYS IS HOME ALONE .Physical changes in the brain .Diagnosis of Dementia .Searching for home or people from past .Disorientation to time .Proceed to Care Plan as needed . Review of a PT Therapy Progress Report dated 7/29/2022 for Resident #2 revealed, .Functional Skill Assessment Bed Mobility .Independent .Transfers .Independent .Ambulation Walk 10 feet = Independent Walk 50 feet with Two Turns = Independent Walk 150 feet = Setup or clean-up assistance .Mobility Function Score (ranges from 0-12; 12 being the highest function) = 12 . Review of a PT Treatment Encounter note dated 7/29/2022 for Resident #2 revealed .Conversation with patient who stated she is ambulating ad lib [at pleasure] in the facility with the use of rollator. Patient amb [ambulate] 300ft [feet] in 6 min [minute] with rollator Review of a Skilled Nursing Note dated 8/1/2022 for Resident #2 revealed, .walks with walker. Wanders occasionally, dementia noted . Review of a Social Services Noted dated 8/2/2022 for Resident #2 revealed, .Resident is alert with confusion, requires curing and redirection daily by Staff . Review of a Nurses Note dated 8/2/2022 for Resident #2, revealed, .Notified at 6:28 PM that resident was found in front reception hallway/front lobby, turned around asking for help to the front door. Employee explained to her that she must have just come inside the front door and employee had previously seen resident about 6:20 PM outside walking .toward facility with walker clothes .employee assisted resident to hallway, to CNA [Certified Nursing Assistant] on the hallway and CNA assisted resident to her room .Prior to this incident .at approximately 6-6:10 pm Resident come out of her room with walker, purse, keys, and some clothing. Resident walking in the F hallway .Resident didn't have wanderguard [electronic bracelet used to protect residents from elopement] in place. Placed new Wanderguard transmitter on left ankle. Walk and Talk [a facility systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering] performed by staff and all residents accounted for. Increased visual checks, monitoring resident every 30 minutes. Notified daughter, Notified [Medical Director], Notified facility Director of Nursing [DON]. No injuries noted . Review of facility document Falls Committee Meeting Agenda dated 7/29/2022 revealed, an Interdisciplinary Meeting was held at 9:00 AM Resident #2 was reviewed with the following note .sundowns [the appearance of confusion, agitation, and other severely disruptive behavior markedly worsening at night in older patients with Dementia]: packs clothes enters other residents room @ [at] night - But stays on unit .Home/ALF [Assisted Living Facility] soon . Review of the facility's investigation of elopement dated 8/3/2022, which occurred on 8/2/2022 revealed, a Brief Interview of Mental Status (BIMS) Assessment score of 7 for Resident #2. Review of measurements requested from Community Care of [NAME] County Maintenance Director on 11/16/2022, revealed 0.5 miles or 2,640 feet distance from facility front door to creek using paved surfaces, 0.3 miles or 1,584 feet distance from far end of service drive area using paved surfaces to the creek, and 0.6 miles or 3,168 feet from facility back door to the creek using paved surfaces. Review of Time and Date website on 11/15/2022 revealed, weather in Murfreesboro, Tennessee for 8/2/2022 at 6:15 PM was a Temperature of 88 degrees Fahrenheit per website: https://www.timeanddate.com/weather/usa/murfreesboro/historic?month=8&year=2022. Observation of the train traveling on tracks across from facility entrance on 11/15/2022 at 9:30 AM, 11:10 AM, 11:50 AM, 4:30 PM, 5:15 PM, and on 11/16/2022 at 8:40 AM. During a phone interview on 11/15/2022 at 8:22 AM, Family Member #1 stated Resident #2 was admitted to the facility following a hospitalization for rehabilitation, and PT. Family Member #1 stated .the facility called me immediately after she tried to leave on 8/2/2022. I believe she became confused and followed someone out the door trying to go home During an interview at the entrance to F Hallway on 11/15/2022 at 10:00 AM, Medical Records Personnel #1 stated I was coming in late on 8/2/2022, walking toward F Hall and I looked out the window around 6:20 PM and saw a lady pushing a rollator walker down the driveway towards the front entrance with a purse and pile of clothing in a dry cleaner bag. I assumed she was a visitor bringing a resident some clothing, so I continued walking to the F Hall nurses desk. I finished my business there and walked around toward the front entrance reception area around 6:25 PM, and the same lady was now in the front reception hall. I asked her for her name and realized at that point it was [Resident #2]. [Resident #2] was confused and tired, so I got a wheelchair and assisted her back to F Hall and asked for help from the CNT [Certified Nursing Technician] on duty. During a phone interview on 11/15/2022 at 10:45 AM, LPN #1 stated that on 8/2/2022, Resident #2 had her clothes, purse, and keys walking with rollator up and down F Hall and was easily re-directed to return to her room. Around 6:00 PM to 6:10 PM Resident #2 was seen with rollator walker, purse, keys, and some clothing walking in F Hall toward the nurse's station. During an interview in the conference room on 11/15/2022 at 11:00 AM, Assistant Director of Nursing (ADON) confirmed that documented wandering/exiting behaviors exhibited by a resident should have been brought to the interdisciplinary team attention to review plan of care and initiate increased monitoring interventions as appropriate. During a phone interview on 11/15/2022 at 11:07 AM, CNT #1 confirmed her written statement that on 8/2/2022 Resident #2 was last seen on F Hall at 6:00 PM, was returned to F Hall at 6:25 PM, has a history of packing up all her belongings every night saying she wants to go home, and is easily redirected to go back to her room. During an interview on 11/15/2022 at 11:30 AM Maintenance Director and Assistant maintenance Director confirmed written statement dated 8/2/2022 that they were working in front of the facility completed their work at 6:00 PM, left the facility at 6:05 AM (confirmed by Time Clock Plus Records) and no residents were seen outside the facility. During an interview in the conference room on 11/15/2022 at 3:30 PM DON confirmed the expectation is when a resident has a history of/or identified as a wander/elopement risk, nursing should contact the physician to obtain an order for a WanderGuard which will initiate a care plan for wandering/elopement for the resident. During a phone interview on 11/15/2022 at 5:17 PM with RN #1 she confirmed she completed a Wandering/Elopement Assessment on Resident #2 on 7/28/2022 due to the resident was wondering the hall with her belongings on her rollator walking toward the doors asking if it was raining. RN #1 stated she did not remember any specific training on how to complete the Wandering/Elopement Assessment, the determination of At risk to wander or elope the facility but is not physically or mentally able was based on her nursing judgement that Resident #2 was easily re-directed to return to her room and Resident #2 was not cognitively able to follow commands needed to exit the facility. RN #1 further confirmed that she worked the 7 PM to 7 AM shift on 8/2/2022, received report of Resident #2's elopement, and a WanderGuard was placed on the resident. The surveyors verified the acceptable Immediate Action Removal Plan on 11/15/2022 at by: 1. The surveyors verified that Resident #2 received a WanderGuard and placed on Walk and Talk Residents list on 8/3/2022. Surveyors verified with medical record review frequent checks started every thirty minutes for the next 24 hours on Resident #2 on 8/2/2022. 2. The surveyors verified the facility educated staff on elopement risk management. 3. Surveyors verified with medical record review frequent checks started every thirty minutes for the next 24 hours on Resident #2 on 8/2/2022. 4. The surveyors verified the facility held an Elopement Assessment Changes Inservice on 8/3/2022. The facility implemented elopement assessments to be done on admission and again in 48 hours. The nurse would obtain an order for a WanderGuard for residents determined at risk for exiting the facility. Every ambulatory resident admitted will have WanderGuard placed X 7 days then re-evaluated. 5. If a resident is found to be an elopement risk, interventions will be addressed and communicated to all staff. If any resident has behaviors that are exit seek, behavior monitoring will be initiated and the behaviors documented. 6. All residents, new admissions, readmissions, and those residents who experience significant change will be assessed and considered for the least restrictive measures to ensure their safety and well-being and promote resident independence. The facility is required to submit a Plan of Correction for F-(Tag).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on job description review, facility policy review, and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable wellbeing of the residents. The failure of Administration to ensure adequate supervision was provided and to ensure the care plan was updated, which placed 1 of 13 sampled Residents (Resident #2) reviewed for risk of wandering and/or elopement with a diagnosis of Dementia in 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 Administrator was notified of the Immediate Jeopardy on 11/15/2022 at 3:04 PM in the Administrator's Office. The facility was cited Immediate Jeopardy at F-835. The facility was cited at F-835 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 8/2/2022 to 11/15/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 11/15/2022 at 7:18 PM. The corrective actions were validated onsite by the surveyors on 11/15/2022 at 7:30 PM. 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 facility is required to submit a Plan of Correction. The findings include: Review of Community Care of [NAME] County Nursing Home Administrator job description updated 2020, revealed, .This position has direct twenty-four (24) hour, seven (7) days a week, operational authority .Provides the leadership framework for planning, directing, coordinating and improving Services at Community Care of [NAME] County that are responsive to the needs of the patients .The administrator will ensure the development and implementation of policies and procedures for program operations .and will also assume direct responsibility for the planning and coordination of the Dietary, Housekeeping, Laundry, Maintenance, Business Office, Security, Nursing, and all other departments of Community Care of [NAME] County .Ensures development and implementation of organization-wide and unit specific age specific, safety, security . Review of [contracted agency] Administrator job description undated revealed, .Positions Supervised: Business Office Manager .Director of Maintenance & Housekeeping .Director of Nursing .Social Worker .The Administrator is responsible for administering, directing, facilitating, supporting and coordinating all activities of the community ensuring that quality care, financial and people objectives are in compliance with all local, state and federal laws and in accordance with United Church Homes, Inc. policy .Identifies and maintains accountability for security within assigned areas of responsibility .Ensures all care, treatment and services are provided with appropriate dementia care protocols . (Administrator is employed by contracted agency and contracted to serve as Administrator of Community Care of [NAME] County). Review of the facility's policy titled, Elopement and Wandering Residents, revised 5/1/2020, revealed, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Adequate supervision will be provided to help prevent accidents or elopements . The Administration failed to ensure care plans were developed for 1 of 13 sampled residents (Resident #2) reviewed for risk of wandering and/or elopement with a diagnosis of Dementia. Refer to F-656. The Administration failed to ensure adequate supervision for 1 of 13 sampled residents (Resident #2) reviewed for risk of wandering and/or elopement with a diagnosis of Dementia, which resulted in an elopement. Refer to F-689. During an interview on 11/15/2022 at 1:10 PM the Administrator stated he had been expecting the State Surveyors and was not surprised at receiving an IJ for the elopement incident of Resident #2. The surveyors verified the acceptable Immediate Action Removal Plan on 11/15/2022 at by: 1. The surveyors verified that after the elopement on 8/2/2022 Resident #2 received a WanderGuard and Elopement Plan of Care was put in place on 8/3/2022. 2. The surveyors verified a Wandering Elopement Assessment dated 08/03/2022 for Resident #2 was completed to show at risk to wander from or elope facility. 3. The surveyors verified the facility held an Elopement Assessment Changes Inservice on 8/3/2022. The facility implemented elopement assessments to be done on admission and again in 48 hours. The nurse would obtain an order for a WanderGuard for residents determined at risk for exiting the facility. Every ambulatory resident admitted will have WanderGuard placed X 7 days then re-evaluated. 4. The surveyors verified a facility elopement drill was performed on 8/12/2022. 5. On 11/15/2022 surveyors verified the facility educated staff on care planning and crafting of care plans. 6. Designee to report in facility weekly at-risk meeting regarding nursing notes and elopement risk assessments to ensure that all in need of a care update was completed. Weekly reporting to at-risk Interdisciplinary Team (IDT) meeting for 3 months and then monthly following for 3 months. The findings and progress will be reported in the quarterly Quality Assurance meeting. 7. On 11/15/2022, Executive Director of Managed Communities educated the Administrator on F835, and how it related to updating care plans in the community. The facility is required to submit a Plan of Correction for F-(Tag).