**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility documentation review, medical record review, observation and interview the facility failed to provide adequate supervision to prevent elopement for 1 resident (#68) of 5 residents reviewed who were wander/elopement (Residents who have a history of leaving or trying to leave the facility, or have wandered or have the potential to wander into unsafe areas) risks resulting 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 informed of the Immediate Jeopardy (IJ) on 11/5/19 at 6:50 PM in his office. An extended survey was conducted from 11/5/19 to 11/6/19. F-689 was cited at a scope and severity of J. F-689 J is Substandard Quality of Care. The Immediate Jeopardy was effective from 7/27/19 through 8/20/19. The facilities corrective action plan, which removed the IJ, was received and the corrective actions were validated onsite on 11/6/19 F-689 was cited at a scope and severity of J as past noncompliance. The facility is not required to submit a plan of correction for F-689 J. The findings include: Review of the facility policy, Missing Residents and Elopement, dated 8/1/16 revealed .It is the policy of this facility that all residents are provided adequate supervision to meet each resident's personal care needs .All residents will be assessed for behaviors or conditions that put them at risk of elopement .All resident's assessed to be at risk of elopement will have this issue addressed in their plan of care .Residents that are at risk of elopement will be provided at least one of the following safety precautions: staff supervision of facility exits either directly or by video camera .door alarms on facility exits .a personal safety device that notifies facility staff when the resident has left the facility without supervision .all personal safety devices, door alarms and video cameras will be tested and document weekly .at no time will any door alarm or personal safety device be deactivated without direct supervision of the exit .Potential safety hazards on the exterior of the facility shall be identified such as wooded areas, water hazards, and busy roads .Should an alarm on one of the exits to the outside of the facility sound, staff will immediately respond to determine the cause of the alarm . Medical record review revealed Resident #68 was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy, Vascular Dementia without Behavioral Disturbance and Wandering. Review of Resident #68's hospital records dated 7/15/19 revealed approximately 1 week prior to the hospitalization, and susequent admission into the facility the resident had wandered from his home, became lost in the woods and sustained rib fractures. Medical record review of Resident #68's 5 day Minimum Data Set (MDS) dated [DATE] and Discharge MDS dated [DATE] revealed the resident had a Brief Interview of Mental Status Score of 4 indicating the resident had severe cognitive impairment. Continued review revealed the resident wandered daily. Medical record review of Resident #68's comprehensive care plan dated 7/26/19 revealed the resident was high risk for elopement and wandering. Continued review revealed .roam alert bracelet was applied to resident to reduce risk of elopement .monitor resident location with frequent visual checks .monitor doors when staff and visitors come and go . Continued review revealed the resident was at risk for falls. Medical record review of Resident #68's progress notes dated 7/26/19 through 8/6/19 revealed the resident wandered in and out of resident rooms. Medical record review of Resident #68's Elopement Risk Review dated 7/26/19 revealed .the resident had a history of wandering and elopement .hangs around facility exits and/or stairways .responds poorly to staff re-direction when roaming into areas that are 'off limits' or unauthorized .has the physical ability to leave the building .becomes agitated, confused and/or disoriented or displays consistently poor judgement (would not be able to safely care for him/herself outside the facility) .at risk to elope and should be placed on the Elopement Risk Protocol .Resident has a history of trying to elope, he does not do redirection to [too] easily from staff . Medical record review of Resident #68's Wandering Risk assessment dated [DATE] revealed .Resident is cognitively impaired with poor decision making .resident is alert but non-compliant with facility protocols regarding leaving the unit .unauthorized opening doors to the outside without regard to their personal safety .lingering around exit doors, attempting to exit with visitors without authorization .displays behaviors, body language, indicating an elopement may be forthcoming . Medical record review of Resident #68's Fall Risk Review dated 7/26/19 revealed the resident was at risk for falls related to Syncope and Dementia. Review of the facility's investigation for Resident #68 dated 7/27/19 revealed the resident exited the building through the front door of the facility. Interview with Licensed Practical Nurse (LPN) #5 on 11/5/19 at 4:19 PM in the conference room revealed she was working on 7/27/19 when Resident #68 exited the facility out the front entrance door. Continued interview revealed I was on the hallway and a 'tech' [Certified Nursing Assistant (CNA) # 6] came out of room [ROOM NUMBER] and yelled at us that [named resident] was outside. Telephone interview with LPN #6 on 11/5/19 at 4:48 PM revealed I was on the hall at the time he was visiting with family in the dining room. One of the CNA's saw him outside through another resident's window; she came out and told me he was outside so I went out to get him and bring him back inside. I was just concerned about getting the resident to safety. Telephone interview with CNA #6 on 11/5/19 at 5:01 PM confirmed I saw him walking outside in the parking lot out of room [ROOM NUMBER]'s window. I first thought his daughter was with him then when I looked again I realized she wasn't, nobody was; I came out of the room and yelled at other staff that [named resident] was in the parking lot. Observation on 11/5/19 at 5:10 PM from room [ROOM NUMBER]'s window revealed the inability to view the front entrance area of the building. Continued observation revealed the ability to view the side parking lot and the 4 lane highway. Telephone interview with Resident #68's family member on 11/6/19 at 2:42 PM revealed I was there, I had gone to the bathroom and when I came out he [Resident #68] was not where I left him, so I started looking for him. I walked all the hallways even looking in rooms to see if he was there. Continued interview revealed I walked around the building for approximately 10 minutes or so; then when I got to Station 1 [nurses' station 1] the staff started yelling 'he's outside' and then everybody started running toward the front door so I went too. When I got to the front door I saw him. He was already down to the road, fixing to get on the road. Interview with the Director of Nursing (DON) on 11/5/19 at 5:38 PM at the front entrance door revealed the DON confirmed Resident #68 was not safe outside. The facility's corrective action plan included the following: 1. On 7/27/19 Resident #68 was brought back into the facility by staff members without injury. A head to toe assessment was competed on Resident #68. The resident was placed on 1:1 staff monitoring. Education and Elopement Training was administered to staff. Confirmed placement and function of residents with wanderguards (Alarm bands placed on residents at risk for exiting the facility which alarms once the resident nears the exit doors) was completed on 7/27/19. The facility completed 100% of Elopement assessments on all residents on 7/27/19. Maintenance Director immediately reviewed all doors on 7/27/19. 2. Elopement drill was completed on 8/8/19. Elopement plans reviewed at an adhoc Quality Performance Improvement (QAPI) meeting on 8/20/19. 3. All residents facility wide had their assessments for elopement risk reviewed for accuracy. The surveyors verified the facility's corrective action plan as follows: 1. The surveyors interviewed staff to confirm the resident was brought back inside the facility to safety and placed on 1:1 monitoring. The surveyors verified a skin assessment was completed on Resident #68 with no skin issues identified. The surveyors reviewed the maintenance log for the functioning of the door alarm system on 7/27/19. The surveyors interviewed random staff concerning elopement in-services on 7/27/19 and what the procedures were for door alarms sounding and what they would do when an alarm sounds. The surveyors reviewed the facility's investigation dated 7/27/19. The surveyors checked the door alarms and the staff responded to the alarms immediately. 2. The surveyors Varified the facility elopement drill dated 8/8/19 and the adhoc Qapi meeting minutes. 3.The surveyors varified elopement risk assessments on all residents who resided in the facility on 7/27/19.