**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for elopement. The facility failed to put interventions in place to prevent Resident #1 from eloping from the facility after she broke her window and attempted to leave through her window on 10/29/24. Resident #1 broke her window again and successfully eloped from the facility on 11/01/24. An IJ was identified on 11/06/24. The IJ template was provided to the facility on [DATE] at 4:45 PM. While the IJ was removed on 11/08/24, the facility remained out of compliance at a scope of isolated and severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for unsafe elopements, injuries, and hospitalization. Findings included: Review of Resident #1's admission record, dated 11/06/24, reflected she was a [AGE] year old female who initially admitted to the facility on [DATE], readmitted on [DATE], was discharged to the hospital on [DATE], had an RP, and had diagnoses including cerebral infarction due to embolism of left middle cerebral artery (a medical condition that occurs when an embolism blocks blood flow to the middle cerebral artery, resulting in an ischemic stroke), essential (primary) hypertension (a common condition that occurs when the pressure of your blood is consistently too high), aphasia (a language disorder that makes it difficult to understand, speak, read, or write), flaccid hemiplegia affecting left dominant side (a condition that causes paralysis in the left side of the body, making it difficult or impossible to move), hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side (a condition that occurs when a stroke or other brain injury damages the right side of the brain, causing weakness or paralysis on one side of the body), chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe), unspecified anxiety disorder, muscle wasting and atrophy (terms for the loss of muscle tissue and strength), other abnormalities of gait and mobility, other lack of coordination, and need for assistance with personal care. Review of Resident #1's comprehensive MDS assessment, dated 10/29/24, reflected no BIMS indicated, no wandering behaviors exhibited, no wander/elopement alarms used, and required supervision with walking. Review of Resident #1's BIMS assessment, dated 10/28/24, reflected staff couldn't conduct a BIMS evaluation because Resident #1 was rarely/never understood. Review of Resident #1's care plan, closed 11/06/24, reflected Resident #1 used anti-anxiety medications related to adjustment issues. Staff were required to monitor, document, and report PRN any adverse reactions to anti-anxiety therapy, such as unexpected side effects, including mania, hostility, rage, aggressive or impulsive behavior, and hallucinations. Resident #1's care plan also reflected that she had a behavior problem where she got agitated and broke the window related to visual hallucination of someone trying to get in her room through the window. Staff were required to administer medications as ordered, monitor and document for side effects and effectiveness, discuss Resident #1's behavior if reasonable and explain/reinforce why behavior was inappropriate and/or unacceptable to the resident, praise any indication of Resident #1's progress/improvement in behavior, and provide a program of activities that is of interest and accommodates Resident #1's status. Resident #1's care plan also reflected she had a communication problem related to cerebrovascular accident (stroke). Review of Resident #1's progress notes, from 10/07/24 through 11/07/24, reflected, -A note by LVN B on 10/29/24 at 3:14 AM, which stated, New admit day 7/7. Resident [Resident #1] was awake and going back and forth from dining area and her room multiple times at hour of sleep. This writer asked resident if she needed anything, if she was feeling okay. Resident nodded yes that she was okay and resident nodded yes on not feeling sleepy. No discomfort noticed. Resident returned back to her room at approximately 1:50 AM. -A note by LVN B on 10/29/24 at 7:22 AM, which stated, Heard glass braking at approximately 6:00 AM; this writer and other nursing staff started checking room to see if something was broken. Heard yelling coming from resident room. Resident was blocking the door from opening and yelling. This writer was able to coach resident to let nursing staff in the room. Once the door open resident immediately went to this writer and was bleeding from her left arm. Holding pressure to try to stop the bleeding. One cut is bleeding profusely on the left forearm which was wrapped with a pressure dressing. Called EMS due to the possibility of needing stitches. Did notice other small cuts on the left arm which weren't bleeding much. Staff members check resident room and outside resident room signs of any intruder none were seen. Nursing staff which was in the processes of coming in to shift change saw resident breaking the window. EMS took resident to hospital for evaluation for possible stitches. -A note by LVN B on 10/29/24 at 7:26 AM, which stated, Notified RP of resident going to hospital. Notified the NP of resident going to hospital. -A note by LVN C on 10/29/24 at 1:33 PM, which stated, Resident returned with no new orders from the hospital. -A note by LVN B on 10/30/24 at 1:56 AM, which stated, Resident up multiple times throughout the night. Continue to educate on safety and fall precautions. Will continue to monitor. -A note by LVN B on 10/30/24 at 6:27 AM, which stated, Resident went to sleep for around 2 hours then was again awake walking in hallway, and dining area. Watching TV in dining area. Resident continues to express fear this writer assure resident no one was going to break in to the facility. Assure resident that there are plenty of staff members here to keep her safe. Resident had her door open due to afraid of someone breaking in through the window. Resident also express pain to her eye and ear, resident express it had to do with the door but denies getting hit and denies bumping into the door. Resident also denies another person harming her. Gave PRN Acetaminophen. Also place medical fax for provider. Resident currently in dining area. -A note by LVN C on 10/30/24 at 11:34 AM, which stated, Resident up in dining room area watching tv. Night shift report her being awake most of the shift and remain in dining room because she didn't want to be alone. -A note by LVN B on 10/31/24 at 3:01 AM, which stated, At 2:15 AM; heard crying from resident room. Resident had pushed bed away from wall and was searching for something on the floor. Resident was squeezing herself between there. Then resident showed this writer a picture of a little girl she got from the floor. Resident continued crying showing the picture to this writer. Noticed resident was stuck this writer helped resident out of between the wall and bedside. Resident was helped to dining area. The resident kept trying to show picture to this writer. From what this writer can assess no new injuries noticed. Resident refused full assessment. Resident kept pointing at her arm making a gesture of something biting her. This writer asked resident if something bite her she said no asked if she hurt her arm again resident first said yes then said no. Resident showing her left arm to this writer. This writer reminded resident she had a previous injury from the window glass resident first said yes then said no. This writer asked resident if she hurt her arm when she pushed the bed out resident first said yes than said no. This writer asked resident if this writer can check her vitals but resident refused. Resident currently in dining area in wheelchair. -A note by LVN B on 10/31/24 at 5:42 AM, which stated, Resident yelling out multiple times this morning started at approximately 5:00 AM. Resident would point at another resident and yell. This writer would assure resident that the other resident was okay. At approximately 5:30 AM resident was standing in the dining room bending down as if she was reaching for something and dangling her arms. This writer went to resident to remind resident of her weakness due to the stroke. Resident kept pointing at her arm this writer asked if it hurt resident said no this writer asked if resident if she couldn't move it like before resident nodded yes. This writer reminded resident of her being in the facility for rehab so she can recover from her recent stroke. Resident continues in dining area. -A note by LVN B on 10/31/24 at 6:05 AM, which stated, At approximately 5:50 AM; resident standing in front of back patio door and started doing back kicks. Resident did 5 back kicks to glass door. This writer and other staff were able to stop resident before damage to door. Resident went to back patio and sat herself onto the floor refusing to enter the building. Resident wanted to go home. Resident agreed come back in to facility and resident called family member. Called on-call provider NP to notify of resident behaviors. -A note by LVN C on 10/31/24 at 9:44 AM, which stated, Resident alert and oriented x 2 visited with boyfriend this morning, but still anxious/restless. Remain in dining room area with staff. -A note by LVN B on 10/31/24 at 1:37 PM, which stated, Resident has new orders melatonin 5mg q hs for insomnia, Ativan 0.5mg q 8 PRN for agitation/anxiety and psychiatrist evaluate/treat. RP notified. -A note by MA D on 10/31/24 at 9:35 PM, which stated, Melatonin Oral Tablet 5 MG Give 1 tablet by mouth at bedtime for insomnia. Note didn't mention anything about the refusal entry indicated in Resident #1's MAR/TAR for October 2024. -A note by LVN B on 11/01/24 at 5:48 AM, which stated, At approximately 3:20 AM; resident broke her window and left running. Resident left running down the street. CNA tried to follow resident down the street but lost sight of resident and unable to find resident. Police was called, ADON and management was contacted. CNAs started driving around to see if they can find resident. Police officers were given a description of resident wearing a green long sleeve shirt with camouflage pants, possibly no shoes. Called RP left a message called again spoke with RP at 4:20 AM also called resident's at approximately 3:50 AM; he states he plans on searching for resident too. Multiples management currently searching for resident. this writer double checked around the outside of the facility. Also staff members check residents rooms. -A note by LVN B on 11/01/24 at 6:49 AM, which stated, At approximately 2:30 AM resident was sleeping in bed. -A note by LVN C on 11/01/24 at 7:00 AM, which stated, Resident RP notified that staff did find [Resident #1] running up the street but refused staff assistances or come to facility. Resident entered coffee shop where staff remained with her until EMS/Police arrival. Transported by EMS to Hospital. -A note by LVN B on 11/01/24 at 7:59 AM, which stated, At 4:42 AM; On-Call provider NP was notified of resident leaving facility and police being notified also of multiple staff looking for resident. -A note by LVN B on 11/01/24 at 9:35 AM, which stated, Resident was located by staff about 2 blocks from facility, as she saw the staff members, she went into a coffee shop where she stayed sitting down. Staff remained outside monitored resident through window and securing exit doors. Barista came outside and stated the resident appeared to get more agitated when she saw the staff. EMS and police was activated. Resident was taken to hospital in 4-point restraint and multiple seat belts as she was refusing to go to the hospital. Per staff report, resident refused EMS assessment and became very agitated when asked to roll up sleeves. Review of Resident #1's physician progress note, dated 10/31/24 and electronically signed by the NP on 11/02/24 at 11:49 PM, reflected the NP visited Resident #1 on a chief complaint related to following up on emergency room visit for anxiety and insomnia. The NP stated, On 10/29, patient [Resident #1] was transferred to the ER after she sustained a laceration with bleeding to the left forearm after she broke the window and tried to exit the building. In the ER, the laceration was approximated with steri-strip. CT head showed no acute changes. X-ray left forearm showed no foreign body. Patient was discharged back to the facility. Nurse reports that patient is very anxious and possibly hallucinating in the night and is not sleeping. Patient seen sitting on the wheel chair. She has expressive aphasia, but calm and cooperative and nods her head to yes or no questions. She denies any pain or discomfort. Left forearm laceration covered with Kerlix dressing. Nurse reports that patient is ambulatory but is impulsive and with unsteady gait. Will start on Ativan 0.5mg q 8 hours PRN anxiety and Melatonin 5mg q HS for insomnia. Will refer to psych services in house to eval and treat. Review of Resident #1's orders, dated 11/06/24, reflected Resident #1 was started on giving one tablet by mouth of 5 mg of Melatonin at bedtime on 10/31/24 at 8:00 PM and order ended on 11/02/24. Resident #1 was also started on giving one tablet by mouth of 0.5 mg of Ativan every eight hours as needed for anxiety/agitation for 30 days on 10/31/24 at 1:00 PM and order ended on 10/31/24 and started again on 10/31/24 at 1:30 PM and order ended 11/02/24. Resident #1 was also started on psychiatrist to evaluate and treat her one time only for five days on 10/31/24 at 1:15 PM and order ended on 10/31/24 and started again on 10/31/24 at 1:45 PM and order ended on 11/02/24. Review of Resident #1's order summary report, dated 11/06/24, reflected, -Prescriber Written order for Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 8 hours as needed for anxiety/agitation for 30 Days ordered and started on 10/31/24 and ended on 11/30/24 -Prescriber Written order for Melatonin Oral Tablet 5 MG (Melatonin) Give 1 tablet by mouth at bedtime for insomnia ordered and started on 10/31/24 and no end date. -Prescriber Written order for psychiatrist to evaluate/treat one time only for five days ordered and started on 10/31/24 and ended on 11/05/24. Review of Resident #1's MAR/TAR schedule for October 2024 and November 2024 reflected Resident #1's administration entries for Ativan oral tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 8 hours as needed for anxiety/agitation for 30 Days were blank from 10/31/24 through 11/02/24. Resident #1's administration entries for Melatonin Oral Tablet 5 MG (Melatonin) Give 1 tablet by mouth at bedtime for insomnia indicated Resident #1 refused the tablet on 10/31/24 and it was blank on 11/01/24. Review of Resident #1's admission wandering evaluation, dated 10/22/24, reflected she had no history of wandering/elopement and was not a wandering risk. There were no wandering reevaluations in Resident #1's assessments. Review of Resident #1's plan of care, from 10/22/24 through 11/01/24, reflected Resident #1 exhibited wandering behavior and frequent crying on 10/30/24 at 9:59 PM. Review of the facility's investigation file for Resident #1's incident on 11/01/24 reflected on 11/01/24, ADON reviewed residents at risk for elopement, IDT reviewed Resident #1's chart to determine timeline of events for investigation process, staff were interviewed regarding if they seen anyone trying to leave the facility and none were identified, nursing, dietary, housekeeping and activities staff were reeducated on elopement procedure, broken window was monitored until maintenance repaired it, maintenance inspected the facility windows and no issues were noted, and all exit door codes were changed. Resident #1's self-inflicted injury incident, dated 11/01/24, reflected, At approximately 2:30 AM, resident was sleeping in bed. At approximately 3:20 AM; This writer heard a loud noise of glass breaking. This writer ran to resident room and CNA went to the front of the building. This write did not see resident in the room and noticed the broken window. When this writer went outside this writer saw all the broken glass. A staff member which was sitting outside in the front porch of the building she heard the crash of the glass and saw the resident jump out the window and started running down the street and she and a CNA started to run after resident. This nurse returned to the building and called the police, description was provided, also called management. She was wearing a green blouse and camouflage pants and no shoes. CNA followed resident in the direction she was traveling, she then outran him, and he lost sight of her momentarily, however, other staff were dispatched to assist with the situation and search sorrowing area. Resident was traveling west and staff came down heading east. When the resident saw staff she ran into a coffee shop. Staff stayed monitoring resident through coffee shop window and also secured the exit doors. Barista stepped outside and informed the staff that the resident appeared to not want the staff inside the coffee shop. He went back inside and provided the resident with coffee and water as she sat at the coffee bar. EMS and police were activated. Up on arrival, 2 police officers and 2 EMS attendants restrained resident to the stretcher for transport to the hospital. Staff on sight noticed resident refused assessment by EMS. Resident out of facility. RN E wrote a statement, undated, and stated, I was contacted via telephone by ADON A regarding assistance with a resident that broke a window and left the facility. The nurse stated she was behind resident heading west towards downtown area on the street. Immediately headed towards that direction in my vehicle. Resident was spotted on the street heading to coffee shop. I followed resident in my vehicle and parked my care when I noticed resident going into the coffee shop. On arrival, [ADON A] was present. EMS and police department were on their way. We waited outside the coffee shop until they arrived. ADON A wrote a statement, undated, and stated, I received a call from the staffing ADON around 3:36 AM on 11/01/24 regarding a resident that broke the window, run away from the building but followed by staff. I immediately headed to the location of the resident and spotted her in abandon building in the street close to the facility. It was too dark around the area; I did not get close to her because I didn't want her to run. I kept in contact with co-workers around the area. When my co-worker came, she walked faster heading [NAME] of MLK as she was running from us until she reached the coffee shop. It appeared like she had seen me following her. We stayed outside of the coffee shop monitoring her through the window and keeping exit doors safe. All of the staff posted on the perimeter arrived at the coffee shop to assist. LVN B wrote a statement, dated 11/01/24, and stated, At approximately 2:30 AM resident was sleeping in bed. At approximately 3:20 AM; I heard a loud noise of glass breaking. This writer ran to resident room and CNA went to the front of the building. I did not see resident in the room and noticed the broken window. When I went outside I saw all the broken glass. A staff member which was sitting outside said resident jump out the window and started running down the street and CNA had ran after resident. CNA lost sight momentarily due to her already too far away. Both staff members stated the resident was wearing a green long sleeve shirt with camouflage pants, CNA said it looked like she possibly did not have shoes on. Police was called and given a description of resident also Management was called. 2 CNAs were driving around the area to see if they can spot resident. Also one C.N.A. and a nurse followed the resident on foot. Staff were told to no approach resident by them self's due to resident behavior to call for help if they see resident. I walked around the building to double check if resident had returned and also I and other staff members check all residents rooms in the facility. Nurse received a call from treatment nurse that she had spotted the resident and the resident ran into a coffee shop, and that all other staff arrived at the coffee shop to assist with resident. CNA F wrote a statement, undated, and stated, I was on my break, sitting outside the main entrance when I heard continuous banging by a window to the left, at 3:15 AM. I was on my way back into the building, when I heard a crash of glass and saw a female jump out of the window and ran down into the street. I met with the nurses on Floor 1, who came out and tried to find the resident. Ad Hoc QAPI meeting, dated 11/01/24, reflected the ADM, DON, MD, ADON A, and RN G met on 11/01/24 to discuss the followed summary, which stated, 11/01/24 At 2:30 AM resident observed asleep in bed by staff, at approximately 3:20 AM; resident broke her window and left running. Resident left running down the street. CNA tried to follow resident down the street but lost sight of resident and unable to find resident. Police was called, ADON and management were contacted. CNAs started driving around to see if they can find resident. Physician, RP and family notified. Resident was located by staff about 2 blocks from facility. EMS and police was activated. Resident was taken to hospital in 4-point restraint and multiple seat belts as she was refusing to go to the hospital. RP and Physician notified with the update. Resident transported to Hospital ED for evaluation/treatment via EMS. Facility notified of the resident's schizophrenia and bi diagnosis by ED staff. IDT reviewed medical records, conclusion that the resident experienced a psychiatric episode due to aphasia secondary to cerebrovascular accident. Resident unable to communicate frustration/fear of persecution. IDT determined not reportable based on provider letter content. Elopement protocol/procedure re-education with staff initiated. During an interview on 11/06/24 at 9:29 AM, the MS stated a female resident [Resident #1] broke the window in her room. The MS stated he didn't know how the female resident broke the window in her room. The MS stated he couldn't recall the date when the female resident broke the window in her room, but believed the incident happened early in the morning before 7:00 AM or possibly 6:30 AM. The MS stated he got a call on 11/01/24 at 5:14 AM to come early to the facility to repair a window. The MS stated staff didn't tell him what happened and how the window broke other than the female resident broke the window. The MS stated no one was in room when he came to the facility. The MS stated on 11/01/24, he repaired the window, which was the 2nd time the female resident broke the window. The MS stated the first time the female resident broke her window in her room happened during the week of 11/01/24. The MS stated he and the other maintenance staff member repaired the window on 11/01/24 at 7:00 AM. An observation of the outside of Resident #1's room on 11/06/24 at 9:35 AM reflected there were still pieces of broken glass on the ground. Resident #1's window was repaired. Resident #1 wasn't in her room. During an interview on 11/06/24 at 9:42 AM, the MSA stated two weeks ago, a window broke. The MSA stated a couple days later, the same window broke a second time in the early morning. The MSA stated the first time was during the day the window broke. The MSA stated he cleaned up all the glass in the room. The MSA stated the second time was in the morning when the window broke and when he came to help repair it. The MSA stated when he got there, he was told the female resident [Resident #1] broke the window. The MSA stated he didn't know how the female resident broke her window and wasn't told how the female resident broke window. The MSA stated he didn't know why the female resident broke the window. The MSA stated he helped repair the window the same way as the first time. The MSA stated the first time the female resident broke her window, he had a replacement window and the second time the female resident broke the window, he had to have a company come out to replace the window. The MSA stated the window wasn't repaired any different than the first time he repaired the window. During an interview on 11/06/24 at 10:03 AM, the DON stated Resident #1 was in the hospital. The DON stated on 10/29/24, Resident #1 had a nervous breakdown and broke her window. The DON stated Resident #1's incident happened the week before Tuesday (10/29/24). The DON stated she was not sure if it was Tuesday, but believed it was 2 weeks ago on Thursday or Friday (10/24/24 or 10/25/24) when Resident #1's incident happened. The DON stated last Tuesday (10/29/24), Resident #1 broke the window the first time. The DON stated that around 6:00 am, Resident #1 had a delusion, saw that someone was trying to come through her window, and she broke the window. The DON stated she was out of the facility when Resident #1 broke the window. The DON stated she sent Resident #1 out to the hospital because she sustained a laceration and came back same day (10/29/24). The DON stated Resident #1 didn't go out the window the first time. The DON stated staff monitored Resident #1 every shift and psychiatric services visited Resident #1 after the incident. The DON stated Resident #1 was also put on medication (Ativan) after the incident. The DON stated she didn't know if staff documented monitoring Resident #1 every shift. The DON stated she tried to move Resident #1 to another room, but Resident #1 insisted to stay in the same room. The DON stated two days later (10/31/24), Thursday or Friday (10/31/24 or 11/01/24), Resident #1 broke the window again and left the facility. The DON stated the incident happened around 3:00 AM. The DON stated LVN H and CNA I saw Resident #1 and followed her to a coffee shop. The DON stated there were also staff in their cars who followed Resident #1. The DON stated she didn't know how long the LVN H and CNA I followed Resident #1 for. The DON stated Resident #1 sustained a laceration from the incident. The DON stated Resident #1 refused to let staff approach her during the incident. The DON stated Resident #1 had a nervous breakdown and was delusional. The DON stated she called EMS and they took Resident #1 to the hospital after the incident. The DON stated she was also not working the second time Resident #1 broke the window. The DON stated she didn't know why Resident #1 broke the window. The DON stated she answered her phone around 4:00 AM. The DON stated the ADM handled and managed Resident #1's incident. An attempt to contact Resident #1 was made on 11/06/24 at 10:!5 AM. A voicemail and call back number was left. Resident #1 didn't return the call before exit. An attempt to contact Resident #1's RP was made on 11/06/24 at 10:16 AM. A voicemail and call back number was left. Resident #1's RP didn't return the call before exit. An attempt to contact Resident #1's family was made on 11/06/24 at 10:17 AM. voicemail and call back number was left. Resident #1's family didn't return the call before exit. During an interview on 11/06/24 at 10:25 AM, the ADM stated Resident #1 was a [AGE] year old female who had a stroke and left sided weakness. The ADM stated on 10/29/24 at 6:00 AM, Resident #1 broke the window twice. The ADM stated last week, Resident #1 broke her room window. The ADM stated Resident #1 told him that she saw a man, was afraid, and broke her window. The ADM stated Resident #1 didn't leave after she broke the window, staff responded to the incident, and staff repaired window. The ADM stated the staff did medication changes and sent a psychiatric referral for Resident #1. The ADM stated staff didn't repair Resident #1's window any differently after her incident. The ADM stated Resident #1 used an object to break the window. The ADM didn't describe what the object was that Resident #1 used to break the window. The ADM stated staff heard glass breaking and LVN C was working during the time. The ADM stated on 11/01/24 in the early morning, Resident #1 broke the window. The ADM stated ADON J, who was notified by LVN B, who was notified by CNA I that CNA I heard glass break and observed Resident #1 climb out the window. The ADM stated a nurse, who was outside the facility, also observed Resident #1 climb out the window. The ADM stated Resident #1 outran staff and disappeared passed the funeral home. The ADM stated staff conducted a call tree and were unable to locate Resident #1 until an hour later. The ADM stated Resident #1 was found on the street in her panties and a shirt. The ADM stated Resident #1's pants were found on a fence. The ADM stated RN E observed Resident #1 running into traffic and into a 24 hour coffee shop. The ADM stated staff held Resident #1 at the coffee shop. The ADM stated he notified the police department and EMS. The ADM stated Resident #1 vigorously fought the police department and EMS. The ADM stated the hospital notified staff that Resident #1 had schizophrenia and bipolar disorder, which the facility didn't know. The ADM stated the police department was familiar with Resident #1. The ADM stated Resident #1 used paper towels and assumed she broke the window with her hands. The ADM stated Resident #1 cut her arm along a fence that she hopped and hid in someone's backyard. The ADM stated staff only observed Resident #1 observed fence cut on her arm and no cuts anywhere else. The ADM stated Resident #1 told him that she broke the window because she was afraid. The ADM stated ST and IDT interviewed Resident #1 and all Resident #1 wrote was scary on a piece of paper. The ADM stated he didn't know when ST and IDT interviewed Resident #1. The ADM stated he didn't get to interview Resident #1. The ADM stated he didn't know Resident #1 had a history of schizophrenia and was not on a normal medication regimen for the diagnosis. The ADM stated he didn't report the incident to the SA because it didn't meet the reporting criteria and because Resident #1 was seen leaving by staff, knew where Resident #1 went, and never stopped looking for Resident #1. The ADM stated Resident #1 didn't elope, had a psychotic break, had a case of psychosis, and that her incident didn't meet definition of elopement. The ADM stated had he felt it was a reportable incident, he would've called it in to SA. The ADM stated the fact staff saw Resident #1 leave, reviewed Resident #1's incident, did AD-HOC (a meeting scheduled outside normal schedule) QAPI, looked at multiple areas, and did an investigation and timeline, he believed Resident #1's incident wasn't reportable and staff responded appropriately. The ADM stated to report elopement, it would be within 24 hours or immediately and if the incident involved serious injury. The ADM stated according to the latest provider letter, the facility had 24 hours to report the incident to the SA. The ADM stated residents couldn't be impacted if their incidents were not reported to SA. The ADM stated he didn't consider Resident #1 to have been a missing resident during the incident. An attempt to contact LVN C was made on 11/06/24 at 11:06 AM. A voicemail and call back number was left. LVN C didn't return the call before exit. An attempt to contact RN K, who worked on Resident #1's hall on 10/31/24, was made on 11/06/24 at 11:29 AM. A voicemail and call back number was left. RN K didn't return the call before exit. During an interview on 11/06/24 at 11:31 AM, NA L stated he observed Resident #1 was restless on 10/31/24 from 2:00 PM through 10:00 PM. NA L stated he believed Resident #1 was restless [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #1) reviewed for accidents and hazards. The facility failed to identify Resident #1 as an elopement risk from his admission paperwork or complete a wandering/elopement assessment within 24 hours of admission. On 02/08/24 he eloped from the facility for approximately three hours and was located 1-2 miles from the facility at a busy intersection of a street and a highway. The noncompliance was identified as PNC. The IJ began on 02/08/24 and ended on 02/15/24. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for unsafe elopements, falls, injuries, and hospitalization. Findings include: Review of Resident #1's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included unspecified dementia, abnormalities of gait and mobility, type II diabetes, essential hypertension (high blood pressure), and cognitive communication deficit. He was discharged from the facility on 03/11/24. Review of Resident #1's admission MDS assessment, dated 02/14/24, reflected a BIMS of 4, which indicated a severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected he utilized a wheelchair. Section P (Restraints and Alarms) reflected he required a wander/elopement alarm. Review of Resident #1's care plan, revised 02/08/24, reflected he was an elopement risk/wanderer related to history of attempts to leave the facility unattended with interventions of 1:1 monitor location and a wander guard in place on right ankle. Review of Resident #1's admission paperwork, dated 01/13/24, reflected the following nursing progress notes from his previous facility: [Resident #1] was noted off-site by [BOM] . This nurse assisted [BOM] with bringing [Resident #1] back into facility. Police were present at this time Review of Resident #1's admission paperwork, dated 01/13/24, reflected the following nursing progress notes from his previous facility: [Resident #1] was brought over to memory care after an elopement Review of Resident #1's admission paperwork, dated 01/13/24, reflected the following nursing progress notes from his previous facility: [Resident #1] just left via facility van . [Resident #1] transferring to (psychiatric hospital) for behaviors and elopement Review of Resident #1's nursing progress notes in his EMR, dated 02/08/24 at 12:50 PM and documented by RN A, reflected the following: Reported by family that [Resident #1] has left facility to sightsee and is waiting on someone to pick him back to the building. [Resident #1] was interviewed upon being brought back to the facility. [Resident #1] stated that he wanted to get out of the facility to go look around and he planned to return to the facility. Stated he did not see anything wrong with it . He then proceeded to say that he sat where he could watch the door and waited till someone went through the door and followed them outside . 1:1 initiated for close monitoring. Social services, psych referral initiated and PT/Speech eval (evaluation) obtained Review of Resident #1's Pre-Restraint Assessment/Screening, dated 02/08/24, reflected the following: Wander guard to right lower leg to alert staff due to [Resident #1] wandering outside facility related to confusion and not apprehending safety measures secondary to Dementia. Review of Resident #1's Wandering Evaluation, dated 02/08/24, reflected he was at moderate risk of wandering/eloping. During an interview on 03/25/24 at 1:25 PM, the DON stated she was in the morning meeting on 02/08/24 when the ADMC called and informed her she received a text message from Resident #1's FM B saying he was on (street name) and did not know how to get back to the facility. She stated they went and located him and brought him back. She stated when he was interviewed, he told the ADM he saw people coming and going so he tried to open the door and a nurse told him he could not leave. She stated he told the ADM, I'm going to show her I can leave. She stated he apparently waited for the nurse to be busy and then followed someone out. She stated the wandering/elopement assessment had not been done prior to the elopement. She stated it was SW C's responsibility and they should be completed within 24 hours of admission. She stated SW C was immediately suspended and then she voluntarily quit. She stated she knew he was at risk of elopement but thought the memory care unit was too restrictive for him so she placed his room on the second floor. She stated after the elopement, a wander guard was put on him and he had 1:1 supervision. She stated a negative outcome of not completing a wandering/elopement assessment in the timeframe would be exactly what happened with Resident #1. During an interview on 03/27/24 at 8:50 AM, the Receptionist stated when residents wanted to leave or had an appointment, they signed out at the nurses' station and the nurses would either call her to inform her or would walk the residents down themselves. She stated Resident #1 left the faciity on [DATE] before she had arrived at 8:00 AM for her shift. She stated FM B called her sometime after 9:00 AM to inform her Resident #1 had texted them. She stated she went upstairs and told the Administration staff immediately. She stated after that elopement, in-services were done with all staff regarding elopement and wandering risks. During an interview on 03/27/24 at 9:08 AM with the ISW, she stated she was filling in to assist SW D with social work duties and had been for around two weeks. She stated she was primarily doing the MDS assessments and the BIMS. She stated SW D was doing the wandering assessments but she completed some if he was not available. She stated after Resident #1's elopement, all staff were in-serviced on elopement, monitoring residents that were near the front door, and what to do after an elopement occurred. She stated wandering assessments were important in order to identify if a resident had exit-seeking behaviors. She stated if a resident was high risk, interventions could be put in place such as 1:1, redirection, and finding activities, they liked to keep them occupied. During an interview on 03/27/24 at 9:19 AM, SW D stated he was responsible for the first floor's residents social work assessments, wandering UDAs, discharge planning, and smoking contracts. He stated wandering assessments were to be completed within the first 24 hours of admission in order to get a baseline on the resident's behaviors. He stated if the resident was a high risk, precautions needed to be put into place to ensure there was no elopement. He stated Resident #1 had not been his resident as he had resided on the second floor. He stated there was an Elopement Binder at both nurses' stations and the Receptionist's desk with pictures and face sheets of residents with a high risk of elopement. He stated those helped nurses to ensure they knew which residents they needed to monitor more closely. During a telephone interview on 03/27/24 at 9:26 AM, LVN E stated she worked 10 PM - 6 AM on the first floor. She stated she saw Resident #1 on 02/08/24 attempting to go out the front door and she told him he could not go out. She stated it must have been between 6 AM - 7 AM as she was waiting for the next shift's nurse to relieve her. She stated she called the nurses' station upstairs but there was no answer. She stated she went down the hall to get her belongings and when she returned, he was not there anymore. She stated she believed he had gone back upstairs. She stated she assumed he understood he was not able to leave. She stated after his elopement they were in-serviced on elopement risks, what to look for, and if you did not know the resident to ensure you reach the nurse upstairs. During an interview on 03/27/24 at 9:33 AM, RN A stated she worked on 02/08/24 and Resident #1 was one of her residents. She stated she did her initial rounds around 5:50 AM and he appeared to be in bed asleep but she did not physically go and look. She stated when he was admitted he had a history of elopement but did not know that until after the incident. She stated if the initial wandering/elopement assessment was completed, she would have put in interventions and would have notified the CNAs. She stated she was in-serviced on the elopement policy and physically seeing each resident at the beginning of each shift. During an interview on 03/27/24 at 9:56 AM, the ADMC stated she was responsible for marketing and admitting residents to the facility. She stated the DON was responsible for going over the clinicals for potential new admissions and would decide to either accept or deny them. She stated when she received the clinicals for Resident #1 the first time, there was no mention of elopement. They thought Resident #1 was a female (because of the name) and there were no female beds available so she assumed the clinicals were thrown out. She stated when they found out Resident #1 was a male, the DON approved his admission. She stated the second set of clinicals (which mentioned elopement) was sent to them the day before he was admitted and she and the DON thought it would contain the same information as the first set of clinicals. She stated she did not review the second set of clinicals and was not sure if the DON had. During an interview on 03/27/24 at 10:17 AM, the DON stated she was responsible for reviewing clinical records for a potential new admission. She stated after she reviewed Resident #1's first set of clinicals, she did not believe there was enough documentation. She stated there was only two pages of nursing notes and his History and Physical. She stated they also though Resident #1 was a female and they did not have a female bed available. She stated she shredded the clinicals and asked the ADMC to go to the facility he was residing at to assess him for a potential future admission. She stated the ADMC assessed him and relayed that he was just a grumpy old man, he was not agitated, and he was talking and laughing with the staff. She stated from the ADMC's assessment and the fact his first set of clinicals were not that bad, she approved the admission. She stated they requested his clinicals again and they received them the day before he was admitted . She stated she did not review them that time because she thought they would be the same as the first set. She stated because she knew Resident #1 liked to move around, she made sure he was placed on the second floor. Attempted interviews with SW C on 03/27/24 at 9:50 AM and 1:15 PM were unsuccessful. Review of a written witness statement by LVN E, dated 02/08/24, reflected the following: As this writer was in the nurse station noticed a resident from the second floor by the exit door which go to the receptionist area. [Resident #1] was tapping on the door window. This writer pass [sic] by resident get some paperwork which this writer had printed. This writer told [Resident #1] the receptionist wasn't there yet also that resident's [sic] weren't able to sign out yet. [Resident #1] looked at this writer then looked away. This writer had to gone [sic] down the hall and when this writer returned [Resident #1] was no longer there. Review of an Investigation Statement completed by RN A, dated 02/08/24, reflected the following: 1. When did you last care for the resident? 2/8/24 around 5:50 AM on my morning round 2. In what capacity were you care for this resident? Charge nurse 3. Did you witness the incident? No 4. How did you become aware of the incident? I was notified by ADON that [Resident #1] cannot be found and was not in the facility. 5. What did you see concerning the incident? [Resident #1] exited the building without signing out. 6. What did you hear about the time of the incident? I was notified that the family member called the facility that [Resident #1] out of facility. 7. What immediate action did you take? Went to check [Resident #1]'s room and instructed the team to do a head count and check exit door. . 12. What, if anything, is our knowledge of the resident? [Resident #1] is cooperative, follows commands, nurse did not observe any exit seeking behavior. Review of an Investigation Statement completed by LVN F, dated 02/08/24, reflected the following: 1. When did you last care for the resident? N/A 2. In what capacity were you care for this resident? N/A 3. Did you witness the incident? No 4. How did you become aware of the incident? Was made aware by staff member that [Resident #1] could not be located 5. What did you see concerning the incident? N/A 6. What did you hear about the time of the incident? N/A 7. What immediate action did you take? Assisted in the search of [Resident #1] and ensured all other residents were accounted for. . 12. What, if anything, is our knowledge of the resident? Prior to this incident, [Resident #1] had informed this writer that he would escape this facility; relayed message to [SW C ] Review of an Investigation Statement completed by SW C, dated 02/08/24, reflected the following: 1. When did you last care for the resident? N/A 2. In what capacity were you care for this resident? N/A 3. Did you witness the incident? No 4. How did you become aware of the incident? [LVN F] informed [SW C] on 2/7/24 that [Resident #1] told her that he was going to break the window and get out of here. [LVN F] stated that [Resident #1] went to the dining area window and started to hit it . 5. What did you see concerning the incident? Nothing - [Resident #1] has been in the facility for a week today and has not presented any wandering or elopement risk until [SW C] was told yesterday about what was said. [SW C] did not see [Resident #1] hit any windows or try to leave the facility. . 7. What immediate action did you take? I did not take any action because I did not think that [Resident #1] was going to leave the building. [Resident #1] has not presented any actions of leaving or wanting to leave until yesterday. . 12. What, if anything, is our knowledge of the resident? [Resident #1] has dementia with behaviors. [Resident #1] is oriented but has some cognition impairment. He is quiet, comes out of his room and hands out in the dining room area. 13. What additional information do you have that has not already been discussed regarding the incident? [SW C] asked [LVN F] this morning (2/8/24) if she documented what [Resident #1] told her so [SW C] can inform the managers in meeting. [LVN F] said, it's no need to document it because he has a history of elopement and the facility should have placed him in the unit when he got here. So now the ADM And DON are looking for him on [major highway]. Review of the facility's Ad-Hoc QAPI agenda, dated 02/09/24, reflected the ADM, DON, SW D, SW C, MAINTD, AD and MD were in attendance. They discussed ensuring facility practices were in line with elopement policy and procedures and social workers were to complete an audit of elopement assessments. Review of an in-service entitled Elopement and Wandering residents, dated 02/09/24, reflected staff from all shifts were reeducated on the facility's elopement policy. Review of an in-service entitled Walking Rounds/Resident Accountability, dated 02/10/24, reflected all nursing staff from all shifts were reeducated on the following: On-coming Nurse will do walking rounds and ensure all residents are in-house and/or accounted for. Review of Elopement Policy Post Training/Education Quizzes, from 02/08/24 - 02/12/24, reflected all staff completed and passed the quiz. Review of SW C's Counseling Report, dated 02/12/24, reflected the following: Substandard Job Performance - Failure to ensure that an accurate assessment of a new admission did not have a completed elopement assessment for [Resident #1]. The policy and procedure state that admission assessments are completed within 48 hours of admission to the policy. The failure to ensure timely and accurate completion of the admission assessments have the potential to result in inaccurate information for a resident. Review of the facility's investigation regarding Resident #1's elopement, dated 02/15/24, reflected the following: Incident: On 02/08/24 at approximately 9:15 AM, [FM B] of [Resident #1] reported that he had left the building and was on (major highway) sightseeing and waiting on someone from the facility to come pick him up and bring him back. Upon notification, the facility began to execute its elopement procedures in order to find the resident. [Resident #1] was located not far from the facility about 30 minutes later by the ADM and DON and brought back to the building. He was interviewed upon being brought back to the facility and stated that he wanted to get out of the facility to go look around and he planned to return. He also stated that he did not see anything wrong with it, as he was safe crossing the streets, looking both ways at each intersection. Facility Action: - Executed elopement procedures. - Located [Resident #1]. - RP notified. - Doctor notified. - Head to toe assessment completed. - Wander guard issued. - 1-on-1 monitoring initiated. - Psych referral initiated. - Therapy eval (evaluation) completed. - Report submitted to HHSC. - Staff in-serviced on elopement procedures. In review all of the information provided to the incident, it was determined that no specific individual was at fault for [Resident #1]'s elopement, however the facility could have been more diligent in assessing the resident as a high risk for elopement upon admission and put the proper interventions in place such as a wander guard, which would have immediately alerted the staff when he exited the building. Review of the facility's Elopements and Wandering Residents Policy, dated 11/21/22, reflected the following: 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. . Policy Explanation and Compliance Guidelines: . 4. Monitoring and Managing Residents at Risk for Elopement and Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay bye the interdisciplinary care plan team. The noncompliance was identified as PNC. The IJ began on 02/08/24 and ended on 02/15/24. The facility had corrected the noncompliance before the survey began.