**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remained free of accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #3) of 7 residents who were reviewed for accidents and supervision in that: The facility failed to ensure Resident #3 did not elope after she was identified to be of high risk for elopement based on pre-admission documentation received from Resident #3's previous nursing home placement that was submitted prior to Resident #3's admission on [DATE]. Resident #3 eloped on 12/23/2023 around 12:33 p.m., and was found on 12/23/2023 around 2:00 p.m. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 12/18/2023 and ended 01/10/2024. The facility had corrected the noncompliance before the survey began. The deficient practice could place residents at risk and could result in harm and serious injury. The findings included: Record review of Resident #3's Face Sheet, dated 01/23/2024, revealed Resident #3 was a [AGE] year-old female who was admitted into the nursing facility on 11/28/2023. Resident #3's diagnoses included Huntington's Disease (an inherited condition that stops parts of the brain from working properly over time), Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Anxiety Disorder, unspecified (a type of mental disorder where you may respond to certain things or situations with fear or dread and may experience physical signs of heart pounding and sweating, but does not meet the exact criteria for any other anxiety disorder but significant enough to be distressing and disruptive), and Dysphagia (swallowing difficulties), unspecified. Record review of Resident #3's admission MDS assessment, dated 12/10/2023, revealed a BIMS score of 10, which indicated moderate impairment. Section B0100 revealed Resident #3 had adequate hearing with no difficulty in normal conversation. Section B0600 revealed Resident #3 had clear speech and was usually understood. B1000 revealed adequate vision without corrective lenses. Section E0900 of the assessment revealed Resident #3 did not exhibit the behavior of wandering. Record review of Resident #3's admission Nurse Note, dated 11/28/2023, revealed RN B completed the admission process with Resident #3 and completed the physical assessment on 11/28/2023 at 4:26 p.m., when Resident #3 arrived. Resident #3 arrived at the nursing facility by the facility's van and was transported in via wheelchair. The document revealed RN B recorded Resident #3 was oriented to person and time, was able to walk independently without the use of aides and had a history of wandering. The admission Nurse Note revealed Resident #3 would require a secure unit. Record review of Resident #3's Elopement Risk Assessment, dated 11/28/2023, completed by LVN D, revealed Resident #3 was an elopement risk. Further review revealed Resident #3 could ambulate independently, recognized stop lights and signs, knew precautions when crossing streets, could recognize her own physical needs, and knew her name. The assessment revealed Resident #3 had made statements to leave her previous facility within the last month. Record review of Resident #3's SecureCare Environment Screening Tool, dated 11/28/2023, revealed Resident #3 did not continue to display exit seeking behaviors, was dependent on staff for mobility, and had a history of exit seeking. Record review of Resident #3's electronic Care Plan clinical records on 01/24/2024 revealed Resident #3 did not have a Baseline Care Plan. Record review of Resident #3's Care Plan, dated 12/26/2023, revealed Resident #3's plan was updated to identify Resident #3 was a risk for Elopement and a history of elopement by climbing out her window, to include interventions on 12/26/2023. The plan identified interventions to include, - distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident #3 was reevaluated and found to be appropriate for the secured unit, was moved to the secured unit where the windows do not open all the way to prevent exiting the facility that way. Family to be notified of attempts to leave the facility. Identify patterns of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. If the resident is exit-seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Monitor for fatigue and weight loss. PCP was notified when Resident #3 was feeling sad and wanted to go see her family member, antidepressants added to help her. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Record review of Resident #3's Progress Notes, dated 11/30/2023 at 9:08 a.m., revealed Resident #3 went into the front unsecure unit of the facility to attend church services and returned to the secure memory care unit at 9:50 a.m., with no exit seeking behavior observed. Record review of Resident #3's Progress Notes, dated 12/05/2023 at 10:03 a.m., revealed Resident #3 went into the front unsecure unit of the facility to attend bible study, with no exit seeking behavior observed. Record review of Resident #3's Progress Notes, dated 12/08/2023 at 1:26 p.m., revealed Resident #3 went into the front unsecure unit of the facility to watch a movie and have popcorn, with no exit seeking behavior observed. Record review of Resident #3's Progress Notes, dated 12/18/2023 at 10:41 a.m., revealed DON C document Resident #3 was being transferred to the front unsecure unit of the facility for a trial period and permission was received by Resident #3's family member. Record review of the Nursing 24-hour Report, dated 12/18/2023, revealed Resident #3 would participate in a trial transfer to front from back, continue medication with move, can ambulate, and monitor for exit behaviors. Record review of Resident #3's Care Plan Risk for Elopement, dated 12/18/2023, revealed staff would monitor Resident #3 to ensure she would not elope from the facility every hour for 24-hours and every 4-hours for 72 hours (3 days). Record review of the document revealed there was no other interventions documented or put in place to prevent Resident #3 from leaving the facility unattended other than monitoring. Record review of a documentation sent by cell phone text, dated 12/18/2023 at 4:47 p.m., revealed DON C sent a text to all employees of the facility and confirmed that 37 employees read the text that stated, Reminder: Please keep an eye on Resident #3. She eloped at her previous facility, but she was on COVID isolation and was physically attacked by another resident. Record review of Resident #3's monitoring documentation, dated 12/18/2023, revealed staff documented Resident #3 from 11:00 a.m. through 7:00 p.m. with hourly documented location; 8:00 p.m. through 5:00 a.m. with a line marked, which indicated Resident #3 was in her room; and 6:00 a.m. through 11:00 a.m. with hourly documented location. Review of the 4-hour monitoring documentation revealed staff documented Resident #3 from 12/19/2023 at 11:00 a.m. through 12/21/23 at 11:00 a.m. with documented location noted every 4-hours. Record review of Resident #3's Event Nurses' Note, dated 12/23/2023 at 5:07 p.m., completed by DON C, revealed Resident #3 was found walking down the road by another resident's family who called the facility, and the nurse on duty went to pick her up. Resident #3's window was found open, and footprints were outside on the ground. DON C documented the facility camera did not show evidence Resident #3 went out the front door. During an interview on 01/24/2024 at 9:40 a.m., Resident #3 said she left the facility by herself because it was Christmas time and she wanted to see her family. Resident #3 said she would not try to escape out of her window again and knew she was wrong for leaving the facility. Resident #3 said her family member moved her to be closer to where she lived, and Resident #3 said she wished her family member would come to visit her more often. Resident #3 said she should not have left the facility alone without telling anyone but Resident #3 said she was frustrated and wanted to see her family. Resident #3 said she was mad at her family member for not picking her up. During an interview on 01/24/2024 at 10:20 a.m., LVN A said Resident #3 had not attempted to leave the facility by herself during the period she was admitted to the nursing home on [DATE] and moved to the front, unsecured section the facility on 12/18/2023, for a trial period to live in a least restrictive environment. LVN A said Resident #3 returned to the memory care secure unit on 12/23/2023. LVN A said Resident #3 had not displayed exit-seeking or negative behaviors when she resided on the secure memory care unit. LVN A said Resident #3 acted content and happy by her facial expressions and interactions with other residents and nursing staff. LVN A said when he heard that Resident #3 had left the facility, he was shocked, as Resident #3 had never demonstrated exit-seeking behavior while on the secure unit. During an interview on 01/24/2024 at 12:16 p.m., Resident #3's Family Member said she was contacted by the nursing facility when Resident #3 left the facility unaccompanied on 12/23/2023. Resident #3's Family Member said Resident #3 told her the reason she left the nursing home by herself was she wanted to come see her for Christmas and was frustrated. Resident #3's Family Member said she told Resident #3 that she could not leave by herself, and Resident #3 was apologetic and told her she would not leave the facility again. Resident #3's Family Member said she was contacted by the facility and had agreed for Resident #3 to move to the front, unsecured area of the facility for a trial period. Resident #3's Family Member said Resident #3 had told her she felt safe at the new facility and did not complain like she did when she was residing at the previous facility. Resident #3's Family Member said she was surprised that Resident #3 left unaccompanied. During an interview on 01/24/2024 at 12:37 p.m., Resident #5's Family Member said she had departed the facility on 12/23/2023, but could not remember the time, and drove approximately a half mile from the facility when she saw Resident #3 as she walked on the side of the road. Resident #5's Family Member said Resident #3 carried a paper bag with the same name of the convenience store that was located approximately 0.6 miles from the facility and Resident #3 was walking in the direction away from the store. Resident #5's Family Member said Resident #3 walked in a safe manner and looked like she was fine, but Resident #5's Family Member said she was startled to see Resident #3 by herself. Resident #5's Family Member said she stopped her car to check on Resident #3 and called the facility to notify the nurse that Resident #3 was away from the facility. Resident #5's Family Member said when she rolled down her window and asked Resident #3 if she remembered her and Resident #3 responded yes. Resident #5's Family Member said Resident #3 told her she wanted to see her family in San [NAME]. Resident #5's Family Member said Resident #3 said she knew San [NAME] was too far to walk but she was mad at her family and went to the store to get a coke and a snack. Resident #5's Family Member said the nurse from the facility and police arrived and talked to Resident #3 in a respectful manner. Resident #5's Family Member said Resident #3 was transported back to the facility. During an interview on 01/24/2024 at 1:50 p.m., DON C said Resident #3 was new to the facility and she was placed in the memory care secure unit due to her history of leaving the facility without notifying staff at the previous facility Resident #3 resided in. DON C said Resident #3 was admitted on [DATE] and then moved to the unsecure part of the nursing facility for a trial period 12/18/2023 because Resident #3 had not attempted to leave the facility since she was admitted . DON C said the decision to transfer Resident #3 was discussed in the administration stand-up morning meeting and documented in the facility 24-hour report. DON C said the nursing staff would have been notified by reading the 24-hour report that Resident #3 had a history of elopement, and the information would be shared with the nursing staff verbally. During an interview on 01/24/2024 at 3:06 p.m., LVN D said she had been at the facility since 2019 and was familiar with Resident #3. LVN D said she worked on the floor when Resident #3 moved to the front, unsecure part of the nursing facility for a trial period and Resident #3 did well. LVN D said Resident #3 would sit in the same chair in the front common area. LVN D said she was aware Resident #3 was at risk for elopement and monitored Resident #3 during the first three to four days of her trial period. LVN D said Resident #3 would walk to her room and then back to the common area and sit in the same chair. LVN D said Resident #3 never left the area unless she went to activities, such as bingo or listened to live music. LVN D said she never witnessed Resident #3 demonstrate exit seeking behaviors and when LVN D heard Resident #3 had left the facility, LVN D said she was shocked. During an interview on 01/24/2024 at 3:59 p.m., LVN E said she received a phone call from Resident #5's Family Member who reported she had witnessed Resident #3 outside the facility on the side of the road near a convenience store. LVN E said she left the facility and went to pick up Resident #3. LVN E said Resident #3 told her she wanted to go see her family and was frustrated that she was not with her family for Christmas. LVN E said when she arrived, Resident #3 did not want to return to the facility, so LVN E called the police. LVN E said when the police arrived, Resident #3 calmly complied and returned to the facility. LVN E said she attended the in-service on 12/27/2023 that covered elopements and how to respond when a resident eloped. During an interview on 01/24/2024 at 4:16 p.m., CNA F said she had worked at the facility for 14 months and was familiar with Resident #3. CNA F said she was on duty in the memory care secure unit the day Resident #3 left the facility by herself. CNA F said when the staff became aware Resident #3 was not at the facility, an all-staff alert was made, and all staff began searching the facility and surrounding area outside (this was at the same time that LVN E received the phone call from Resident #5's family member). CNA F said staff became aware Resident #3 was not in the building at the same time LVN E had received the phone call from Resident #5's Family Member and had left the facility to pick up Resident #3. CNA F said LVN E had not reported Resident #3 had eloped to all employees on duty in the facility, so an all-staff alert went out and everyone began searching for Resident #3 in the facility and outside grounds. CNA F said LVN E reported to the other nurse on duty Resident #3 had been seen away from the facility and left the building without notification to all staff. During an interview on 01/29/2024 at 10:59 a.m., MDS Case Manager G said she had been at the facility for three (3) years. MDS Case Manager G said she knew in advance if a new residence was going to be admitted and the DON would print out the preadmission paperwork. MDS Case Manager G said the charge nurse on duty would pass the information to the nursing staff coming on duty by use of the 24-hour report and verbally. MDS Case Manager G said the information that Resident #3 was elopement risk on 01/18/2023, when she was moved to the front, unsecure part of the nursing facility for a trial period would have been provided by verbal report from the nurse on duty to the on-coming staff and by use of the 24-hour report. MDS Case Manager G said when Resident #3 transferred into the unsecure part of the facility, interventions should have been in her care plan. During an interview on 01/29/2024 at 1:48 p.m., the Administrator said he had agreed to move Resident #3 to the front, unsecured area of the facility on 12/18/2023 for a trial period to determine the least restrictive environment. The Administrator said Resident #3 had not demonstrated or voiced any intentions of leaving the facility by herself and he felt a trial period was appropriate. The Administrator said the staff monitored Resident #3 appropriately during the early time period of the move and Resident #3 made no attempts to leave the facility. The Administrator said when Resident #3 eloped, the facility immediately put measures in place to ensure her safety. The Administrator said the facility held an ad hoc IDT meeting and contacted the physician and transferred Resident #3 to the secure memory care unit of the facility where the windows would not open wide enough to allow Resident #3 to crawl through. The Administrator said an elopement risk assessment was completed for Resident #3 and 15-minute monitor was initiated and completed for Resident #3 on 12/23/2023 through 12/26/2023. During an observation on 02/12/2024 at 1:15 p.m., observed the window in a resident room on Hall 1. Observed the large window had a screen and observed approximately six to eight inches above the top windowpane, a small silver metal box was attached to the window frame. Observed the box was approximately 1 inch by 1 inch in size and located on the left side of the window frame. Opened the window and observed the window only opened about six inches and did not provide enough space for a person to crawl through. During an interview on 02/12/2024 at 2:15 p.m., DON C said she informed staff that Resident #3 would be transferred to the front, unsecured part of the nursing facility on 12/18/2023 and provided the information that Resident #3 had a history of elopement. DON C said she informed staff verbally and through the facility's messaging system. DON C said the facility used a cellular application that communicated with all staff who had the application on their phone. DON C said she had the text message and the documentation of 37 employees who read the text message that informed staff Resident #3 must be monitored for elopement due to leaving the facility she previously resided in. During an interview on 02/12/2024 at 1:40 p.m., Maintenance Supervisor I said the facility had installed window limiters and placed them in all the windows within the facility. Maintenance Supervisor I said the facility completed the task based on a precaution after a resident eloped from the facility by kicking out her screen and exiting out the window. Maintenance Supervisor I said on 12/27/2023, he went to the local hardware store and bought all the window limiter locks that was in stock and ordered the number the facility would need to install in all windows. Maintenance Supervisor I said the supply was shipped and arrived approximately one week later. Maintenance Supervisor I said he placed the locks on the resident rooms, lobby, offices, kitchen/dining room, and every window in the facility within a few days after the locks arrived. Maintenance Supervisor I said when he looked at the receipt, the window limiters arrived on 01/05/2024, so he had all the devices installed by 01/10/2024. Maintenance Supervisor I said prior to the installation of the window limiter locks, the memory care unit had a screw like barrier to prevent the window from opening no further 6 to 8 inches. Maintenance Supervisor I said the facility changed the code on the keypad every month as a precaution as well. Maintenance Supervisor I said he had been in-serviced on elopements and how to respond when a resident eloped on 12/27/2023. During a phone interview on 02/12/2024 at 3:28 p.m., CNA J said she was on duty when Resident #3 eloped on 12/23/2023 and was assigned to Hall 1. CNA J said she had walked with Resident #3 to her room from the dining room after lunch at approximately 12:00 p.m., or 12:05 p.m. CNA J said she remembered Resident #3 had said she wanted to take a nap. CNA J said she walked into Resident #3's room and observed as she laid down on her bed. CNA J said she knew Resident #3 had a history of leaving the facility unaccompanied. CNA J said she had been in-serviced on elopements and how to respond when a resident eloped or was not located in the facility on 12/27/2023. CNA J said she had been trained on the elopement policy and what action she should take if a resident was missing from the facility. CNA J said she attended the in-service on how to prevent elopement episodes and elopement response on 12/27/2024. During an interview on 02/12/2024 at 3:54 p.m., the Administrator said he had reviewed [NAME] footage on 12/23/2023 from Hall 1 and had observed Resident #3 enter her room at 12:33 p.m. and did not observe Resident #3 exit during the time up to 2:20 p.m., when the facility was notified she was observed away from the facility. During an interview on 02/13/2024 at 11:00 a.m., DON C said the Care Plan Risk Assessment for Elopement was completed for Resident #3 on 12/18/2023. DON C said when Resident #3 moved to the unsecure, front unit of the facility, the move was considered a transfer and the policy was implemented. DON C said the policy gave specific details on how the transfer would be made based on case-by-case basis according to the need of the resident. DON C said Resident #3 could independently ambulate and walk without assistance. During an interview on 02/14/2024 at 10:46 a.m., the Administrator said he arrived at the facility on 12/23/2023 immediately after he was informed Resident #3 had eloped. The Administrator said an Ad Hoc QA Meeting with the IDT team was held and the Elopement Risk Assessments were discussed. The Administrator said the physician, family, and staff were involved in the meeting and agreed Resident #3 would be safer in the secure memory care unit. The Administrator said Resident #3 was moved after the physician gave orders and the Care Plan was updated with interventions to prevent further elopement. The Administrator said the Maintenance Director had gone to the local hardware store on 12/27/2023 and purchased all the window limiters in stock and installed them in the windows in the front unsecure part of the facility. The Administrator said an Ad Hoc QAPI meeting was held on 12/27/2023 to further address incident of elopement. The Administrator said all staff were in-serviced on elopements and what actions to take if a resident was missing. During an interview on 02/14/2024 at 4:31 p.m., Physician K said he was familiar with Resident #3 and was aware Resident #3 left the faciity on [DATE]. Physician K said Resident #3 was in no danger when she left the facility unsupervised. Physician K said Resident #3 had no history of falls, was alert and had a steady gait. Physician K said Resident #3 had mild symptoms of her diagnosis and was in no physical or mental danger when Resident #3 left the faciity on [DATE]. Record review of receipts for the local hardware store revealed window limiters were purchased on 12/27/2023 and additional locks were ordered. Review revealed the window limiters were delivered to the facility on [DATE]. Record review of the Ad Hoc QAPI, dated 12/27/2023, revealed the content of the meeting resulted in the need for elopement risk assessments to be completed before moving out of the Memory Care Unit. Additionally, the Secure Care Unit Decision Tree would be utilized before a resident was transferred out of the Memory Care Unit. Record review of the Provider Investigation Report, dated 12/29/2023, revealed the Administrator reviewed [NAME] footage during the investigation after Resident #3 had eloped and observed Resident #3 had entered her room at 12:33 p.m., on 12/23/2023 and was not observed to come out during the timeframe when she was found missing. At 2:20pm, LVN E had received a call from Resident #5's Family Member had observed Resident #3 approximately half a mile from the facility. On 02/15/2024 at 10:05 a.m., extended the sample and randomly reviewed records for completion of elopement assessments. Record review of Resident #6's Elopement Assessment, dated 12/23/2023 revealed the facility completed the action of completing assessments on all residents. Record review of Resident #7's Elopement Assessment, dated 12/24/2023 revealed the facility completed the action of completing assessments on all residents. Record review of Resident #8's Elopement Assessment, dated 12/23/2023 revealed the facility completed the action of completing assessments on all residents. Record review of Resident #9's Elopement Assessment, dated 12/23/2023 revealed the facility completed the action of completing assessments on all residents. The Administrator was notified of an Immediate Jeopardy (IJ) on 02/15/2024 at 12:14 p.m. and was given a copy of the IJ Template. Explained a plan of removal would not be required due to the fact that all interventions were corrected prior to on-site entrance date of 01/23/2024. It was determined these failures placed Resident #3 in an Immediate Jeopardy (IJ) situation from 12/18/2023 through 12/23/2023. The facility took the following actions to correct the non-compliance and to prevent elopements from the facility, following the incident, to include: 1. QAPI completed 12/27/2023 - IDT Team - Regarding Elopement Incident. 2. Resident #3's care plans were revised on 12/24/23 to include goals and interventions, related to Elopement. 3. Resident #3 was placed on the secured unit on 12/23/23 with documented monitoring. 4. 12/23/23 - 12/26/23: Elopement Risk Assessments were completed for all residents in the facility. Care Plans were reviewed and updated, if needed, for all individuals that met the criteria for high risk. 5. All staff were trained on elopement on 12/27/2023. 6. The facility ordered window restrictors on 12/27/2023 and placed them on every window in the facility, approximately 1 week later once they were received. Record review of the facility's policy, Elopement Prevention, dated 10/07/2010, revealed every effort would be made to prevent elopement episodes while maintaining the least restrictive environment for residents who were at risk for elopement. During an observation on 02/15/2024 at 1:03 p.m., to complete random window observations, observed the front window located by the front entrance door and observed a small silver metal box was attached to the window frame. Observed the box was approximately 1 inch by 1 inch in size and located on the left side of the window frame. Observed the window limiter lock prevented the window from opening more than 6 inches. During an observation on 02/15/2024 at 1:05 p.m., observed the window in the office of the Administrator and observed a small silver metal box was attached to the window frame. Observed the box was approximately 1 inch by 1 inch in size and located on the left side of the window frame. Observed the window limiter lock prevented the window from opening more than 6 inches.