**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure the environment was as free of accident hazards was possible and each resident receives adequate supervision to prevent accidents for 1 of 21 resident (Resident #55) reviewed for accidents and hazards, in that: On 03/20/2025 at about 9:30pm, Resident #55 was able to get out of a window in a common room on the secure unit without staff's knowledge, pull off 3 wood fence pickets and leave the premises. Facility staff were not aware Resident #55 was not in the building until he was returned by law enforcement at approximately 01:00 AM on 03/21/2025. A past non-compliance Immediate Jeopardy (IJ) situation was identified on 04/02/2025 at 3:37 PM. The Immediate Jeopardy began on 03/20/2025 and ended on 03/24/2025. The facility had corrected the non-compliance before the survey began. The failure placed residents at risk for weather exposure, injury, hospitalization and/or death. Findings included: Review of Resident #55's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of dementia, late onset Alzheimer's disease, anxiety, bipolar disorder, high blood pressure, non-insulin dependent diabetes mellitus, and psychosis. Review of Resident #55's Quarterly MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Score Summary, the resident scored 3 out of 15 indicating severe cognitive impairment. Section E - Behavior, subsection E0900 - Wandering, Prescence & Frequency, Has the resident wandered? 1. Behavior of this type occurred 1 to 3 days was selected. Review of Resident #55's physicians orders dated 02/26/25 revealed an order May reside on secure unit r/t Dx: (diagnoses) Dementia, Bipolar disorder, Anxiety. Review of Resident #55's Comprehensive Care Plan dated 03/04/25 and reviewed/revised 03/21/25 revealed Focus: I have been evaluated as a wandering risk r/t specify: decreased safety awareness, confusion, wandering behavior [Resident] resides on the secure unit. [Resident] has a history of elopement from other prior facilities. [Resident] carries around a bed roll packs bag to leave everyday. Date initiated 03/21/25. Goal: I will remain free of injuries associated with wandering behaviors thru this review period with a target date of 06/10/2025. Interventions/Tasks: attempt to redirect resident when packing items and remind resident he resides in facility. Check my location frequently. Encourage me to participate in activities of my preference. Engage me in diversional activities when indicated. Observe me for s/s of agitation, pacing, repetitive verbalization of wanting to leave/go home, restlessness, report increased behaviors to nurses for further interventions. Offer resident the ability to call his family when behaviors are occurring. Provide me re-orientation as needed. Focus: [Resident] has a behavior problem AEB resident eloped out of a window, through a privacy fence which he ripped fence panels off of, and was found walking the streets. Date initiated 03/21/25. Goal: [Resident] will remain in facility without further elopements. Interventions/Tasks: ADMNister medications as ordered. Monitor for side effects and effectiveness. Anticipate and meet The resident's needs. Caregivers to provide the opportunity for positive interaction, attention. Stop and talk with him/her as passing by. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Monitor resident whereabouts frequently to ensure not attempting to elope. Provide a program of activities that is of interest and accommodates residents status. During an observation on 04/01/2025 at 02:13 PM, revealed Resident #55 was sitting in the common room on the secure unit working on a diamond painting project with a staff member present recording resident's activity every 15 minutes. During an observation on 04/01/2025 at 02:15 PM, revealed the windows in the common room on the secure unit, had window stops secured which allowed the window to raise 6 or less. During an observation on 04/02/25 at 07:00 AM, revealed a new gate with a keypad and doorbell noted along the fence surrounding the secure area. There were no bowed, cracked or loose pickets noted around the secure area. On the east side of the facility, an old gate was open, and the fence was missing 2 pickets, but with no access to the secured area. On the south side of the facility the gate was open, but with no access to the secure unit. Observation of the road in front of facility revealed a speed limit of 30. During a telephone interview on 04/02/25 at 08:21 AM, Resident #55's Guardian stated she was assigned to Resident #55 2 weeks ago. She stated the current facility was the 3rd facility the resident has been admitted to in the past month or so. The Guardian stated she felt the facility addressed the elopement appropriately and she was fine with every 15-minute checks instead of 1:1. She stated she had talk with Resident #55's family member in who resided in another state about relocating him closer, but the family member was not able to care for him. The Guardian explained Resident #55 was living with a family member in another city but was repeatedly being found and returned by law enforcement. The guardian stated the problem was not the facility but the system. She stated the facility communicated with her very well. She stated the facility was working overtime to keep the resident safe but he was cognizant enough to develop a plan and carry it out. The Guardian had offered to purchase and install window alarms but was waiting on decision from facility. She stated the window stops were on the windows prior to the elopement but were placed higher than they were. The Guardian stated the maintenance man immediately lowered the stops after the elopement. She stated the facility was not failing, or had an issue of poor care, it was the archaic system. During an observation on 04/02/25 at 08:20 PM, revealed one nurse and one CNA were present on the secure unit. During an interview on 04/02/25 at 08:20 PM, LVN G stated he was on duty the night of the elopement. He stated as soon as they were made aware of the elopement, a head count was done, doors were checked, and the outside perimeter was checked. LVN G explained he discovered the pickets missing in the wood fence outside the windows in the common room. He also noted the window in the common room was open and indicated with hands approximately 8. He stated he thought it was interesting that the resident chose fence pickets between the 2 windows in the common room. The fence pickets removed by Resident #55 were not visible when looking straight out either window. LVN G stated he did not hear any unusual noises the evening of the incident. LVN G explained Resident #55 received a sandwich at approx. 9:00 PM, ate it at the nurse's station then walked down the hall towards his room. LVN G stated he gave the Resident #55 his evening and the resident stated he was going to bed. The nurse observed the resident enter his room and shut the door. He stated since the roommate had already received his PM meds, the nurse did not enter the room again until doing the head count. LVN G explained they tried to not wake the roommate (in bed A) because he became agitated. He stated the CNA working on the night of the incident was new to the unit. He stated the usual CNA had called in sick. LVN G stated the replacement CNA had trained for almost 2 shifts. He explained the Activity Director was assisting on the unit until approximately 9:00 PM. LVN G stated when Resident #55 returned, he was wearing a long sleeve shirt, pants, shoes and was carrying his blanket roll. LVN G stated policy was to conduct rounds every 2 hours. LVN G stated Resident #55 made verbal statements about leaving but did not actively exit seek. He stated he did not feel the incident was a facility failure, measures were in place to prevent elopement such as keypad locks on all the exit doors, screws or stops in all the windows to limit height they could be raised, a 6' wood privacy fence around the courtyard and walk-way bordering the unit. LVN G stated he was told the resident was found on the access road. When asked how to get to the access road he stated a turn left or right onto a nearby street would get there. No one knew which direction the resident took. LVN G stated an elopement drill was done after the incident and the following week. He stated Resident #55 was put on 1:1 supervision with every 15-minute activity documentation. He stated in-services were done on elopement and every 2-hour rounds. LVN G stated the census on the secure unit the night of incident was 21. During a telephone interview on 04/02/25 at 08:49 PM, the local county Sherriff's Deputy stated she received the first call about the resident walking along the side of the road sometime after 9:00 PM on 03/20/25. The Deputy stated she interviewed him at the time and considered it a consensual stop. She stated the resident seemed cognizant and he explained to her that he was going to his family member's. The Deputy stated the resident was alert, oriented, answered questions appropriately, there were no signs of distress, and his walking ability was steady. She saw no reason to investigate further. The Deputy stated she received a 2nd call at approximately 11:00 PM about a man walking along the roadside a couple miles from the facility. She stated the resident appeared more altered but again was able to tell his name and that he was going to his family member's house. She explained that she called EMS to assess and checked the resident's driver's license for flags. She explained flags were put on the DL for situations like dementia. She stated the resident had no emergency contact information on him or linked to his DL. She contacted the address on his DL, no one knew who he was. She then made a report to APS. The Deputy stated APS told her they had information in bits and pieces on the resident d/t all the times he left his family member's house and was returned by law enforcement. She explained APS also stated the resident had been in other places but had left each of them several times. The Deputy stated she checked the missing person's report, but the resident's name was not listed. She stated EMS checked the resident, obtained a full set of vital signs, and determined he was in perfect health. She stated EMS reported his body temperature was normal. The Deputy stated she then decided to take him to the sheriff's department while trying to find out where he needed to be. She stated she finally reached his family, but they were not able to tell her where he was supposed to be. She explained one family member told her he was supposed to be in a nursing home 124 miles north. She stated she had other officers calling different facilities in surrounding counties. She stated one county reported notes on the resident that he lived with his [family member]. The deputy stated the resident was with her from 11:00 PM until she returned him to the facility. She described his reaction upon returning was pleasant, no behavior or statement of distress, only stated he wanted to see his family member that lived by the base. The deputy stated once inside the building the resident knew exactly how to get to his room. The Deputy stated when she located the resident, he was appropriately dressed and was carrying a bed roll with snacks so he was prepared. She stated the resident was not walking in the roadway either time, he was well off to the side. Review of weatherspark.com (https://weatherspark.com/h/d/7167/2025/3/20/Historical-Weather-on-Thursday-March-20-2025-in-Brownwood-Texas-United-States#metar-22-55) revealed the weather on 03/20/2025 at 10:55 pm, was 48.4°F, with no precipitation. During an observation on 04/02/25 between 09:00 PM and 09:20 PM of the road in front of the facility revealed 4 vehicles traveling south and 3 vehicles traveling north. During an interview on 04/03/25 at 05:51 AM CNA H stated she was scheduled to work the night of the incident but was sick. She stated she worked 2 partial shifts with the CNA that covered for her. CNA H stated training on elopement prevention included on-line modules and in-services. She explained training monitored by HR. CNA H stated the night of the incident, HR called her and had her participate in the elopement drill via phone. She explained the effect on residents of failing to provide training would be bad. She stated staff was trained to not give out the door codes and methods to block a resident from attempting escape without antagonizing the resident. She stated elopement drills were done for both day and night shifts. CNA H stated the best training to prevent elopement was to know the residents. During an interview on 04/03/25 at 08:43 AM, the Administrator stated staff call-ins were covered by PRN staff or having one of the 3 CNAs assigned to the front hall to float to the secure unit. She stated every 2-hour rounds were not done on Resident #55 because staff knew if the resident and/or his roommate were woken up by staff, they became agitated and were up all night. She stated because both residents in the room were independent, staff avoided irritating them. She stated her expectations were for rounds to be done every 2 hours but also wanted to keep in mind resident rights and preferences. She stated a few residents on other halls specifically requested not to be bothered. The Administrator stated policy was for law enforcement to be called when a resident was discovered missing, an eyes on count done, and the facility and perimeter checked. Review of the facility policy titled Wanderer Management, Monitoring System & Resident Elopement Protocol dated reviewed 01/2023 revealed 1. If a resident is noted to be missing, the following must be initiated immediately: Notify the Administrator/designee immediately. Perform a complete search of the interior of the building. This should include every room, including bathrooms, break rooms, storage rooms, closets, etc., Initiate an external search outside of the building, including the facility grounds and community, on foot and by vehicle. Interview staff to determine who may have seen the resident last and try to determine when they may have been seen last, including what they were wearing, etc. Notify local law enforcement and provide them with a complete description of the individual. Notify the resident's family and physician. Call area hospitals, bus stations, train stations, grocery stores, liquor stores, etc. Notify state agency per state law. Notify other nearby nursing homes. Postscript added to end of policy: Education: Staff to physically see and check on patients every 2 hours to ensure safety. The facility implemented the following corrections prior to survey entrance on 04/01/2025. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. The following records of interventions were reviewed: 1. Record review of 1:1 supervision and every 15 minute activity documentation of Resident #55 revealed supervision began on 03/21/25 and was ongoing. 2. Record review revealed the facility conducted elopement policy and every 2-hour resident checks in-services. Documentation of interviews with multiple staff members on their knowledge of elopement procedures and every 2-hour resident checks was on file. 3. Record review of the facilities An elopement drill revealed an elopement drill was conducted on 03/21/2025 and again on 03/28/2025. 4. Record review of maintenance records on 04/03/25 revealed the door to the secure unit and outside fence gate lock codes were changed on 03/24/2025. 5. Record review of maintenance documentation revealed the broken fence pickets were replaced, and all pickets were reinforced with screws on 03/21/2025. 6. An Ad hoc committee (a temporary group formed to address a specific issue or task) was created to evaluate effectiveness of interventions weekly for 8 weeks. Meetings were conducted on 03/21/2025 and again on 03/28/2025. 7. Residents with wandering/elopement risks were to be reviewed for risk potential daily for 30 days. Documented reviews began 03/22/2025 and were conducted daily.