**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensured each resident received adequate supervision for one (Resident #1) of four residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 was free from accidents. Resident #1 eloped from the facility on 3/20/25, was able to obtain access to a truck at a private residence near the facility. Resident #1 was involved in an accident and was transported to the ER on [DATE]. The facility failed to ensure Resident #1 checked out when leaving the facility and was monitored to ensure he returned. The process to get back in the facility after 10:00 PM (when the doors were locked) required him to have a phone to call the nurses station to be let in, Resident #1 did not have a phone. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 03/25/25 at 4:24 PM and an IJ template was provided. While the IJ was removed on 03/26/25 at 5:54 PM, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for unsafe elopements, falls, injuries, dehydration, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male admitted to the facility 01/22/25 with diagnoses including frontal lobe brain tumor (cancerous or non-cancerous growth in this area), dementia (a decline in mental ability that interferes with daily life), psychotic disorder (loss of cognitive functioning), alcohol dependence (a chronic condition characterized by a compulsive and uncontrollable pattern of alcohol consumption that leads to significant negative consequences in various aspects of life). He was not his own RP. Review of #1's admission Elopement/Wandering Evaluation assessment dated [DATE] reflected he had no wandering or elopement behaviors, and he had intact cognition. Review of Resident #1's care plan dated 01/22/25 reflected no problem areas and no interventions for wandering or elopement behaviors. Review of Resident #1's SLUMS (St. Louis University Mental Status) examination dated 1/29/25 reflected a total score of 28 which indicates normal cognition. Review of Resident #1's hospital records dated 03/21/25 reflected Resident #1 was seen in the ER for complaints of bilateral knee pain and right-hand pain due to motor vehicle collision. Review of Resident #1's SLUMS examination dated 3/25/25 reflected a total score of 15 which indicated dementia. Review of a doctor's order dated 01/22/25 reflected the following: may have psychiatrist to evaluate and treat as needed/indicated. Review of the facility self-report dated 03/21/25 reflected the resident was last seen by an ALF resident around 11:00 PM on 03/20/25. The ALF is connected to the SNF, and he was seen out of a window. He was found on 03/21/25, around 4:00 Am- 5:00 AM, by the local police department. He was involved in a car accident. He had minor cuts and abrasions and is still in the ER. He will be released back to the facility. The resident has never eloped before. He has a tumor in front of brain and may have shifted to hinder his decision making. He is going into the secure unit upon return. Narrative of the incident: Resident is independent with ADLs and has a history of navigating the unit safely with no exit seeking tendencies. No alleged perpetrators. Key witnesses of the elopement include LVN, and Assisted Living resident. The resident was seen several times just prior to the elopement exhibiting behaviors that were normal for him (i.e., approaching the nurse's station to call his brother). Facility staff executed missing resident protocols according to policy; facility administration responded as well as [NAME] Police Department and deployed a thorough search of facility and surrounding community blocks. Resident was located and sustained minor cuts and abrasions as a result of a motor vehicle crash. Resident allegedly left facility and located an unlocked vehicle and drove off in that vehicle. Resident currently at [NAME] Hospital for evaluation. Actions and Notification: Staff handled the missing resident protocol well. We plan to conduct a missing resident in-service for each neighborhood for good measure. Direct care staff promptly notified Administration. Administration promptly called in additional staff for search efforts, and a call was quickly made to the police department. The family was also notified right away. The physician was also notified. Review of Resident #1's hospital records dated 03/21/24 reflected associated diagnoses: abrasions of multiple sites; motor vehicle crash-minor; cognitive decline; bilateral knee pain; bacterial pneumonia; chest wall contusion; contusion of hand, right. Review of police report dated 3/21/2025 at 5:22 AM reflected Resident #1 was located by an officer in a field with cuts on his hand and an abrasion on his head, and he was yelling for help. An ambulance was dispatched to the location to transport Resident #1 to the hospital. During an interview on 03/24/25 at 1:45 PM with the ADM, he revealed he had moved Resident #1 to the memory care unit on 03/21/25 after he eloped. The ADM stated staff had been in-serviced on missing residents. He stated that Resident #1 did not have a history of wandering or elopement behaviors. The ADM stated the doors were kept unlocked during the day and that the doors were locked from the outside at 10:00 PM nightly. The ADM stated after 10:00 PM the resident and/or family members were responsible for calling the nurses station to be let back into the facility. The ADM stated that residents must sign in and out when leaving or returning to the facility. The ADM stated that all staff were to be monitoring all residents by reviewing the sign in and sign out sheet and by making rounds. The ADM stated the residents are to sign out at the nurse's station when leaving the facility. ADM stated nursing staff are make routine resident checks on each unit at least once per 8-hour shift. During an interview on 03/24/25 at 2:00 PM, the ADON stated the charge nurse called her on 03/20/25 at 10:45 PM notifying her Resident #1 was missing. She stated CNA A advised that she had searched the inside of the facility before calling. She stated she was not able to find Resident #1. The ADON stated she had initiated an outside facility search and notified all managers. Law enforcement assisted with the search. Resident #1 was [NAME] to the hospital by local authorities. During an interview on 03/24/25 at 2:23 PM, LVN A stated she was notified by CNA A that Resident #1 could not be located in his room, restroom, or the common areas. LVN A then conducted her own search on 3/20/2025 around 10:15pm to try and locate Resident #1, during which he was unable to be located, and she contacted the ADON at 10:45 PM to report Resident #1 missing. During an interview on 03/24/25 at 2:51 PM with Resident #1 he stated he did not really remember leaving or how he left the facility. He stated he was going to see his brother who lived a couple miles from the facility. He stated he was okay but had abrasions from crawling in a pasture. He stated he took a truck that he thought was his is friends' truck, drove it to the end of the driveway and could not turn the steering wheel and ended up in a ditch. During an interview on 03/24/25 at 3:37 PM, CNA A stated she was checking on Resident #1's roommate on 3/20/2025 around 10:15pm when she noticed Resident #1 was not in his room. CNA A stated that she went to look at the sign out log at the nurse's station to see if Resident #1 had signed out, and his name was not located on the log. CNA A notified LVN A that she could not locate Resident #1 at that time. On 03/24/25 at 3:45 PM, attempts were made to interview CNA B. A return call was not received prior to exiting. During a telephone interview on 03/25/25 at 12:06 PM, Resident #1's POA revealed that on 12/8/24 Resident #1 went into the hospital and was diagnosed with Right frontal glioblastoma. He stated the doctor told him he would have 3-6 months to live. He stated Resident #1 was doing chemotherapy and radiation during the month of January. Resident #1 was taking chemotherapy in pill form. The doctors told him since Resident #1 completed chemotherapy and radiation treatments they gave him one year to live, and that no one with that kind of tumor lived past a year. He stated Resident #1 had not had any exit seeking or elopement behaviors prior to 3/21/25. He stated Resident #1 had short term memory deficits. He stated the facility went over the facility handbook and made it clear resident had to be signed in and out when leaving the facility. The facility called him immediately when Resident #1 was missing. Resident had a few scrapes on his knees and hands. During a telephone interview on 03/25/25 at 4:35 PM, Resident #1's PCP stated that the resident's current diagnosis was glioblastoma. He stated the facility called his nurse the night Resident #1 went missing, but she missed the call, and facility contacted PCP first thing the next morning. The PCP stated he has not been able to see resident since he was admitted to the facility due to the resident going to radiation treatment. He sated his NP saw the resident on 3/5/25. He stated he was not aware of the resident having any signs of confusion. Resident #1 had been patient of his since 1/22/25. Review of the facility's Elopement/Unsafe Wandering Policy, dated 03/2013, reflected the following: the facility will strive to prevent unsafe wandering while maintaining the least restrictive for residents at risk for elopement. The staff will identify residents who are at risk of harm due to unsafe wandering including elopement. Review of the facility's Routine Resident Check Policy, dated 07/2013, reflected the following: staff shall make routine checks to help maintain resident safety and well-being. To for safety and well-being of our residents nursing staff shall make a routine resident. Review of the facility's handbook dated 2025 reflected the following: prolonged absences- Resident may sign out on pass as long as health permits and there are no physician orders stating otherwise. You must sign out at the nurse's station when you leave and must sign back in when return. The ADM and the DON were notified on 03/25/25 at 4:24 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 03/26/25 at 03/26/25 at 4:36 PM: Action: EXIT-DOOR SECURITY POLICY: Facility will keep all exit doors secured at the facility 24 hours a day, 7 days a week, with either a locking device or an alarm to protect residents. The locking devices will keep the doors locked, requiring anyone exiting the building to ask a staff member to temporarily override the locking mechanism. All staff are provided with the keypad override code. Staff will confirm the identity of the individual exiting the building, and ensure they are signed out if they are a resident. The exit doors that do not have locking devices are equipped with a loud, ongoing alarm that will alert staff that someone has passed through. Staff will confirm the identity of the individual that has passed through. Any exit door that is temporarily unsecured (i.e. no locking device and no alarm) will be manned with a staff member continuously while unsecured. Start Date: 8 a.m. on 3/26/25. Completion Date: 5 p.m. on 3/26/25 Responsible: Administrator, Nursing Administration, Social Worker, and Maintenance will collectively ensure these remedies are in place by 5 p.m. today (3/26/25), and we will be checking these doors daily to evaluate the effectiveness of this new door security policy for 30 days, beginning today and ending on April 26th, 2025. Action: DOORBELL POLICY: A doorbell is placed on each secured exit door to ensure residents and visitors who are outside have a way to alert staff to let them in 24 hours a day, 7 days a week. A sign will accompany the doorbell button on the door instructing those outside to push the doorbell button to enter. Start Date: 8 a.m. on 3/26/25. Completion Date: 5 p.m. on 3/26/25 Responsible: Administrator, Nursing Administration, Social Worker, and Maintenance will collectively ensure these remedies are in place by 5 p.m. today (3/26/25), and we will be checking these doorbells daily to evaluate the effectiveness of this new doorbell policy for 30 days, beginning today and ending on April 26th, 2025. Action: IN-SERVICING ALL STAFF: All staff will be in-serviced by Administration (i.e., CEO, Administrator, DON, ADONs, Social Worker) over one.) the new exit-door security policy, & 2.) the new doorbell policy by 5 p.m. on 3/26/25. All present staff are in-serviced in-person; all staff not on shift have been in-serviced by phone. These policies and procedures will be part of new hire orientation ongoing. Start Date: 8 a.m. on 3/26/25. Completion Date: 5 p.m. on 3/26/25 Responsible: Administrator, Nursing Administration, and Social Worker will collectively ensure all staff are in-serviced by 5 p.m. today (3/26/25). Administrator, Nursing Administration, Social Worker, and Maintenance will collectively be visually checking the effectiveness of these new policies daily and, if necessary, providing additional in-servicing for 30 days, beginning today and ending on April 26th, 2025. The Surveyor monitored the POR on 03/26/25 as followed: During an interview on 03/26/25 at 3:30 PM, the DON stated all doors will be locked throughout the facility. The front door would be unlocked from 8:00 AM to 5:00 PM Monday through Friday and monitored by the front desk staff. After 5:00 PM residents and families would have to ask a staff member to let them out of the facility. A doorbell was placed on all exit doors for residents and families to be let in the facility. Exit doors that do not have locking devices or alarms would be monitored by facility staff. The DON stated the ADM was sending out a mass email notifying families of the added security measures. All staff were in-serviced on the exit-door security policy. All staff were in-serviced on the exit-door security and doorbell. Staff were told to ensure the doors always remained locked. She stated staff were making visual checks throughout the facility. She stated all staff were provided with the keypad override code. She stated staff would confirm the identity of the individual exiting the building, and ensure they are signed out if they are a resident. All staff and visitors were instructed to use the front door entrance when entering and exiting the facility. She stated they would keep a log to document the effectiveness of the door security and doorbell policy. During interviews on 03/26/25 from 4:00 PM - 5:25 PM, one LVN, two CNAs, a MT, and NA from all different shifts all stated they were in-serviced before their respective shifts began on 3/26/2025 on exit door security and doorbell policy. All exit doors were to be in night mode 24 hours a day. The two doors that were not locked had alarms. All staff have been instructed when the alarm goes off, they are to check to see who it was. Doorbells had been put in place on all locked outside doors to alarm staff someone needed to enter the facility. Administrative staff were going to be monitoring all doorbells daily to make sure they were properly working. The MT stated he would keep a monitoring log for doorbells and door alarms. Staff were to identify the person and their purpose of entry. If not aware of person and purpose they were to ask the charge nurse to reassure purpose of entry. All staff stated if they were unable to locate a resident, the nurse should be notified immediately. Observation on 03/26/25 at 5:30 PM revealed Resident #1 sitting in the common area of the memory care unit no signs of wandering. Observations on 03/26/25 at 5:35 PM revealed all facility exit doors had been equipped with either a locking device or an alarm that triggered upon opening. This was tested by the surveyor on all exits to ensure security. Review of in-services entitled new policies dated 03/26/25 reflected, staff from all shifts were in-serviced on all exit doors to remain secured at the facility 24 hours a day, 7 days a week, with either a locking device or an alarm to protect residents. A doorbell was placed on each secured exit door to ensure residents and visitors who are outside have a way to alert staff to let them in 24 hours a day, 7 days a week. Review of facility exit-door security policy dated 03/26/25 reflected the following: Facility will keep all exit doors secured at the facility 24 hours a day, 7 days a week, with either a locking device or an alarm to protect residents. The locking devices will keep the doors locked, requiring anyone exiting the building to ask a staff member to temporarily override the locking mechanism. All staff are provided with the keypad override code. Staff will confirm the identity of the individual exiting the building, and ensure they are signed out if they are a resident. The exit doors that do not have locking devices are equipped with a loud, ongoing alarm that will alert staff that someone has passed through. Staff will confirm the identity of the individual that has passed through. Any exit door that is temporarily unsecured (i.e., no locking device and no alarm) will be manned with a staff member continuously while unsecured. Review of facility doorbell policy dated 03/26/25 reflected the following: Doorbell is placed on each secured exit door to ensure residents and visitors who are outside have a way to alert staff to let them in 24 hours a day, 7 days a week. A sign will accompany the doorbell button on the door instructing those outside to push the doorbell button to enter. The ADM and DON were notified the IJ was removed on 03/26/25 at 5:54 PM. However, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.