**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of seven (6) residents (Resident #1) reviewed for accidents and hazards: The facility failed to develop and implement interventions to prevent Resident #1 's elopement from the facility. Resident #1 eloped from the facility on 03/31/23 and was returned to the facility by local police department. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/31/2023 and ended on 03/31/2023. The facility corrected the non-compliance before the investigation began. This deficient practice could place the residents at risk for harm, serious injury or death. The findings were: Record review of Resident #1's admission record dated 10/31/23 documented an [AGE] year-old male admitted to the facility on [DATE] and discharged on 04/01/23. The form further documented Resident #1 with diagnoses including, unspecified atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the atrial chambers of the heart), muscle weakness generalized (reduction in the power exerted by muscles resulting in an inability to perform a given task on first attempt), muscle wasting and atrophy (a decrease of muscle mass and strength), abnormalities of gait and mobility (any unusual or unexpected patters of movement or changes in the way an individual walks or moves), lack of coordination (group of symptoms that cause impaired direction), fall, Alzheimer's disease onset (progressive disease that destroys memory and other important mental functions). Resident #11 was not identified as his own responsible party. Record review of Resident #1's MDS assessment dated [DATE] revealed cognitive pattern was not tested. The MDS documented a 0 when asked Has the resident wandered?, indicating the behavior had not been exhibited. Record review of Resident #1's comprehensive care plan revealed that Resident #1 was an elopement risk/wanderer related to disoriented to place, history of attempts to leave facility unattended, resident wanders aimlessly with an initiated date of 03/31/23 and a revision date of 04/01/23. Listed goals included the resident's safety will be maintained through the review date. Listed interventions included, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Other goals included identify pattern of wandering and initiate visual checks Q2hrs (every two hours) . All with initiation date of 04/01/23. Record review of Resident #1's physician order revealed an order for behavior monitoring for (wandering, agitation, exit seeking behavior) medication (name of med) document # of times resident has exhibited the above behavior during shirt. Intervention codes: 00 none; 1) 1 on 1; 2) Activity; 3) Adjust room temperature; 4) Backrub; 5) Change position; 6) Give fluids; 7) Give food; 8) Redirect; 9) Remove resident from environment; 10) Return to room; 11) Toilet .every shift document resident outcome following intervention using the following codes . with a start date 03/31/23 and that was discontinued with no end date noted. Record review of Resident #1's April 2023 licensed nurse administration record of dated 11/03/23 revealed order had been completed and documented for every shift on 04/01/23 as ordered. Record review of Resident #1's Wandering Evaluation completed upon admission on [DATE] at 01:08 a.m., documented a summary of finding score of eight (8) indicating resident was a moderate risk for wandering. Additional comments included Patient tries to get out of bed and voices that he wants to leave the facility. A&Ox1 (alert and oriented to self). Record review of Resident #1's progress notes signed and dated by LVN D on 03/29/23 at 01:14 p.m. revealed, Resident was constantly getting up from bed and trying to go into other resident's room, [Nurse practitioner] was notified by night SN (skilled nurse) and got new orders for melatonin 5 mg (milligrams) prn (as needed) at bedtime. SN got verbal consent from resident's sister to administer medication as ordered. Medication was administered. Orders carried out. Record review of Resident #1's progress notes signed and dated by LVN E on 03/30/23 at 01:20 p.m. revealed, Behavioral issues: plays with feces, goes into other resident's rooms, and undresses .melatonin for insomnia. Record review of Resident #1's progress notes signed and dated by LVN B on 03/31/23 at 03:29 revealed, [Police] came to facility to ask if we were missing a resident. Did a quick head count and resident was not in bed. It was confirmed that it was our resident. Resident was placed in wheelchair and brought into facility and back to his room. Assessed resident and no injuries noted. Case # left by PD. Reported to [administrator] and RP made aware. Record review of Resident #1's progress notes signed and dated by MSW on 03/31/23 at 10:07 a.m. revealed, LMSW (licensed master social worker) spoke to patient's daughter/POA (power of attorney) via telephone. SW (social worker) informed patient's daughter that patient needs a memory care unit due to elopement and wandering behaviors. Patient's daughter in agreement with referral and chose [nursing facility]. SW sent clinical information to liaison for [nursing facility for processing. SW to follow. Record review of Resident #1's progress notes signed and dated by LVN A on 03/31/23 at 11:26 a.m. revealed, resident agitated wandering in 100 and 400 halls, redirected resident several times. Spoke with [physician assistant] regarding resident's condition and elopement episode from previous shift. New order for Zyprexa 5 mg (milligram) po (by mouth) x 1 (times one) dose and continue with Zyprexa 5 mg po qhs (every night at bedtime) orders carried out. Placed call to RP and second contact x 3 attempts to obtain consent for Zyprexa. No answer left voicemail. [Nurse Practitioner] aware of new order for Psych consult, pending at this time. Record review of Resident #1's progress notes signed and dated 03/31/23 at 07:54 p.m. by LVN C revealed, visual check every 2 hours. Record review of TULIP (HHSC online incident reporting application on 10/31/23 at 09:00 a.m. revealed the facility made a self-reported incident on 04/01/23 p.m. at 05:18 p.m. regarding Resident #1's elopement). Record review of facility Incidents by Incident Type dated 10/24/23 for reporting period March 2023 listed elopement incidents: Resident #1 dated 03/31/23 at 03:00 a.m. Record review of the facility map and evacuation routes, a total of eight (8) exits were identified as exit doors. Initial rounds were conducted on 10/31/23 beginning at 08:30 a.m. throughout the facility. The facility was well lit, temperature was comfortable, and staff were seen appropriately interacting and assisting residents in their rooms and in the hallways. The facility census was ninety-eight (98). Resident rooms were clean, orderly, without any noted hazards or clutter. There were no sounds of yelling, screaming, or moaning. Residents in bed had their call lights within their reach. Call lights were observed activated and timely answered. Nurses were administering care and medications in a timely manner. Water and belongings were observed at the bedside of the residents and within their reach. No resident was observed to display any disrupting or aggressive behaviors. No injuries or bruising was noted on any resident that would raise suspicion of abuse or neglect. There were no active cases of COVID-19 positive residents in the building. Visitors were observed entering and exiting through the main entrance after being allowed entrance. Other exit doors locked and secured with codes and screech alarm. Observation on 10/31/23 at 09:00 a.m. of the surrounding streets revealed a highly trafficked four lane road with a center lane and a speed limit of 40 miles per hour. Interview on 11/01/2023 at 10:45 a.m., CNA P revealed she had been employed eight (8) years by the facility and her responsibilities included assisting the nurses and residents on hall 100. CNA P stated exit doors have a code that allows entry or exit through them. CNA P stated staff should not be sharing codes with residents or visitors. CNA P stated she did not recall a resident who may have eloped anytime within the past year. Interview on 11/01/2023 at 11:00 a.m., CNA Q revealed she had been employed three (3) weeks by facility and her responsibilities were assisting the nurses and residents on hall 100. CNA Q stated she received report and rounded on all residents assigned to her on the hall she worked. CNA Q stated she tried to maintain an open communication with other staff to account for all residents. CNA Q stated she was not aware of any residents who had been missing recently. CNA Q stated if a resident was missing she would ask a coworker or nurse to assist in helping find the resident. that exit doors had alarms that activated if pushed. CNA Q stated she did not have access codes to the exit doors. Interview on 11/01/23 at 11:35 a.m., CNA R revealed she had been employed for three (3) years by the facility and her responsibilities included assisting the nurses and residents of hall 200. CNA R stated exit doors do not have cameras, but they do have alarms that are activated if pushed. CNA R stated alarms on the doors could be deactivated when a code is entered on the keypad. CNA R stated that not all staff members had the codes and if they did they should not share them with residents and visitors. CNA R stated she was unaware of how often the exit door codes were changed. CNA R stated residents could only go outside if they were signed out with a family member. CNA R stated she had not been in a situation like that. CNA R stated staff are instructed to search for the resident in every hall and room. CNA R stated she would ask other nurses or CNAs for the whereabouts of the resident and that the nurse would decide what protocol to follow. CNA R stated the nurse will notify administration and family. Interview on 11/01/23 at 12:20 p.m., CNA S revealed she had been employed for eight (8) years by the facility and her responsibilities including assisting the nurses and residents of hall 300. CNA S stated residents were not allowed to go outside unless with family members after they had signed them out but not by themselves or unsupervised. CNA S stated the facility was a nonsmoking facility and there was no designated area for smoking or staff to assist residents outside of the building. CNA S stated if a resident was missing, she would ask a nurse and other staff on the whereabouts of the resident and inform the administrator or the DON. CNA S stated she would look for the resident in hallways, rooms and everywhere until found. CNA S stated the next step would be to involve the police. CNA S stated exit doors have an alarm that is deactivated with a code that secures the exit. CNA S stated exit doors will alarm if a resident attempts to exit. CNA S stated staff do not share codes with residents or visitors. Interview on 11/01/23 at 12:35 p.m., CNA T revealed she had been employed for three (3) months by the facility and her responsibilities included assisting the nurses and residents of hall 300. CNA T stated residents are not allowed to go outside unsupervised. CNA T stated residents may go outside if accompanied by family. CNA T stated there was no assigned area outside for residents to out to. CNA T stated exit doors are secured by an alarm that would deactivate with a code entered on a keypad. CNA T stated codes are not shared with residents or visitors. CNA T stated residents were accounted for on each round. CNA T stated rounds were done every two (2) hours or more often if needed. Interview on 11/01/23 at 12:55 p.m., CNA U revealed she had been employed for five (5) months by the facility and her responsibilities included assisting the nurses and residents of the facility as a float CNA. CNA U stated residents are not allowed to go outside unsupervised unless with family. CNA U stated exit doors are secured with an alarm that will activate if opened. CNA U stated alarms can be deactivated by codes that must be entered on a keypad. CNA U stated residents nor visitors have access to the codes. CNA U stated she made sure all residents were in the facility during rounds and rounds are done every two hours or more often if needed. CNA U stated she will report to the nurse if a resident is not found in the facility. CNA U stated staff will look for resident in his/her room, restroom, and all areas of the facility. Interview on 11/01/23 at 02:50 p.m., RN/MDS revealed she had been employed for two and a half (2.5) years by the facility and her responsibilities included infection control duties, assistant director of nursing duties and as part of the interdisciplinary team to create patient care plans. RN/MDS stated the facility had no designated areas for smoking and residents were only allowed to go outside if supervised as part of their therapy or with family. RN/MDS stated residents were accounted for when staff performed their rounds. RN/MDS stated exit doors had codes that were not shared with residents or visitors. RN/MDS stated she was not aware of any incidents involving elopement. Interview on 11/01/23 at 03:20 p.m., LVN A revealed she had been employed for 9 years by the facility and her responsibilities included floor nurse and was recently promoted to assistant director of nursing one (1) month prior to this date. LVN A stated she accounts for all residents in the facility by doing a walking round when getting report. LVN A stated if a resident is missing at any time she will look in each room and ask other staff to help locate the resident in other areas of the facility. LVN A stated she would then notify the family, the physician, the administrator, and the police. LVN A stated she would then search outside the facility in each direction. LVN A stated this process is not delayed stating, immediately, you do not wait minutes, if you cannot find the resident in the facility you activate the elopement protocol if a resident cannot be found. LVN A stated rounds by staff are done every two (2) hours and more often if needed and this is how often it is checked to see if residents are here. LVN A stated if residents are at risk of elopement the rounds are increased to every thirty (30) minutes. LVN A stated the facility does not have a locked memory care unit. LVN A stated the facility had an elopement incident months ago, we did have a resident during night shift. LVN A stated staff did not know resident was at risk for elopement and continued by stating, he was a new patient. LVN A stated, he never voiced an intent to leave. He was in room [ROOM NUMBER], I was not here and was not the nurse. LVN A stated LVN B was the nurse assigned. LVN A stated residents are not allowed to go outside unsupervised and can only go with family members. LVN A stated residents nor visitors have access to the exit door codes. LV A stated staff do not know the exit door codes and do not share the codes with residents or visitors. LVN A stated exit doors have an alarm that will be activated if pushed. LVN A stated the push bar must be held for fifteen (15) seconds for the door to release and the alarm will sound. LVN A stated abuse including physical, mental, sexual, verbal, and negligence is reported to the abuse coordinator, the administrator. Interview on 11/01/23 at 04:00 p.m., LVN F revealed she was a new nurse to the facility only having been employed there for three (3) days and her responsibilities included floor nurse and administering medications. LVN F stated she was present when incident happened and did not know any of the details; however, she stated she was aware she needed to perform walking rounds to ensure all residents were in the facility. LVN F stated rounds were performed every two (2) hours or more often if needed. LVN F stated that if a resident could not be located within the facility, the elopement protocol would be initiated and that involved looking at all areas within the facility and outside the facility. LVN F stated physician, family and the police would be notified. LVN F stated exit doors were secured by alarms that were deactivated with a code. LVN F stated the alarm will not stop until someone deactivates it. LVN F stated abuse including verbal, physical, misappropriation of property, and neglect are reported to the abuse coordinator, the administrator. Telephone interview on 11/01/23 at 04:35 p.m., LVN C revealed he had been employed for eight (8) months by the facility and his responsibilities included floor nurse of hall 300. LVN C stated Resident #1 was admitted around 10:00 p.m. during his shift on 03/28/23. LVN C stated he performed his assessment, which included an elopement risk assessment, and it indicated Resident #1 was a Moderate risk. LVN C stated Resident #1 was ambulatory, he was curious about going to the therapy room, the halls, and going to other rooms. LVN C stated Resident #1 used a walker. LVN C stated his family was present at the time of admission and did not mention Resident #1 having a history of leaving or eloping. LVN C stated Resident #1 was alert and oriented only to self and not oriented to situation. LVN C stated, Resident #1's judgment and critical skills were impaired. LVN C stated he did not remember all of the details of the incident being that time had elapsed; however, LVN C stated Resident #1 was only at the facility for a short period due to Resident #1 being sent to the hospital. LVN C stated Resident #1 was brought back to the facility after his hospital stay but did not give me any details only that he [Resident #1] was brought back and no new implementations were placed. LVN C further went on to state he ensures all residents are in the facility by doing a walking round. LVN C stated rounds are performed every two (2) hours or more often if needed. LVN C stated other staff can alert nurses if a resident is missing. LVN C stated verify if resident was not out on pass, stepped out with family, on an appointment, or in an activity. LVN C stated staff involve other staff when searching for a missing resident and they must all look at other areas of the building including restrooms. LVN C stated the facility has no designated smoking area and residents are not allowed to go outside unsupervised. LVN C stated if a resident is unable to be located, the local authorities, director/administrator must be notified. LVN C stated that once the resident is found and returned to the facility a full head-to-toe assessment, skin assessment, vital signs must be completed. LVN C stated that the resident must also be interviewed if possible and it must be determined if the resident needs to go to the emergency room for further evaluation and treatment. LVN C stated exit doors have an alarm on top called a screamer. LVN C stated the alarm can be turned off by a key located at the nurse's station. LVN C stated only staff have access to the key. LVN C stated alarms can be deactivated with codes. LVN C stated staff do not know the codes. LVN C stated codes should not be shared with other staff, visitors, or residents. Telephone interview on 11/02/23 at 02:20 p.m., LVN B revealed she had been a nurse employed by the facility for two (2) years and her responsibilities included floor nurse of halls 100, 200 and 300. LVN B stated she was assigned to work hall 100 on 03/31/23. LVN B stated she did not recall the exact details of the incident that happened on 03/31/23 that involved Resident #1. LVN B stated she had performed her initial rounds and ensured the residents were in the facility. LVN B stated she physically rounded to ensure residents were in the rooms and in the facility every two (2) hours and more often if needed. LVN B stated no resident was missing during her last round. LVN B stated no exit door alarm was heard. LVN B stated that the local police department brought the resident to the facility and asked if the resident was missing. LVN B stated that after performing a quick headcount of the residents, the staff realized the resident was from hall 100. LVN B stated she could not remember resident's name or when exactly it happened. LVN B stated her CNA was on break during that time and the resident could not have been gone more than 30 minutes. LVN B stated resident was found by police walking towards [NAME] Road on Sugar Avenue. LVN B stated she performed a head-to-toe assessment upon his return, notified the administrator, the director, and the resident's family of his elopement. LVN B stated staff and herself inspected exit doors and discovered that the exit door at the end of hall 100 had been left unlocked. LVN B stated staff will check exit door to make sure they are locked. LVN B stated a red light above the door indicates the door is locked. LVN B stated that a turn switch can unlock the door and the red light will turn green. LVN B stated after Resident #1's return, the exit door was inspected and a green light indicating the door was unlocked was observed. LVN B stated she did not know how or who left the door unlocked. LVN B stated she could not predict any negative outcome that could have happened to Resident #1 or any other resident with elopement. Interview on 11/02/23 at 04:00 p.m., DON/RN revealed she had been a nurse employed by the facility and assigned to her position for two (2) months. DON/RN stated her responsibilities included oversight of the nurses and staff and oversight for the care of the residents. DON/RN stated she was not employed by the facility on 03/31/23 when the incident happened. DON/RN stated there was no provider investigation report related to the incident and could not reference or give any information related to the incident. DON/RN noted the resident was discharged from the facility since 04/01/23 and was unable to further investigate the incident. DON/RN outlined the facility's current elopement emergency response (ER) plan being implemented. DON/RN stated a code green announced to staff indicated an elopement or missing resident. DON/RN stated all staff were assigned to look in assigned areas and they had routes (such as emergency exit routes) to look for the missing resident. DON/RN outlined two different phases as part of their elopement ER plan. DON/RN stated phase I was when staff searched inside the facility and in the parking area. DON/RN stated phase II was when staff searched anywhere outside the property line. DON/RN stated the resident representative, physician and police would be notified of the resident's missing status. DON/RN stated staff did not waste time. DON/RN stated that once the resident was found, staff should perform a head-to-toe assessment of the resident, notify the resident representative and the physician, document, and place a one to one (1:1) observation of the resident. DON/RN stated the facility had taken an initiative to prevent future elopements including frequent in-servicing of staff on topics of elopement, perform wander/elopement risk assessment to identify high risk elopement residents, and frequent testing of the facility exit doors to make sure doors are locked and secured. Furthermore, the DON/RN stated the facility made sure someone was always at the reception area and that staff rounded to make sure doors remained locked. DON/RN stated exit door codes do not frequently change because not everyone has access to the codes and not everyone has access to the main key located at the nurse's station. Interview on 11/03/23 at 01:40 p.m., Interim Adm A revealed he had been an interim administrator for the facility and that 11/03/23 would be his last day before he was assigned to a different location. Interim Adm A stated he was not familiar with the incident that happened on 03/31/23 involving Resident #1 because he was not there. Interim Adm A stated there was no provider investigation report and he could not reference the report to give any information. Interim Adm A also noted Resident #1 was no longer an active resident of the facility. Interim Adm A stated he was informed a resident was missing and was not sure what process was done or not done. Interim Adm A stated the facility did have a code system that was announced when a resident was missing. Interim Adm A stated the code was divided into two (2) phases: phase I was characterized by immediately informing facility staff and searching for the resident within the facility, informing the ADON, DON and family and performing a head count of all residents. Interim Adm A continued explaining that phase II was characterized by calling the police and helping the entire interdisciplinary team locate the resident outside the facility. Interim Adm A stated exit doors are equipped with a secondary alarm with a 15 second delayed egress and a stop alarm (screech annunciator). Interim Adm A stated exit doors also backup system that was put up in April or May and had a key system with a light system indicating when the door was unlocked and locked (red indicates the door is locked and green indicates the door is unlocked). Interim Adm A stated the facility has prevented future elopements by conducting elopement drills and in-services amongst the staff, evaluation of every exit door at regular intervals, ensuring no one is given the codes to the exit doors, and changing the codes once the codes have been breached. Interim Adm A stated no other elopements have occurred since the single incident that occurred in March. Interim Adm A stated staff have been in-serviced. The following record reviews were conducted by the survey team to ensure the Past Non-Compliance was corrected The following interviews were conducted by the Survey Team on 11/02/2023 and 11/03/2023: 6 CNA's, 2 LVN's, and 2 RN. -Staff acknowledged understanding of the topics they were in-serviced regarding wandering and elopement. -Inservices reflected 45 nursing staff were trainined. Record review of work history report documentation stating, Category: Doors: Task Completion .Marked done on-time . marked each exit tested for dates 11/05/2022 through 10/31/2023 Record review of facility in-service training report revealed facility had a training over Missing Resident In-service on 04/04/23. Record review of facility policy and practices titled Door Alarm/Exit Stopper with no implemented date noted, quoted in part, Exit doors have a Door Alarm/Exit Stopper to provide safety for residents that are confused and have a tendency to wander about the facility . Record review of facility policy and practices titled Wandering/Missing Residents with no implemented date noted, quoted in part, some of the SCC''s facilities do not have secured units and it becomes very important to identify residents who walk or wheel themselves unrestricted and become a threat to leave the facility unattended due to their confusion .The facility must ensure the resident's safety while utilizing the least restrictive means available . Record review of facility policy and practices titled Missing Resident/Patient (Code Green) with no implemented date noted, quoted in part, Process .to help ensure all resources available are coordinated to locate a missing resident/patient, an aggressive campaign may be organized to safely locate and return the resident/patient who has wandered or is deemed missing .