**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 and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent him from eloping from the facility on 05/05/25. He was found down the street away from the facility and was brought back by the local police department. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 05/05/24 and ended on 05/06/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents who require supervision at risk of harm, severe injury, and possible death. Findings included: Record review of Resident #1's Quarterly MDS Assessment, dated 09/16/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS (mental status assessment) score of 09 indicating he had moderate cognitive impairment. His active diagnoses included non-traumatic brain dysfunction (causes damage to the brain by internal factors such as lack of oxygen, exposure to toxins, or pressure from a tumor), non-Alzheimer's dementia (the loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform activities of daily living), and Parkinson's disease (a brain disorder that affects movement and causes tremor, stiffness, and slowness). His MDS indicated he had behaviors of having delusions and had exhibiting wandering behavior for 1 to 3 days. Record review of Resident #1's Wander Data Collection, dated 12/23/24, reflected a score of 14 which was considered high. Record review of Resident #1's Wander Data Collection, dated 04/20/25, reflected a score of 24 which was considered high. Record review of Resident #1's Wander Data Collection, dated 05/06/25, reflected a score of 24 which was considered high.Record review of the facility's Provider Investigation Report, completed by the Former Administrator and dated 05/07/25, reflected on 05/05/25 at 7:00 PM Resident #1 wandered away from the facility, and he did not sustain any injuries. The Investigation Summary reflected the following:RE: [Resident #1].Age 71 Dx: Unspecified Dementia, Insomnia, PTSD, Parkinson's. BIMS 7.This is written follow-up to a previously reported incident for [the Facility] concerning a wandering event for [Resident #1].[Resident #1] walked out the front door of the facility following a couple out. [Resident #1]'s wander guard was operational. During the investigation, [Resident #1] claimed that he waited until someone exited and counted the clicks (the time before the door locks) and walked out after them around 7:00pm. [Resident #1] was seen less than a half mile from the facility at a [local business] and escorted back to the facility after he told the police where he lived which was [the Facility].[Resident #1] has a history of PTSD and gets very anxious when he cannot contact his wife. If this occurs, he paces the floor looking for her. This day, he was determined to go find her. Nurse [LVN A] saw [Resident #1] attempt to use the front door twice which triggered the wander guard alarm.Both times, she redirected him to his room. Around 7:00pm, he went to lunch and returned to pass medications to her residents. At 8:00pm, police returned [Resident #1] to the facility. [LVN A] performed an assessment to which there were no injuries to [Resident #1]. [LVN A] failed to put [Resident #1] on 1:1 at 6:45 or contact facility administration. [LVN A] failed to notify the facility administration upon his return until after because she was passing medication. She notified the DON at 11:19pm by text. Administrator began exhaustive investigation immediately.During staff interviews, staff state they heard the alarm and went to help get [Resident #1] away from the door the first two times but no one seems to recall the alarm at 7:00pm. Investigation shows [Resident #1] was wearing the wander guard and upon immediate inspection, the wander guard system worked properly with [Resident #1]s device.The Administrator immediately initiated the post elopement plan of action. Staff were immediately inserviced on the elopement policy and were not allowed to work their next shift until training and testing was completed. A wander guard check of the 4 individuals in the facility all functioned properly. An audit of wander guard maintenance checks and elopement drills were done and were done and recorded. The QAPI team along with Medical Director was immediately called to ADHOC QAPI meeting to discuss next steps and education. Witness statements from everyone present from 6:00pm to 8:00pm on 5/5/25 were interviewed and witness statements collected.In conclusion, [LVN A]'s failure to notify administration caused a situation that required a 1:1 assignment to be missed. Her failure to protect and monitor resident as the charge nurse ultimately led to her immediate dismissal for putting a client at risk of danger. Upon investigation, it was clear that this charge nurse decision put our system in jeopardy.Record review of Resident #1's Psychiatric Evaluation, dated 05/07/25, reflected the following: HPI: The resident is a [AGE] year-old married Caucasian male who was seen for psychiatric evaluation due to a recent episode of elopement from the building.He has no recollection of leaving the building. The resident has been on one-to-one supervision since he was brought by the police to the facility. The resident was found at [a local drug store] after he left this facility. Record review of Resident #1's Provider Notes, dated 06/04/25, reflected the following: Visit Date: 05/04/25.HPI: Staff report that patient has been trying to elope and is increasingly anxious. Family also concerned. Record review of Resident #1's Progress Notes reflected the following entries:- 05/05/25 at 10:42 PM, LVN A wrote: nurse did assessment and body check was done, no bruise or injury noted as at this time [sic]. respiration was even and unlabored. [sic] no pain noted. - 05/06/25 at 11:51 AM, LVN B wrote: resident is seated on the chair at this time, alert [sic] and oriented x2, all [sic] vitals are a stable, has [sic] a wander guard in place, continues [sic] on 1;1 supervision, assisted [sic] with all adls. - 05/06/25 at 12:22 PM, the SW wrote: SW called resident's wife regarding elopement last night. She is giving permission for Psych eval. She is agreeable to come in on 5/7/25 to meet with the Psychiatrist.remains on one-to-one supervision. - 05/08/25 at 7:47 AM, LVN B wrote: resident received resting in bed, on [sic] 1:1 supervision, wander [sic] guard to rt leg is in good working condition, all [sic] vitals are stable Record review of Resident #1's Physician's Orders reflected the following order: Wander Bracelet on right ankle r/t wandering/exit seeking behaviors. Nurse to check placement and function q shift including skin check under bracelet with a start date of 10/20/24. Record review of Resident #1's Medication Administration Record for May 2025 reflected his Wander Guard was checked on each of the three shifts from 05/01/25 to 05/08/25. Record review of Resident #1's 15 Minute Monitoring Sheets, dated 05/06/25 to 05/07/25, indicated where the resident was or what he was doing. Record review of Resident #1's 1 to 1 Monitoring sheets, dated 05/08/25, indicated where the resident was or what he was doing. A telephone interview with Resident #1's RP was attempted on 09/11/25 at 12:48 PM; however, the attempt was unsuccessful as she did not answer or call back. Interview via telephone on 09/11/25 at 12:26 PM with CNA E revealed she worked with Resident #1 on 05/05/25 when he eloped from the facility. CNA E said she was trying to redirect him from the front door, and keep him inside the facility. CNA E said Resident #1 was in an uproar that day about his wife coming to get him, and he was determined to get out. CNA E said other staff tried to calm him down, but nothing worked. CNA E said she had never seen Resident #1 near the front door before this day (05/05/25), but that was where he kept going towards. CNA E said Resident #1 was behaving this way because he wanted to leave and be with his wife. CNA E said when he supposedly got out through the front door, she was at the end of her hall giving a resident a shower so there was no way she would be able to hear the alarm or respond to it. CNA E said she was given report that he was acting this way even before lunch as well. CNA E said she had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. CNA E said she also knew that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, she was supposed to report that to the nurse. Interview via telephone on 09/11/25 at 12:39 PM with [NAME] F revealed she was working the evening Resident #1 left the faciity on [DATE]. [NAME] F said she saw Resident #1 at the front door and was wondering why the police were there at the facility too. [NAME] F said she saw him earlier walking down the street by himself and wondered to herself how he got out of the facility without someone watching him. [NAME] F said she saw Resident #1 around 8 PM but he was already with the police who were bringing him back to the facility. [NAME] F said she saw him down the street near the grocery store. [NAME] F said she had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. [NAME] F said she also knew that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, she was supposed to report that to the nurse. Interview via telephone on 09/11/25 at 12:44 PM with LVN B revealed she worked with Resident #1 during the morning shift of 05/05/25. LVN B said Resident #1 seemed to be his normal self, he used a walker to move around with, and she never saw him trying to go to the front door or making an attempt to leave. LVN B said she checked his Wander Guard during her shift and it was working as evidenced by him going near the door and setting the alarm off. LVN B said she had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. LVN B said she also knew that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, she was supposed to report that to the DON. A telephone interview was attempted on 09/11/25 at 1:08 PM with CNA H; however, the attempt was unsuccessful as she did not answer or call back. Interview on 09/11/25 at 1:09 PM with RN I revealed he was not Resident #1's nurse on duty on 05/05/25. He stated prior to the incident he had seen the resident at the front door a lot, and the resident kept setting the alarm off. RN I said he saw the CNAs redirecting Resident #1 from the front door to his room or away from the exit door. RN I said he saw the CNAs had it handled and assumed his nurse knew about it as well. RN I said he had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. RN I said he also knew that if a resident was exhibiting exit-seeking or wandering behaviors or if they began to increase, he was supposed to report that to the DON. Interview on 09/11/25 at 1:14 PM with CNA J revealed she cared for Resident #1 while he was at the facility. CNA J said he talked about going to see his wife or going home, but staff would redirect him back to his room and let his nurse know he was trying to exit seek. CNA J said she had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. CNA J said she also knew that if a resident was exhibiting exit-seeking or wandering behaviors or if they began to increase, she was supposed to report that to the nurse. Interview on 09/11/25 at 1:33 PM with the SW revealed she knew Resident #1 could walk well but she did not recall him trying to get out of the facility. The SW said Resident #1 would walk and wander through the facility, but she never saw him having any exit seeking behavior. The SW said she did not remember anything about Resident #1 becoming agitated at not being able to see his wife. The SW said she had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. The SW said she also knew that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, she was supposed to report that to the nurse. Interview on 09/11/25 at 2:17 PM with CNA C revealed he was working with Resident #1 on the night he eloped on 05/05/25. CNA C said he was working with other CNA's who had been trying to redirect Resident #1 away from the front door to his room or the dining room. CNA C said Resident #1 wanted to see his wife and he seemed determined to either talk to her or see her. CNA C said the last time he saw Resident #1 before he had eloped, he was in his room. CNA C said he had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. CNA C said he also knew that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, he was supposed to report that to the DON. Interview on 09/11/25 at 2:24 PM with CNA L revealed Resident #1 had a habit of opening the front door and trying to get out. CNA L said Resident #1's wife would come pick him up and take him home often. CNA L said staff knew to monitor Resident #1 and his wandering behaviors because he walked up and down the hallways all the time. CNA L said it was normal for Resident #1 to sit near the front area and since he looked like a visitor, he could have followed someone out the front door without them realizing he was a resident. CNA L said Resident #1 would not have known how to open the door himself and his Wander Guard would have set the alarm off. CNA L said he had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. CNA L said he also knew that if a resident was exhibiting exit seeking or wandering behaviors, or if they began to increase, he was supposed to report that to the nurse. Interview on 09/11/25 at 2:46 PM with LVN M revealed she had been in-serviced on the facility's procedures for an elopement, and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. LVN M said she also knew that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, she was supposed to report that to the DON. Interview on 09/11/25 at 2:42 PM with ADON D revealed she was not there when Resident #1 eloped from the facility on 05/05/25, but she knew he would sit near the front door area. ADON D said Resident #1 not seeing his wife triggered him to want to leave the facility. ADON D said Resident #1's elopement happened around a time when his wife was not able to come and see him as often as she normally had, and he was trying to find her. ADON D said Resident #1 normally did not approach any exit doors, but would walk around the facility. ADON D said she only knew that Resident #1 left through the front door and was brought back by the police. ADON D said she was not sure how long Resident #1 was missing from the facility. ADON D said Resident #1's Wander Guard was checked every shift by the nurse for placement and functionality. ADON D said all staff knew to keep a close eye on Resident #1 and redirect him if he was to start to exit seek. ADON D said after Resident #1's elopement on 05/05/25, staff were in-serviced, Wander Guards were checked, and Resident #1 was placed on 1:1 monitoring by staff until he discharged . ADON D said all staff should know the facility's procedures for an elopement and should be able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. ADON D said all staff should also know that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, staff were supposed to report that to the DON or their nurse. Interview on 09/11/25 at 3:03 PM with the DON revealed she was surprised that Resident #1 had eloped from the facility. The DON said normally, Resident #1's wife came at a certain time in the evening so while he was not oriented to times, he had a routine he would follow. The DON said Resident #1 was constantly looking for his wife and she would come after dinner was over. The DON said the evening of 05/05/25, she got a call saying Resident #1 had gotten out of the facility, they thought behind a family member or someone leaving through the front door. The DON said Resident #1 was found up the street by the police and was brought back to the facility. The DON said when Resident #1 was brought back and assessed, he was placed on 1:1 monitoring until he was discharged to a different facility. The DON said Resident #1 had a Wander Guard on already and it was functioning as far as she knew. The DON said nurses checked a resident's Wander Guard for placement and functionality every shift. The DON said staff were in-serviced and should know the facility's procedures for an elopement and should be able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. The DON said staff should also know that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, they were supposed to report that to the nurse or herself. The DON said staff were expected to supervise residents at all times to make sure they did not elope from the facility. The DON said the purpose of supervising residents was to ensure they were safe. The DON said if residents were not supervised they could be injured in all kinds of ways by leaving the facility. The DON said she expected and staff had been trained to know what to do if a resident had exit seeking behaviors or had eloped. Interview through the phone on 09/12/25 at 10:27 AM with LVN A revealed she cared for Resident #1 the night of 05/05/25 when he eloped. LVN A said the incident happened a long time ago, and all she remembered was that she saw Resident #1 sitting in the front door area upset because his wife was not there to see him. LVN A said she asked Resident #1 to go back to his room because she was worried about him trying to leave the facility. LVN A said she was keeping an eye on Resident #1 and tried to redirect him. LVN A said she went on break and when she got off her break, the police had brought Resident #1 back to the facility. LVN A said she assessed Resident #1 and he did not have any injuries. LVN A said she checked Resident #1's Wander Guard and it was still working so she was not sure how he got out through the front door. LVN A said she stopped working for the facility shortly after the incident occurred. Record review of an undated witness statement reflected the following: Statement from [LVN A]: [LVN A] stated that [Resident #1] was pacing the lobby all day and around 6:30-6:45 had tried to exit the building and was redirected to his room by her and a CNA, [CNA C]. At this time, asked why she did not notify administration or place on 1:1 she responded that he was redirected. She stated she went to lunch around 7:00 PM and [Resident #1] was in his room. At 8:00pm [sic], [Resident #1] was returned to the building with [City Police Department]. He had exited the building. (When [Resident #1] was asked by [ADON D] what happened, he stated he was looking for his wife. He told police he lived at [Facility Name].) [LVN A] states she did not know that [Resident #1] had exited the building Upon [sic] his return, she failed to place [Resident #1] on 1:1 or contact the DON/Administrator timely. Record review of the facility's Wanderer Management, Monitoring System and Resident Elopement Protocol policy, dated 02/05/25, reflected: Purpose: To monitor safety of residents at risk for elopement. To provide a system to alert staff that a resident may be attempting to leave the facility. Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible.Responsibility: All staff is responsible to ensure resident safety.B. Interdisciplinary Interventions:.2. When a door alarm sounds, staff shall respond immediately and determine cause of the alarm. The staff member responding to the alarm clock shall check the outside of the building to determine if a resident has left the building. If upon investigation, no apparent cause is determined for the sounding of the alarm, the charge nurse shall immediately initiate an accounting of whereabouts of all residents at risk for elopement. The Administrator was notified on 09/11/25 at 4:50 PM that a past non-compliance IJ had been identified related to the facility's failure to provide adequate supervision to prevent an elopement. It was determined this failure placed Resident #1 in an IJ situation on 05/05/25. The facility had implemented the following corrective measures prior to the HHSC investigation: Observation on 09/11/25 at 1:55 PM of Resident #2 revealed she was wearing a Wander Guard and her nurse brought her near the front door, setting the alarm off which indicated the Wander Guard was working. Record review of an Elopement Drill Evaluation Form, dated 05/09/25, reflected the facility completed an elopement drill with staff. Record review of an in-service, dated 05/09/25, and titled Elopement Drill reflected 23 staff participated. Record review of an in-service, dated 05/05/25, and titled Elopement Policy reflected 76 staff were educated on the facility's elopement policy. Record review of an Elopement Policy Quiz, dated 05/06/25, reflected that 76 staff completed the quiz and passed. Record review of a QIPP QAPI Worksheet, dated 05/06/25, reflected a meeting was held to discuss Resident #1's elopement on 05/05/25. Record review of a sheet of paper, dated 05/06/25, and titled Wander guard Individual Checks reflected staff had ensured all 4 residents who used Wander Guards at the time were secured and operational. Record review of a sheet of paper, dated 05/06/25, and titled Exit Door Checks reflected all exit doors were locked and operational. Record review of a Logbook Report, dated 05/07/25, revealed the Maintenance Director had completed a check of residents with Wander Guards on 05/03/25. Record review of the facility's incident/accident log from 05/01/25 to 09/11/25 reflected there were no other elopement incidents that occurred. Record review of a Disciplinary Action Record, dated 05/06/25, reflected LVN A was terminated.