**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1, who was a high risk for elopement for which he wore a WanderGuard device, was provided with adequate supervision to prevent him from exiting the building on 07/28/25. Despite the WanderGuard alarm sounding, RN A turned the alarm off without immediately going outside to determine if there was a resident elopement. The resident was found approximately nine hours after he went missing. He was found two miles away from the facility by the local police department following an extensive search. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 07/28/25 and ended on 07/29/25. The facility had corrected the noncompliance before the survey began.This failure placed residents at risk of harm and/or serious injury. Findings included:Record review of Resident #1's admission MDS assessment, dated 07/03/25, reflected the resident was an [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's Disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), cerebral ischemia (inadequate blood supply to the brain), hypertension (high blood pressure), muscle weakness (a condition where your muscles cannot work with the expected amount of force). The MDS reflected Resident #1 had severe cognitive impairment with a BIMS score of 00. Resident #1 did not exhibit wandering behaviors. The MDS further reflected Resident #1 had Wander/elopement alarm (bracelet detected near a sensor, the system triggers an alert).Record review of Resident #1's care plan, dated 06/24/25, reflected Focus: Elopement risk/wanderer r/t Impaired safety awareness. Goal: Will not leave facility unattended through the review date. Interventions: Document wandering behavior and attempted diversional interventions. Monitor placement and function of Wander Guard Q Shift Wander Guard to Right ankle expiration date 02/24/26. Record review of Resident #1's Elopement Risk Evaluation, dated 06/29/25, reflected Resident #1 was a high risk for elopement. The evaluation indicated Resident #1 had a diagnosis of dementia and Alzheimer's disease. Ambulation: Ambulates independently or with supervision. Mental status: Disoriented. History of elopement in the last 6 months: Two or more Episodes. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility): 2. Yes, wandering is aimless w/potential to go outside, active exit seeking behavior. Record review of Resident #1's physician orders dated 07/01/25, reflected Wander guard to right ankle every day shift every 90 day(s) for wanderguard.Record review of Resident #1's progress notes dated 07/29/25 at 2:02 AM by RN A reflected: Resident active walking on the hallway upon arrival at 1800 [6:00 PM] appeared happy had a smile on his face and very talkative in Spanish. Tolerated his HS meds. Resident started following this nurse while passing the medicine. Approximate 2000 [8:00PM] this nurse did not see resident in the hallway. The nurse and CNA started looking for him in the rooms of 600 hall, we did not see him. This nurse called for code white alerted all the staff in the facility and we started looking for him in and out of the facility. Family called and left them a message to call the facility. The family called back later and told this nurse they will come over to the facility. Administrator was notified.Record review of Resident #1's progress notes dated 07/29/25 at 4:53 AM by Clinical Market Leader reflected: 4:50am police arrived to facility with resident in back seat. Resident able to stand and transfer to wheelchair and brought into facility for assessment by charge nurse. Family also arrived behind police and notified of return to facility. Police notified this writer that EMS would arrive shortly to assess him as this was their protocol. Resident alert and denies pain, water in hand, assisted to his room by nurse and family.Record review of the facility's Provider Investigation Report, completed by the Administrator on 08/05/25, reflected the following: Incident date: 07/28/25, Time of Incident: 8:00 PMDescription of the Allegation: Resident missing from facility Assessment Date: 07/29/25; Time: 4:55 AM;Charge nurse completed head to toe assessment upon resident return on 7/29/25 @ apprx. 4:55 a.m - no injuries notes, resident mood was pleasant and friendly. EMS arrived at apprx. 5:10 a.m. (per PD policy). Completed assessment as well - no concerns. Vitals within normal limits. Attending physician assessed at apprx. 10:30 a.m. no injuries notes - suggested precautionary CBC - normal results - Skin assessment completed during shower by c.n.a. no issues noted. Provider Response: The facility initiated missing resident protocol. Implementing search efforts to include inside facility, outside the facility and an extensive search of the surrounding area by vehicle, on foot, air search and K9 unit. Facility completed a visual census check of all residents in the facility. The facility informed the medical director-administrator-Interim DON-Family-[Name] PD of missing resident. Family reviewed camera footage to establish at timeline and verify description. Facility initiated interviews with all staff working at the time of the incident. Facility reviewed elopement risk assessments for all residents on 07/28 & 07/29/2025. Interventions and care plans were reviewed and modified as appropriate. Facility initiated education and in servicing related to elopement/missing residents as well as abuse/neglect. Facility conducted on site elopement drills for both shifts. Facility initiated education and implemented documented census reconciliation process to be completed at the onset of each shift and again at 2359. Facility adjusted camera system to provide visual monitoring of the front door at each nurse's station. Facility initiated walking rounds to include lobby area during the 6p-6a shift. Installation of wader guard sound box with flashing lights at each nurse's station in addition to the exiting one at the front door. Facility is in the process of installing a camera outside of the front entrance. Charge nurse was suspended pending investigation later terminated. Upon resident return Head to toe assessment X 2 - no injuries noted. No new orders. Family notified upon exit and return - medical director notified upon exit and return. Resident placed 1-1 observations - resident d/c to another SNF with secure area on 7/29/25. Investigation Summary: After completing staff interviews and reviewing video footage it was determined the res was observed to be on 600 Hall walking along side charge nurse. At apprx. 7:40 p.m. resident walked away from the nurse out of camera view as she continued med pass on 600 hall. At apprx 7:51 p.m. res [resident] was seen to be in the front foyer walking around. At apprx. 7:54 p.m. resident was seen on camera following a Hispanic female out the front door. The nurse stated at apprx. 8:00 p.m., she noticed resident was not in his room or on the 600 Hall. Elopement protocol was initiated search efforts included the inside and outside parameters of the facility as well as an extensive search of the surrounding territory. Facility staff and leadership actively engaged in the search by foot and vehicle utilizing resident photo and description. [Department Name] PD became involved in the search to include foot patrol/vehicle patrol/Helicopter search and K9 (canine) unit as well as social media alerts. Multiple family members were onsite assisting in search efforts as well communicating with facility administration sharing leads and search efforts. Resident was located in the parking lot of a nearby car dealership. [Department Name] PD returned the resident at approximately 4:55 a.m. on 7/29/25. Resident was drinking water and smiling. He appeared to have his normal demeanor. Head to toe assessment completed by charge nurse as well as EMT (per PD protocol). No injuries noted, vitals within normal range. Family arrived within minutes of his return embraced resident and assisted staff with preparing him for bed. Resident went to sleep within moments. Shower offered resident no new findings. Labs requested to be followed up at receiving facility as resident was transferred to [Facility Name] in a secure environment. Labs resulted within normal range with no new orders. During follow up conversation with the family, they agreed to resident likely related the Hispanic female he followed out the door to his spouse as she had visited earlier in the evening. Resident did wander within the facility although he had not made previous attempts to exit the facility. Family expressed gratitude and appreciation for the care that was provided to the resident.Record review of RN A's witness statement, dated 07/28/25, reflected the following: To whom it my concern, approximate @ 1900 [7:00PM] resident noted with wet pant and CNA took him to his room and cleaned him up and dressed him on green top and red pants. After he was changed resident started following this nurse while passing HS meds. At approximate 2000 [8:00PM] I noticed resident was not on hallway. Myself and the CNA started looking for him in all the rooms and bathrooms on 600 Hall. We did not locate him and at that time I called Code White. All staff in the facility started looking for him around the in and out of the facility. Family and administrator was notified. Regards, RN A. Record review of CNA B witness statement, dated 07/29/25, reflected the following: Statement of CNA B 500/600 Hall, around 7PM she noticed his pants was wet & she took him into his room & changed out his pants. When she got finished with him, he went back to the nurses. Around 8 he was with the nurse & I was with another resident that was going out & when I came out the nurse asked about him. And I said that he was with you & she told me she couldn't locate him. So, then we all was looking for him together. We could not find him inside the building, so we went outside the building & still was unable to locate him. Witnessed by CNA B.An attempt was made to contact RN A by phone on 09/11/25 at 11:30 AM; however, there was no answer. Interview on 09/11/25 at 11:36 AM with LVN C revealed she worked the night Resident #1 eloped from the facility on 07/28/25 from 6PM-6AM. She stated she was the nurse assigned to 200 Hall and a little after 7:00PM before 8:00PM she had gone to 600 Hall looking for something and she observed Resident #1 standing behind RN A. She stated at approximately 8:00 PM she was notified of the code white. She stated she stopped what she was doing and checked each of her rooms on 200 Hall before she went over to the 600 Hall. LVN C stated that night there was visitors in the building. She stated no WanderGuard alarms were heard that night. She stated everyone was notified and Resident #1 was found on 07/29/25 at around 5:00 AM. LVN C stated Resident #1 was an elopement risk because he would pace the hallways and follow people around. Interview on 09/11/25 at 2:08 PM with CNA B revealed she was the CNA assigned to Resident #1 when he eloped from the facility on 07/28/25. She stated around 7:00 PM she observed Resident #1 with RN A, she stated Resident #1 needed a brief change, so she took him to his room to change him. Once she was done changing Resident #1, Resident #1 went back to the nurse's station to be with RN A. She stated RN A was passing out medications and Resident #1 was following her. CNA B stated she continued to assist other residents and around 8:00PM RN A was calling for her. She stated RN A told her she had heard the WanderGuard alarms go off at the main entrance but did not see anyone and she turned off the alarm. CNA B stated she did not hear any alarms go off because she was in a resident room. She stated RN A asked her for help on checking on the residents and that was when RN A noticed Resident #1 could not be located. CNA B stated RN A called a code white and everyone began to search for Resident #1 inside and outside the facility. CNA B stated Resident #1 was found the following day on 07/29/25 at around 5:00 AM. She stated Resident #1 was assess and had no injuries. CNA B stated Resident #1 was an elopement risk and had a WanderGuard on. She stated Resident #1 was known to pace the hallways and follow people around the facility. CNA B stated Resident #1 was able to walk without assistance. She stated that night Resident #1 followed a visitor out the facility.Interview on 09/11/25 at 2:59 PM with the DON revealed she was on leave when Resident #1 eloped from the facility. She stated Resident #1 was known to pace the hallways and follow staff around the facility but was easily redirected. She stated she could not recall if Resident #1 would exit seek, but he would come to the front area of the facility. She stated after the elopement the facility inserviced all staff on elopement/missing person, what to do in case of an elopement and abuse and neglect. She stated elopement risk assessments and care plans were reviewed. She stated nurses are expected to print out a census and complete a resident head count at the beginning of each shift. The DON stated they also added a new WanderGuard alarm system on each nurse station with flashing lights. She stated they also added a camera at the main entrance and each nurse station surveillance monitors were added to overlook different areas of the facility. Interview on 09/11/25 at 3:10 PM with the Administrator revealed she was notified of Resident #1's elopement at around 8:40 PM. She stated she reviewed camera footage because there were some inconsistencies with what the resident was wearing. She stated camera footage revealed at 7:51 PM Resident #1 was observed following RN A, then it showed Resident #1 walking away from the nurse. She stated at 7:54 PM a visitor was walking towards the main entrance and Resident #1 can be observed following behind the visitor. The Administrator stated according to RN A she heard the WanderGuard alarms go off and the nurse went to go check but did not observe anyone at the front and deactivate the alarm. She stated RN A went back to her hall and completed a head count of her resident and that was when she noticed Resident #1 missing. She stated a code white was called and everyone began the search. She stated Resident #1 was found at 4:55 AM on 07/29/25 by the police department. She stated Resident #1 was located about 2 miles away from the facility at a local business. The Administrator stated when Resident #1 returned to the facility he was happy, a head-toe assessment was completed, and no injuries were noted. The Administrator stated Resident #1 was an elopement risk and had a WanderGuard because he would walk around the facility. She stated Resident #1 never attempted to open doors or tried to go outside. She stated the day Resident #1 eloped, the visitor he followed behind fit the description of his wife. The Administrator stated Resident #1 was probably thinking he was following his wife out. She stated after the incident all staff were in-service on elopement/missing person, abuse and neglect, completed elopement/missing person drills, a new WanderGuard alarm system was placed at each nurse's station, weekly door/WanderGuard checks completed and at beginning of each shift nurses must print out a census and complete a head count of all residents. She stated a camera was placed outside the main entrance and surveillance monitors were placed at each nurse's station. She stated elopement risk assessments were completed on all residents and care plans were reviewed. The Administrator stated Resident #1 was placed on 1:1 supervisor and then discharged on 07/29/25 to a more appropriate placement.Record review of the facility's Elopement/Unsafe Wandering policy, revised January 2022, reflected the following: It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement.This was determined to be a Past Non-Compliance Immediate Jeopardy on 09/11/25 at 4:22 PM. The Administrator and the DON were notified. The Administrator was provided with the Immediate Jeopardy Template on 09/11/25 at 4:25 PM.The facility took the following actions to correct the non-compliance prior to the abbreviated survey:Record review of the facility's Resident frequent Monitoring Tool reflected Resident #1 was placed on 1:1 supervision on 07/29/25 from 5:30 AM until he transferred at 11:30 AM. Record review of Elopement/Wandering Evaluation reflected they were reviewed and completed on Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5 on 07/29/25.Record review of Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5's Care Plans reflected care plans were reviewed on 07/29/25 to reflect them as being at risk for elopements and having WanderGuards.Record review of the facility's Elopement binders located on both nurse's stations and reception reflected pictures of residents who were at elopement risk and contained information regarding the residents.Record review of the facility Elopement Drill Drills reflected a drill was completed on 07/29/25 at 12:00PM.The facility continued to conduct random Missing Person/Elopement drills on the following days: 08/09/25 6:15 PM, 08/14/25 - 8:15 PM, 09/08/25 - 11:05 AM. Record review of facility Emergency Exit Door and Wanderguard Inspection Log forms for all exit doors reflected door checked were completed daily from 07/29/25 through 07/31/25 and then completed once a week from 08/01/25 through 09/06/25 by Maintenance Director. Record review of facility daily Census/Midnight Census print out, start date 07/29/25 through 09/11/25 reflected nursing completing head count of residents. Observation on 09/11/25 at 10:15 AM of nurses' station revealed surveillance monitors were added at each nurses' station that overlook different areas of the facility and outside the main entrance. Observation on 09/11/25 from 2:55 PM through 2:58 PM revealed main entrance WanderGuard alarm was tested with Maintenance Director. Each nurses' station has an alarm for WanderGuard, and the alarm was heard throughout the facility. When alarm goes off flashing light flashes which indicates Code White.Record review of in-services dated 07/28/25 and 07/29/25 reflected all facility staff were in-serviced on: Elopement/Missing Resident, Policy, Procedures, Elopement Book, Abuse and Neglect. Summary of Inservice: Assessment- Residents are assessed upon admission, quarterly and with any changes in condition or elopement attempts. Care Plans are updated for those that are high risk. WanderGuards - WanderGuards must have a physician order and should be changed out every 6 months. Alarms should be responded to immediately in the event a resident is attempting to exit the facility. If a resident is found missing, the employee and team will initiate the missing resident procedures as outlined in the Elopement/Unsafe Wandering Policy and Guidelines (attached) that is located in the elopement. What to do in the event of an Elopement; What to do in the event you are unable to locate your patient; What to do if you hear the alarm going. Elopement Code White, Abuse and Neglect. In-serviced on 08/07/25 reflected Wander guard - New alarm sound/flashing light at nurse's station. [NAME] light flashing and sound possible elopement. When alarm sounds staff will respond accordingly. Wander guard- all staff immediately check foyer/front door area as well outside the door. Interviews on 09/11/25 from 11:36 AM through 5:20 PM with CNA B, LVN C, ADON D, ADON E, Housekeeping F, Housekeeping G, Therapy H, Therapy I, Dietary Supervisor, [NAME] J, CNA K, CNA L, MA O, CNA P, LVN Q, LVN R, LVN S, Social Worker and Maintenance Director who worked the shifts of 6:00 AM-6:00 PM, 6:00 PM-6:00 AM revealed the facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize the elopement/missing person, code white, abuse, and neglect in-service, and where to locate elopement binders. Facility staff were able to indicate new WanderGuard alarm system were added to each nurse's station with flashing lights and elopement/missing person drills were completed. Nursing staff stated a daily/midnight census were printed and head counts were completed before shift, elopement assessment were reviewed/completed (an evaluation to determine any resident at risk of elopement), care plans reviewed for residents who were elopement risk, nurses ensure WanderGuards were checked daily to ensure they were working properly and document on the MAR, and surveillance monitors were added to each nurses station that overlook different areas of the facility. Staff indicated a surveillance camera was also added at the front entrance to provide additional oversight.

**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 1 of 2 residents (Resident #2) reviewed for elopement. The facility failed to provide adequate supervision to Resident #2, who was aphasic and had right-sided hemiplegia, when the resident left the faciity on [DATE] without staff knowledge and made it approximately 1.5 miles from the facility with the assistance of a bystander. The resident was out of the facility for approximately two hours without staff knowledge, and he was located by his family who had placed a tracking device on his shoe. The non-compliance was identified as past non-compliance. The IJ began 09/15/24 and ended on 09/23/24. The facility corrected the non-compliance before surveyor's entrance. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included cancer, hypertension (high blood pressure), aphasia (language disorder that makes it difficult to understand or express language), stroke, and hemiplegia (paralysis or weakness in one side of the body). The MDS further reflected the resident had no speech was but he usually understood others and was also usually understood by others and had memory problems. Record review of Resident #2's care plan created on 06/27/24 reflected the resident was at risk for communication related to aphasia. Interventions included to assist with finding words as needed/appropriate. The care plan further reflected the resident had an ADL deficit performance related to hemiplegia affecting the right dominant side/weakness. Interventions included to monitor/document report to the doctor or as needed of any changes or potential for improvement or declines in function. The care plan did not reflect that Resident #2 was at risk for elopement or wandering. Review of Resident #2's elopement assessments, dated 06/22/24 and 08/03/24, revealed he was a low risk for elopement and wandering. Review of the facility's Provider Investigation Report dated 09/16/24 reflected the following: resident frequently sits outside daily independently or with family. Prior to this incident there have been no attempts to leave the facility property. [Family member] visited with resident on 09/15/24 after this visit at 2:59 p.m. the resident was observed via camera self propelling his wheelchair off facility property. The resident was located near the neighborhood he previously lived in being pushed by an individual unfamiliar to the facility. At apprx 4:30 p.m. the charge nurse and family located the resident via apple tag (that was placed on resident shoe by family). Resident was returned [ sic] him to the facility unharmed. Head to toe assessment and vitals were completed, no injuries or s/s of distress noted Observation and interview on 10/08/24 at 9:16 AM with Resident #2 revealed he was self-propelling his wheelchair out the door to the enclosed courtyard. Resident #2 smiled and greeted the surveyor during the introduction. The resident was not able to complete sentences but was able to answer yes/no questions. The resident was asked if he could write or type his conversation and he shook his head no. Resident #2 was asked if he was doing ok and he said yea and nodded his head. He was asked if he was hurting, and he said no and shook his head. The resident was asked if he sat outside in the front of the building, and he said no and made a circular motion with his hand of the courtyard. He was asked if he only stayed in the courtyard, and he said yes. The resident was asked if he had recently left the facility and he began to laugh and said yes. The resident was asked where he was going but was not able to answer the question and only pointed up. Observation on 10/08/24 at 9:00 AM of the facility revealed there was a shaded patio that extended over the driveway in front of the front entrance. There was a sidewalk that extended around the facility without having to go into the parking lot. Interview on 10/08/24 at 9:39 AM with Resident #2's family member [Family Member #3] revealed the resident admitted to the facility post stroke in June 2024. Family Member #3 stated during the resident's time at the facility, he had never made any attempt to leave. The family said he enjoyed being outdoors. They said the day of the incident, the resident's [Family Member #4] had visited and left the facility sometime after lunch. Later after [Family Member #4's] visit, the resident's [Family #3] arrived at the facility to visit and when he was not found in his regular places the staff began to look for the resident. When he was not found at the facility, they contacted the resident's [Family Member #4] who said she had an air tag on the resident, and she was able to locate the resident. The resident's [Family Member #3] and charge nurse drove to the location and the resident was found, uninjured, and being pushed by a young man. Resident #2's family member stated the resident had let them know he was trying to get back home, and he had been found about 5 blocks from his house. [Family Member #4] stated the reason they had an air tag (tracking device) on the resident was because the nursing home situation was new to them, and it let them know where he was at all times even when he was at doctor appointments and they did not know if the facility staff were aware of the air tag. The resident's [Family Member #4] further stated the resident understood he could not leave the facility and he was not to sit outside in front of the facility anymore and if he wanted to be outside, he had to go to the enclosed courtyard. Interview on 10/08/24 at 1:34 PM with the Social Worker revealed it was difficult to complete a BIMS (a short cognitive screening tool used to assess a patient or resident's cognitive abilities) on Resident #2 because he was non-verbal when he admitted . They called the resident's family to assist with the assessment and when they got to the mood assessment questions, Resident #2 took the sheet and read the questions himself and appropriately answered yes or no or gave a thumbs up or thumbs down. Interview on 10/08/24 at 1:07 PM with LVN F revealed the day of the incident, 09/15/24, he passed medications and saw Resident #2 around 2:00 PM and he was in his room. Later around 4:00 PM, the resident's [Family Member #3] asked him if he had seen Resident #2 because he was not at his usual places, so they began to look for him. While they were looking for the resident, the resident's [Family Member #4] was contacted, and she told them the resident had an air tag on and gave them the location of the resident. The LVN said they were not aware the family had placed an air tag on the resident. He and the other charge nurse and Resident #2's [Family Member #3] went to the location the air tag indicated and he was found by a park being pushed by a young teenager. The resident was assessed, and he was not injured and was taken back to the facility. LVN F said Resident #2's family regularly visited and when they were not visiting, he enjoyed sitting out front of the facility people watching. LVN F said the resident was safe to be outside on his own and he had never tried to leave the facility. LVN F further stated Resident #2 was checked on frequently when he was outside just to make sure he was ok. LVN F also said the front door was locked when there was not receptionist at the front entrance. Interview on 10/08/24 at 3:23 PM with RN G revealed he was Resident #2's charge nurse the day of the incident, 09/15/24. He said that day, Resident #1's [Family Member #4] had visited and left the facility at around 1:30 PM. Resident #2 had a routine where he sat outside in front of the facility, and he had never attempted to leave the premises. RN G said the day of the incident he last saw the resident around 2:30 PM at the nurses' station and sometime after 3:00 PM the resident's [Family Member #3] was looking for the resident. At that time, they began to look for the resident and the resident's [Family Member #4] was called who said she had an air tag on the resident and was able to pull the location of the resident. The RN said he was not aware the family had placed an air tag on the resident when he admitted to the facility. He and the other charge nurse drove to the resident's location and found Resident #2 about 2 miles from the facility. Resident #2 was being pushed by a teenager and upon assessment the resident did not have any injuries. RN G said the resident had been at the facility for a few months, and he had never tried to leave and it was unusual for him to have left that day. Normally when Resident #2 sat outside, the staff checked on him frequently to make sure he didn't need anything. Interview on 10/08/24 at 11:52 PM with CNA H revealed she worked with Resident #2, and he was able to self-propel his wheelchair and only used his call light when he needed to be changed. CNA H said the resident was never exit seeking and only left the facility when he was out on pass with family or he usually sat outside in the front of the facility and they would frequently check on him to see if he needed anything because he did not require supervision to be outside. Interview on 10/08/24 at 2:47 PM with LVN I revealed Resident #2 enjoyed sitting outside and looked at the cars and the visitors coming and going. The resident had never attempted to leave the facility or alluded that he wanted to leave. While Resident #2 was outside staff would make sure to check on him frequently and there were no issues or concerns with elopement. Interview on 10/08/24 at 12:40 PM with the Speech Therapist revealed she had been working with Resident #2 with his expressive speech. He was non-verbal but able to make his needs known with choices and yes and no questions. Based on her assessment the Speech Therapist stated Resident #2 was able to make his needs known. She said the resident would sit outside of the facility and had never alluded that he wanted to leave the facility. Prior to the incident, while the resident was outside, staff knew they were to monitor the resident while he was outside to make sure he was ok, but she felt he was safe to stay outside on his own because he knew to stay on the patio and not go into the driveway or parking lot. Since the incident, the resident was told not to go out the front and instructed to go to the enclosed courtyard if he wanted to be outdoors. The Speech Therapist further stated Resident #2 was able to maneuver his wheelchair pretty well even with having deficits on his right side of his body. Interview on 10/08/24 at 1:17 PM with the Physical Therapist revealed Resident #2 was able to maneuver his wheelchair better now than when he first admitted to the facility. She said it could be challenging to communicate with the resident, but the resident was able to understand what was being told to him and was able to follow instructions and commands. The Physical Therapist further stated she felt like the resident was safe to sit outside alone and he had never tried to leave the facility since he had been at the facility. Staff knew to check on Resident #2 when he was outside due to the summer heat, but the resident mainly sat outside under the shaded patio until his family arrived to visit. Interview on 10/08/24 at 3:48 PM with the DON revealed she was made aware Resident #2 had left the faciity on [DATE]. She was told that through an air tag, the family had placed on the resident , without them knowing, had located the resident around his old neighborhood. The nurses told her the resident had been assessed and there were no injuries noted. The DON said Resident #2 always sat outside in the front and never tried to leave. After the incident, the resident was put on 1:1 for 3 days and elopement assessments were done on the residents and there were no residents identified for elopement. They had elopement in-services and drills to make sure staff knew what to do in case they had an elopement. The DON further stated the front doors were being locked on the weekends or when there was not a receptionist at the entrance. Interview on 10/08/24 at 4:00 PM with the Administrator revealed Resident #2 was alert and oriented and had a history of sitting outside in the front of the facility. The resident enjoyed being outside and would wheel himself sidewalk and at no time had he ever expressed he wanted to leave. The Administrator was made aware the resident had left on 09/15/24 when the resident's wife was not able to locate him in the facility. Resident #2 was located through an air tag that had been placed on the resident by the family, that they were not aware of. Per the family, they asked the resident where he was going, and he told him he was going home. The resident was brought back to the facility unharmed, and they placed a WanderGuard on the resident for safety. The Administrator said they were able to get video footage from the library next door and it captured the resident going by there at 3:17 PM and he was brought back to the facility after 4:00 PM. After the incident the family was told the resident would need to wear a WanderGuard for safety and the front doors would remained locked if there was not a receptionist at the front desk. Resident #2 and his family were told the resident could no longer sit outside unsupervised but could continue to go to the enclosed courtyard if he wanted to be outdoors. There were no other residents identified as being an elopement risk during their assessment. Observation on 10/08/23 at 10:23 AM revealed Resident #2 was sitting with his wife near the front door, and they were asked to get close to the door to verify the WanderGuard was operating correctly, and the WanderGuard began to beep very loudly, and the front door did not open. Record review of the in-services dated 09/15/24 through 09/20/24 reflected staff had been in-serviced on elopements, and instructed the front doors would remain locked unless there was a receptionist at the front entrance. Record review of the facility elopement drills revealed they were conducted on 09/16/24, 09/22/24, and 09/30/24 with all facility staff of various shifts to include dietary, nursing, housekeeping, and therapy. Record review of the elopement assessment dated [DATE] reflected Resident #2 remained at a low risk of elopement. Record review of Resident #2's one-to-one monitoring revealed he was being checked on every 15 minutes and initialed by staff from 09/15/24 through 09/18/24. Record review of Resident #2's care plan revealed it had been updated after the incident on 09/15/24 to reflect the following: Elopement risk/wanderer related to history of attempts to leave the facility unattended. Impaired safety awareness. The resident enjoys sitting in the front portico area on warm days. Interventions included to document wandering behavior, monitor the wanderguard to the left ankle and staff will check on the resident if he wished to sit outside. Interviews on 10/08/24 from 10:27 AM to 3:48 PM with the DON, Housekeeping Supervisor, LVN F, RN G, CNA H, LVN I, and LVN J, who worked various shifts, revealed they were all aware Resident #2 was only allowed in the enclosed courtyard and could not be alone in the front patio unattended. Record review of the facility's Elopement/Unsafe Wandering policy, revised December 2003, reflected the following: Policy It is the policy to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement.

**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 3 residents (Resident #1) reviewed for supervision. The facility failed to ensure a resident with known wandering behaviors was provided with adequate supervision to prevent her from eloping and subsequently falling and sustaining a left hip fracture. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 05/12/23 and ended on 05/13/23. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's face sheet, dated 05/25/23, revealed the resident was an [AGE] year-old female, who was initially admitted to the facility 11/09/20 and readmitted on [DATE]. Resident #1 had diagnoses which included displaced fracture of base of left femur, dementia without behavioral disturbance (impaired ability to remember, think, or make decisions), and Type 2 diabetes (elevated levels of blood sugar). Record review of Resident #1's MDS quarterly assessment, revealed her BIMS score was 6, indicative of severe cognitive impairment. Resident #1 was ambulatory. Record review of Resident #1's care plan, revised 05/17/23, reflected, Focus: Due to changes in my cognition r/t dementia. I have the potential for a negative behavior i.e agitates and will make suggestions of going home. For the most part, I'm redirectable. Goal: Will have fewer episodes of agitation by review date. Interventions: Approach in a calm manner. Assist to develop more appropriate methods of coping and interacting encourage to express feeling appropriately .Focus: Elopement risk/wandering r/t history of attempts to leave facility unattended, impaired safety awareness. Goal: Will not leave facility unattended through the review date. Safety will be maintained through the review date. Will demonstrate happiness with daily routine through the review date. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation. Document wandering behavior and attempted diversional interventions. Elopement Episode 5/12/23 .Focus: Has had an actual fall with left hip fracture r/t poor balance, psychoactive drug use, unsteady gait. Goal: Will resume usual activities without further incident through the review date. Left hip fracture will resolve without complication by review date. Interventions: Provide activities that promote exercise and strength building were possible Room assignment close to the nurse's station. Therapy consults for strength and mobility. Record review of the facility Incident by Incident report, from 05/25/22 - 05/25/23, revealed Resident #1 eloped on 05/12/23. Record review of the facility's Incident Report, dated 05/13/23, reflected the facility received a call from staff at a restaurant located 0.4 miles away from facility on the same side of the road that they may have one of our residents in their establishment. Facility staff went to the restaurant and identified [Resident #1]. [Resident #1] had sustained a ground level fall and was complaining of left hip and leg pain. EMS was present and transported [Resident #1] to the hospital for evaluation and treatment. Facility staff had last visualized Resident #1 in the facility at approximately 2230 hours [10:30 PM] ambulating in the hallway near her room after she had received her last scheduled medication for the day. It is believed that Resident #1 had exited the facility through the front door. The facility doors are unlocked while the receptionist is present and locked via keypad code at the end of the receptionist's shift. Record review of Resident #1's hospital record, dated 05/16/23, revealed Resident #1 admitted on [DATE], with the reason for admission identifed as a fall. The hospital record reflected Resident #1 was diagnosed with a closed fracture of the neck of her left femur. Resident #1 was discharged on 05/16/23. Record review of Resident #1's Elopement Risk Assessment/Wander Data Collection completed on 02/12/23 indicated Resident #1 had a diagnosis of dementia, and she could ambulate independently or with supervision. Resident #1's mental status was alert and oriented. Resident #1 had no history of elopement in the last 6 months, and she made statements about desire to leave the facility. Resident #1 had not exhibited wandering behavior but had a history of wandering. Resident #1 was at low risk for elopement and wandering. Record review of Resident #1's Elopement Risk Assessment/Wander Data Collection completed on 05/13/23 indicated Resident #1 had a diagnosis of dementia and Alzheimer's disease (brain disorder that slowly destroys memory and thinking skill), and she could ambulate independently or with supervision. Resident #1's mental status was intermittent confusion. Resident #1 had one episode of elopement history in the last 6 months, and the resident made statements about the desire to leave the facility. Resident #1 wandered, was aimless with potential to go outside, and had active exit-seeking behavior. Resident #1 was at high risk for elopement and wandering. Record review of progress note, documented by LVN A on 05/13/2023 at 1:37 AM, reflected: Late Entry: Call was received to facility by the nurse on 400/500 hall the person on the end of the line was asking if this is the home of [Resident #1] inform the nurse that resident was at the restaurant, she arrived and fell. This nurse drove to the restaurant and found resident sitting on the chair surrounded by restaurant staff, customer and EMT. Upon arrival the EMT confirmed resident name and date of birth with this nurse, nurse confirmed information. This nurse assessed resident, she was alert and oriented able state name, date of birth , notice that resident was having hard time putting left leg down, resident confirm that she was in pain. Resident couldn't get up, EMT load resident in the ambulance and took resident to the hospital. Observation and interview on 05/25/23 at 9:30 AM revealed Resident #1 lying in bed and watching television. Resident #1 stated she was doing well. Resident #1 was not a good historian and could not recall leaving the facility or having a fall. Resident #1 denied having any pain. Interview on 05/25/23 at 11:37 AM with CNA B revealed she was the assigned CNA on 200 Hall on 05/12/23. CNA B stated her shift ended at 10:00 PM. CNA B stated Resident #1 could ambulate on her own before the elopement incident, and the resident would walk around the facility all the time. She stated Resident #1's usual routine would be walking around the facility until she would get tired and would go back to her room. CNA B stated she could not recall when the last time she had last seen Resident #1 on 05/12/23; however, Resident #1 was walking the halls. CNA B stated Resident #1 did not have an elopement history. She stated Resident #1 would mention wanting to go home; however, the resident had not attempted to leave. Interview on 05/25/23 at 1:21 PM, with LVN A, by phone, revealed she was the nurse on duty for the night of 05/12/23. LVN A stated she was assigned to 100 and 200 Hall. She stated Resident #1's day-to-day behavior was to wander the halls. She stated Resident #1 was known to walk the halls even during the night, and once she was tired the resident would go to bed. She stated Resident #1 had wandering behaviors; however, the resident had not attempted to leave before. She stated Resident #1 eloped during her shift. She stated the last time she observed Resident #1 was around 10:30 PM, she stated the resident was coming from 400 Hall and going towards 600 Hall. LVN A stated the facility had a receptionist until 8:00 PM. LVN A stated the receptionist was responsible for locking and unlocking the entrance doors, she stated they had the code. She stated between 11:45 PM and midnight (12:00 AM) she received a call from a nearby restaurant asking her if Resident #1 was a resident at the facility. She stated she looked around the facility and could not locate Resident #1. She stated she rushed to the restaurant that was about 2-3 minutes away by car. She stated when she arrived at the restaurant Resident #1 was sitting on a chair and was drinking water. She stated Resident #1 verbalized being okay. LVN A stated she assessed the resident, and the resident stated she was in pain. LVN A stated EMTs were on scene already, and they transported Resident #1 to the hospital because she was not able to walk and complained of pain to her left hip. LVN A stated the restaurant staff informed her Resident #1 had a fall. LVN A stated Resident #1 exited the facility through the front entrance door because when she was leaving the facility to go to the restaurant, the front entrance door was unlocked. LVN A stated she was unaware the front door was unlocked until after the incident. She stated she did not hear any alarms going off. Interview on 05/25/23 at 1:36 PM with Receptionist F revealed she worked the day of 05/12/23. She stated her shift was from 2:00 PM-8:00 PM. She stated it was the receptionist's responsibility to lock and unlocked the front entrance door. Receptionist F stated the receptionist had the codes to the door. She stated the front door had two different codes: one code to unlock and lock the door, and the second code was used to exit the front door once it was locked. She stated the night of 05/12/23 when her shift ended, there were still visitors at the facility, so she provided the code to the night nurse whom she believed was RN C or LVN D, so they could let the visitors out. She stated she provided the code that allowed people to exit the facility once the door was locked. Receptionist F stated she locked the door before she left the facility. Receptionist F stated this was the first time Resident #1 had ever eloped. She stated they had not had any previous elopement incidents. Interview on 05/25/23 at 1:43 PM with RN C revealed she worked the night of 05/12/23. She stated her shift started at 10:00 PM; however, she arrived around 9:50 PM. RN C stated she never observed Receptionist F because she was already gone. RN C stated when she arrived at the facility the front door was locked. She stated she was unable to open the front door and called someone to open it for her. RN C stated she observed Resident #1 walking the hallways as her usual routine. RN C stated she could not remember what time she last saw Resident #1. RN C stated between the times of 11:30 PM- before midnight LVN A notified her a restaurant had contacted the facility to notify them Resident #1 was there. RN C stated she and LVN A drove to the restaurant where they observed Resident #1 seated on a chair in the company of the restaurant staff and the EMT team. She stated Resident #1 complained of pain to her left lower limb, and they made the decision to have her checked at the hospital. RN C stated when they left the facility to go to the restaurant the front entrance door was open, and no alarms were heard the entire time. She stated Resident #1 eloped through the front door. RN C stated she was never informed of any family in the facility, and she did not talk to Receptionist F. An attempt was made to contact LVN D by phone on 05/25/23 at 1:49 PM; however, the phone call was unsuccessful. Interview on 05/25/23 at 2:02 PM, the ADON stated she was off duty on 05/12/23. The ADON stated she was made aware of the elopement incident on Monday, 05/15/23. The ADON stated during the facility investigation it was determined Resident #1 eloped from the facility at approximately 11:00 PM via a secured door leading to the main road. The front door of the facility was unlocked because no alarms were heard. The ADON stated there was a miscommunication between Receptionist F, who worked from 2:00 PM-8:00 PM, and the nurse on duty, LVN D. She stated there were still visitors at the facility, and Receptionist F provided the code to LVN D. The ADON stated Resident #1 had a fall and sustained a left hip fracture. She stated Resident #1 was known to wander around but had never attempted to exit the facility before. The ADON stated Resident #1 was easy to redirect. The ADON stated following this incident they trained all staff on missing persons/elopement. She stated they all trained the nurses on conducting a midnight census head count before and after their shift and checking all the doors to ensure they were locked. The ADON stated they changed the front door code so only one code had to be used, and they provided walkie talkies on each nurse's station for communication. Additionally, they implemented random elopement drills and would continue for the drills for the next 4 weeks. Interview on 05/25/23 at 2:12 PM, the DON stated she received a call on 05/13/23 at 12:15 AM from LVN A who informed her Resident #1 had eloped from the facility and was reported to be at a restaurant. The DON stated LVN A went to the restaurant and Resident #1 had complained of pain and EMTs were already on the scene so they took Resident #1 to the hospital. The DON stated during the facility investigation it was determined Resident #1 eloped from the facility at approximately 11:00 PM via the main entrance front door. She stated the front door of the facility was unlocked because no alarms were heard. The DON stated there was a miscommunication between the Receptionist, who worked from 2:00 PM-8:00 PM, and the nurse on duty. She stated there were still visitors at the facility around 8:00 PM, and the Receptionist provided the code to LVN D. The DON stated the front door had two different codes: one code unlocked and locked the door, and the second code was used to exit the front door after it was locked. The DON stated following the incident they trained all staff on missing persons/elopement. The nurses were trained to conduct a midnight census head count before and after their shift and to check that all the doors were locked. They also changed the front door code so only one code had to be used. The DON stated they provided walkie talkies on each nurse's station for communication, and they implemented random elopement drill and would continue the drills for the next 4 weeks. The DON stated they completed an elopement assessment on all current residents. The DON stated Resident #1 had been a resident since 2020 and had not had any elopement incidents. The DON stated Resident #1 had wandering behaviors but had not attempted to leave before. She stated Resident #1 currently could not walk due to her fracture; however, once the resident became more mobile and upon assessment if the resident showed any exit-seeking behaviors, they would find an alternative placement and would transfer Resident #1 to a secure unit. Interview on 05/25/23 at 2:39 PM with CNA E by phone revealed she was the assigned CNA for 200 Hall on 05/12/23. CNA E stated her shift started at 10:00 PM. CNA E stated Resident #1 was known to wander around the facility but did not attempt to leave. CNA E stated the night of 05/12/23 Resident #1 was walking around the halls, she stated she was assisting other residents and the last time she had seen Resident #1 was between 10:30 PM and 11 PM walking on the hall. CNA E stated the entrance door was always locked and they needed a code to unlock it. CNA E stated she did not know the code to unlock the door, she stated the receptionists were responsible for locking and unlocking the doors. CNA E stated Resident #1 did not have an elopement history but she was known to wander the facility. CNA E stated Resident #1 was easy to redirect. CNA E stated facility was notified that Resident #1 was at a nearby restaurant. Interview on 05/25/23 at 4:47 PM with the Maintenance Director revealed the morning of 05/13/23 he received a call from the DON notifying him Resident #1 had eloped. The Maintenance Director stated he came to the facility that night and the door was functioning correctly. The Maintenance Director stated there was a miscommunication between the receptionist and LVN D regarding the door code and the door was left unlocked. The Maintenance Director stated he had been conducting random elopement drills with the staff which consisted of picking a volunteer resident and hiding that volunteer resident in the facility . He stated the nurse on that hall must conduct a head count on the residents on the hall and if someone was missing, they must call Code Pink which was the code for a missing person. The Maintenance Director stated all the staff must meet at the nurse's station where the Code Pink was called and they all got the walkie talkies and they started the search. He stated once the volunteer resident was found the staff who called the Code Pink was the only person who could call it off. He stated he would provide feedback on the staff on how to do things better. He stated the elopement drills will continue for the next 4 weeks. Observation on 05/25/23 at 5:15PM of the Maintenance Director unlocking and locking the main entrance door. Observed Maintenance Director hold the door for 15 seconds and alarms went off. This was determined to be a Past Non-Compliance Immediate Jeopardy on 05/25/23 at 3:00 PM. The DON and the ADON were notified. The DON was provided with the IJ template on 05/25/23 at 5:30PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of the following in-services dated 05/13/2023, Elopement policy and procedure, Visual/Documented census protocol, and Missing Resident/Elopement. In-service reveal all staff completed the training. Record review of the facility Midnight Census reports, starting date 05/13/2023 through 05/25/23, revealed residents head count on both shifts from 6AM-6PM & 6PM-6AM. Nurses signatures on each form were observed. Record review of the facility Emergency Preparedness Drills - Missing Person/ Elopement revealed drills were conducted by the Maintenance Director on 5/13/23 at 1:35 PM and 5/24/23 at 10 AM. Interviews on 05/25/23 from 11:30 AM through 5:20 PM with Receptionist G, Receptionist F, CNA B, CNA E, CNA H, CNA K, CNA L, CNA M, LVN A, LVN I, LVN J and RN C who work the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM were able to verify education was provided to them, nursing staff were able to accurately summarize missing person/elopement policy, missing/elopement code, emergency preparedness missing person/elopement drills, and midnight census count. Record review of the facility's Elopement/Unsafe Wandering policy and procedure, revised 1.2022, reflected the following: It is the policy of this facility to provide a safe environment for all resident through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. 1. Resident with capabilities of ambulation and/or mobility in wheelchair will have an elopement/wandering evaluation completed to determine risks for elopement and unsafe wandering on admission and with observed behaviors of wandering or attempting to elope. 3. Staff shall promptly report any resident who is trying to leave the premises or suspected or being missing to the charge nurse or supervisor to evaluate the need for further interventions. The noncompliance was identified as past non-compliance. The IJ began on 05/12/23 and ended on 05/13/23. The facility had corrected the noncompliance before the survey began.