**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and received adequate supervision 2 of 9 residents (Resident's #1 and #2) reviewed for accident hazards.1. The facility failed to immediately fix a broken window in the Memory Care Unit's dayroom. Resident #1 grabbed a shard of the glass and attempted to remove it. The Surveyor intervened to get the resident to stop grabbing it.An Immediate Jeopardy (IJ) was identified on 07/17/25. The IJ template was provided to the facility on [DATE] at 4:55 PM . While the IJ was removed on 07/18/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.2. The facility failed to ensure Resident #2 did not elope from the facility on 06/05/25. The resident was returned to the facility by the police on 06/05/25.An Immediate Jeopardy (IJ) was identified on 07/31/25. The IJ template was provided to the facility on [DATE] at 11:00 AM. While the IJ was removed on 08/01/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.These failures could place residents at risk for injury up to and including death due to the sharp glass and elopement.Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and residents received adequate supervision for 2 of 9 residents (Residents #1 and #2) reviewed for accident hazards.1. The facility failed to immediately fix a broken window in the Memory Care Unit's dayroom. Resident #1 grabbed a shard of the glass and attempted to remove it. The Surveyor intervened to get the resident to stop grabbing it.An Immediate Jeopardy (IJ) was identified on 07/17/25. The IJ template was provided to the facility on [DATE] at 4:55 PM. While the IJ was removed on 07/18/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.2. The facility failed to ensure Resident #2 did not elope from the facility on 06/05/25. The resident was returned to the facility by the police on 06/05/25.An Immediate Jeopardy (IJ) was identified on 07/31/25. The IJ template was provided to the facility on [DATE] at 11:00 AM. While the IJ was removed on 08/01/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.These failures could place residents at risk for injury up to and including death due to the sharp glass and elopement.The findings included:1. Record review of Resident #1's quarterly MDS assessment, dated 06/17/25, revealed the resident was a [AGE] year-old male admitted on [DATE]. His BIMS score was 3 indicating his cognitive ability was severely impaired. His diagnoses included seizure disorder and schizophrenia (a serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior.) The resident required set-up assistance for wheelchair mobility.Record review of Resident #1's Care Plan, dated 06/19/25, reflected:The resident was at risk for falls.Facility interventions included:The resident needed a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, and personal items within reach.An observation and interview on 07/17/25 at 10:50 AM revealed Resident #1 was in the Memory Care Unit dayroom with 2 other residents. Resident #1 was in his wheelchair sitting next to a table close to the exit door. The window next to the exit door was broken and had a large piece of triangle shaped glass sticking straight up. There were also multiple pieces of glass sticking up and there was one large piece of glass laying in the windowsill. Pictures of the window were taken. Resident #1 said the window had been broken for 2-3 days after an unknown resident in a wheelchair hit it. The resident said he had never cut himself on the window.An interview on 07/17/25 at 10:53 AM with LVN A in the Memory Care Unit revealed she did not know the window was broken. She was walking through the day room. LVN A left the Memory Care Unit.An observation and interview on 07/17/25 at 10:55 AM revealed CNA B entered the day room. She sat in a chair at the table that was blocking the window. She said she would be staying in the day room until maintenance came to fix the window. Resident #1 was in his wheelchair next to her. She said she did not know about the broken window. The Surveyor walked around the corner to the nurse station. An interview with RN C revealed the window was broken 2-3 days ago and she did not know how it happened. She said none of the residents had cuts or injuries. The Surveyor returned to the day room, but CNA B was not there. Resident #1 was next to the broken window and grabbed the largest piece of triangle shaped glass, separate from the other pieces of glass, easily reached by the resident, and tried to remove it. The Surveyor told him to stop. The resident grabbed it again and said he needed to remove it so no one would get hurt. The Surveyor said stop and CNA B returned to the dayroom and told him to stop also. The resident stopped after he was told Maintenance was coming to fix it. The Maintenance Director entered the day room and said the window had been broken for 2 days and he thought the broken glass was removed. He said two days prior the window did not look as bad, and he said it looked like someone hit the window again. The Maintenance Director removed the glass pieces and said he would cover it with a piece of cardboard. He left the room. CNA B had also left the room. The window had a gaping hole with sharp edges. The Surveyor stayed with the window and Resident #1 to make sure he did not touch the window again. The 2 other residents in the day room were still in their same spot.An observation and interview on 07/17/25 at 11:03 AM revealed the Maintenance Director returned. He said there were no cameras in the dayroom. The Maintenance director said he was told that there was just a crack in the window, and he did not know the hole had gotten so big. He placed cardboard over the window and said he had called the window company 2 days ago to fix it, but they had not arrived yet.An interview on 07/17/25 at 11:12 AM with the DON revealed she did not know about the broken window in the dayroom prior to 07/17/25. She said she did not know how it happened. She said the nurse was assessing the residents in Memory Care for cuts and injuries. She said it was everyone's responsibility to check windows and environment issues and report them to be fixed. She said a broken window put residents at risk for harm.An interview on 07/17/25at 12:42 PM with the Administrator revealed he did not know about the broken window and would contact the Maintenance Director. He said staff were supposed to notify him about the broken window.Review of the facility policy, Preventive Maintenance not dated, reflected:The facility will ensure that a comprehensive preventive maintenance program is in place for essential operating equipment. Preventive maintenance will be completed routinely and according to protocol by the Maintenance Supervisor or qualified designee. The facility will maintain documentation of all preventive maintenance.Review of the facility policy, Facility Assessment dated 08/08/24, reflected: The facility assessment addresses the following.A facility-based and community-based risk assessment, utilizing an all- hazards approach.This was determined to be an IJ on 07/17/25. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 07/17/25 at 4:55 PM. The Plan of Removal was accepted at 8:35 AM on 07/18/25 and reflected the following:Interventions:The window referenced on the secure unit was repaired on 07/17/25 by the maintenance director.All windows in the facility and secure unit were inspected by the maintenance director. No additional windows needed repair. Completed 07/17/25.All residents in the secure unit were assessed for injuries by the DON and ADON on 07/17/25. No new injuries were noted.New Process: If there is a window or any area in the in facility that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, or ADON will be notified immediately. If repairs cannot be completed immediately, the administrator will contact the Area Director of Operations for guidance. The process will begin 07/17/25 and ongoing.The Maintenance Director, Administrator, or designee will inspect all windows in the facility weekly to ensure all windows are intact and functioning. Windows that need repair will be addressed immediately. Start date will be 07/17/25 and ongoing.The Administrator, DON, Maintenance Director and ADON were in-serviced 1:1 by the Regional Compliance Nurse and completed as of 07/17/25 on the following:New Process: If there is a window or any area in the in facility that needs repair and presents as an accident/hazard, the staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, or ADON will be notified immediately. If repairs cannot be completed immediately, the administrator will contact the Area Director of Operations for further guidance in ensuring the safety of the residents.Abuse and Neglect failure to repair a broken window immediately could be considered neglect and be a potential hazard to staff and residents.The Medical Director was notified of the immediate jeopardy citation on 07/17/25 by the DON.An ADHOC QAPI meeting was conducted as of 07/17/25 to review the immediate jeopardy citations and subsequent plan of removal.In-services:The Regional Compliance Nurse, Administrator, DON, and ADON will in-service all staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are completed. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. In-servicing began on 7/17/25. Completion date will be 7/18/25.New Process: If there is a window or any area in the in facility that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, or ADON will be notified immediately. If repairs cannot be completed immediately, the administrator will contact the Area Director of Operations for guidance in ensuring the safety of the residents.Abuse and Neglect failure to repair a broken window immediately could be considered neglect and be a potential hazard to staff and residents.Monitoring of the facility's Plan of Removal included the following:Record reviews of the facility Plan of Removal In-services reflected:25 staff were in-serviced on: In Service Training Attendance Roster, dated May 2025, reflected: Service Training Topic:New Process: If there is a window or any area in the in facility that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, or DON will be notified immediately. If repairs cannot be completed immediately, the administrator will contact the Area Director of Operations for guidance in ensuring the safety of the residents.Abuse and Neglect failure to repair a broken window immediately could be considered neglect and be a potential hazard to staff and residents.Observations on 07/18/25 from 9:30 AM to 1:00 PM of the facility, including the Memory Care Unit revealed no broken windows or safety hazards. The broken window in the Memory Care Unit was fixed. Residents in the Memory Care Unit did not have visible cuts or scrapes.Interviews with staff from 07/18/25 at 10:00 AM to 07/18/25 at 1:00 PM were completed. 11 staff were interviewed in person/on the phone who worked all shifts at the facility. The interviewed staff were RN C, LVN A, Activity Director, Housekeeper D, LVN E, CNA F, CNA G, Maintenance Director, LVN H, DON, and the Administrator. The staff were able to verbalize they were in-serviced on the new process. If there was a window or any area in the facility that needed repair and presented as an accident/hazard, staff would ensure that someone remained at the site to protect residents from harm. The administrator, maintenance director, or DON would be notified immediately. Also, they were able to verbalize that failure to repair a broken window immediately could be considered neglect and be a potential hazard to staff and residents.An interview with the Maintenance Director on 07/18/25 at 12:46 PM revealed he was in-serviced regarding the POR for the broken window. The Maintenance Director said he inspected all windows on 07/17/25 and no additional windows needed repair. He said he was supposed to report to the Administrator and Supervisor and get it fixed ASAP if he found a broken window. He said he or staff had to stay with the resident until the window was fixed. He said he had to look everyday to make sure no windows were broken and failure to repair the window could be neglect and present a potential hazard to the residents.An interview with the DON on 07/18/25 at 12:25 pm revealed her role in the Plan of Removal was to ensure staff were in-serviced and assist with in-services. She said if a broken window was found, she would direct staff to stay with the residents until the window was fixed. She said if staff found a broken window, they were to stay with the residents and call the Administrator, DON, and Maintenance Director. She said staff were supposed to check daily for broken windows. The DON said failure to fix a broken window and stay with the resident posed a potential hazard and neglect.An interview on 07/18/25 at 12:10 PM with the Administrator revealed his role in the Plan of Removal was to supervise and make sure the facility stayed in compliance. The Administrator said he would contact the Area Director of Operations if a window was found broken and could not be fixed. He said he would monitor to ensure the Maintenance Director was checking for broken windows and fixing them immediately. The Administrator said if staff found a broken window, they were supposed to stay with the resident and notify the Maintenance Director, DON, and Administrator about the broken window. He said failure to stay with the resident and fix the broken window was a potential accident hazard and neglect. The Administrator said the issue was also discussed at the QAPI meeting held with facility administration.The Administrator and DON were informed the Immediate Jeopardy was removed on 07/18/25 at 2:15 PM. On 07/17/25 at 4:55 PM, an IJ was identified. While the IJ was removed on 07/18/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.2. Record review of Resident #2's admission MDS assessment, dated 06/16/25, revealed the resident was a [AGE] year-old male admitted on [DATE]. His BIMS score was 3 indicating his cognitive ability was severely impaired. His diagnoses included metabolic encephalopathy (brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss, and altered consciousness) and delirium (a serious change in mental abilities. It results in confused thinking and a lack of awareness of someone's surroundings). The resident required set-up assistance for ambulating. Record review of Resident #2's Care Plan, not dated, reflected:The resident was at risk for wanderingFacility interventions included:If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc.Record review of Resident #2's elopement assessment, dated 06/06/25, reflected the resident was severely impaired and verbalized the desire to leave the facility after his elopement on 06/05/25. The resident ambulated independently and was a new admission to the facility. Record review of Resident #2's incident report, dated 06/05/25, and completed by the DON, reflected:Resident removed plexi-glass next to exit door at the back of the unit and left facility. Police saw the resident walk down the street near the facility and brought him back. The police said they spoke to the resident and assumed that he had psychiatric issues. The police returned him to the facility. The resident was unharmed and was immediately placed on 1:1 monitoring.Record review of Resident #2's Provider Investigation Report, dated 06/05/25, reflected: Resident left facility by pushing out a window next to the exit at the back of the building. Last seen in hallway at about 8:30 PM by charge nurse. Returned to facility at 9:45 PM.Skin, trauma, pain and elopement assessments were completed. Assessments were normal. No signs or symptoms of mental or physical distress.Resident put on 1:1 observation. Maintenance repaired window and put up braces so that window could not be pushed out again. Safe surveys obtained. Residents' family, Medical Director, Compliance Nurse, DON, and Administrator contacted.Safe surveys obtained. In-services on elopement, abuse and neglect, resident rights, trauma informed care, and behavior management were given to staff.An observation on 07/17/25 at 10:30 AM revealed Resident #2 was not at the facility. The memory care unit exit doors were locked and there were no windows visible next to the exit doors.An interview on 07/17/25 at 3:15 PM with RN I revealed he had worked at the facility for a year. He said the cameras in the memory Care Unit did not work. He said Resident #2 was admitted on [DATE] between 6:30 PM -7:00 PM. RN I said that he supervised the residents in the memory Care Unit and he saw the resident at about 8:30 PM wandering up and down the halls of the Memory Care Unit. RN I said at 9:15 PM the police arrived with Resident #2. RN I said he was not aware that the resident had eloped from the facility. He said the police told him Resident #2 was found wandering around the neighborhood. RN I said he did not realize that Resident #2 was going to elope. He said when the resident returned, RN I searched the Memory Care Unit to see how the resident eloped. He said he noticed the plexi-glass window next to the back exit door was pushed out. RN I said when the resident returned, they placed him on 1:1 monitoring and did a head count and followed the facility elopement policy. RN I said the resident discharged from the facility on 06/24/25 and was on 1:1 until he discharged . He said Resident #2 did not have any further elopements and no other residents had eloped. RN I said the facility covered the windows next to the exit door with walls.An interview on 07/31/25 at 1:55 PM with CNA K revealed Resident #2 was in the Memory Care Unit when she arrived to work at 6:00 PM on 06/05/25. She said she saw him walking around the unit at 9:15 PM and the police brought him back between 9:45 PM - 10:00 PM. She said the police asked if they were missing anyone. CNA K said she did a head count and realized Resident #2 was not in his room. CNA K stated RN I described him to the police and the police brought him back into the unit. CNA K said they started searching the unit to see how he got out. CNA K said she was checking everything to see how he got past her, and she saw the window next to the back exit door was pushed out. The window was not broken or anything. He just slid out through the opening. She said Resident #2 was being supervised by her and RN I and he was constantly walking around and looking out the windows. He was placed on 1:1 monitoring when he returned to the Memory Care Unit.An interview on 07/17/25 at 2:15 PM with the DON revealed there were no other elopements after Resident #2 on 06/05/25. She said at the time he eloped, he pushed out the plexi-glass window that was next to the exit door, but the staff did not realize he had eloped until the police brought him back. She said RN I saw the resident last at around 8:30 PM.Record Review of Resident #2's 1:1 monitoring from date of elopement to date of discharge revealed he remained on 1:1 observation.Record Review of Resident #2's updated care plan, not dated, reflected:At risk for elopement or has had an actual elopement due to metabolic encephalopathy, and delirium.Resident pushed out plexi-glass on wall and stepped through it.Facility interventions: Resident to remain on 1:1 services until further notice, or until resident discharges from the facility. Window was immediately repaired so others were not at risk for leaving.Review of the facility policy, Elopement Prevention not dated, reflected: Policy StatementEvery effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement.The Elopement Risk Assessment will be completed upon admission. The assessment should be completed by reviewing the resident's medical history and social history. Information may be obtained by reviewing current medical records, if available, interview with resident/family, or conference with the interdisciplinary team member. The assessment tool should be completed, and interventions implemented as indicated. The Elopement Risk Assessment is to be completed at least quarterly and upon change of condition.All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team.The resident's current chart and assessments will be reviewed to determine what changes have occurred that would trigger elopement episodes.The resident's care plan will be modified to indicate the resident is at risk for elopement episodes.Interventions into elopement episodes will be entered onto the resident's care plan and medical record.Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the nurses' notes. Director of Risk Management and\or Director of Nursing Services should be notified of elopement.If a resident is discovered to be missing, a search shall begin immediately. (See policy entitled Elopement Response.)Identify the cause of wanderingWandering may reflect the need to use the bathroom, relieve hunger, thirst, physical discomfort, or desire for exercise.Wandering may be an indication of worsening of confusion secondary to dehydration, infection, congestive heart failure, or medication side effects.Wandering may be in response to uncomfortable temperature, excess stimulation, sensory deprivation, or uncomfortable clothing.The wanderer may be seeking a fulfillment of unmet psychological needs by acting out a habitual routine.The wanderer may be a person who handles stress by being physically active.The wanderer may be simply unable to find his/her room or the bathroom.Intervention StrategiesReduce physical discomfort (e.g., analgesia to reduce pain, more comfortable seating, and scheduled toileting).Use personal items, family photos, or familiar objects to label resident's room clearly.Maintain familiar routines as much as possible.Schedule regular ambulation program or opportunity for exercise.Reduce excess sensory stimulation (sensory overload), decrease noise level and confusion.Use simple, clear language. Tell the resident what you want him/her to do, not what you don't want them to do. (e.g., come with me instead of don't go outside)Approach the resident in non-threatening manner.Do not confront or argue with the resident. Acknowledge the resident's concerns and gently redirect the resident.Follow the resident to see where he/she goes. If the destination is safe, consider use of volunteer companion or family member as a suitable escort.Give resident something to do that makes him/her feel useful (e.g., winding yarn or folding towels).Allow verbalization of feelings.Obtain information from family on pattern of physical activity, daily home routine, style of coping with stress, etc.Environmental ModificationAllow the resident to wander in a safe and secure setting (e.g., closed courtyard or hallway free from obstacles or stairs).Use large signs or pictures to help residents identify his/her room or bathroom.Use full-length mirrors, black doormats, or black tape grid pattern on floor to discourage demented residents from approaching doors.Use signs with large letter stating No/No Entry/Sorry, Door Closed.Use door locks that are out of reach/sight to prevent wanderers from opening doors.Use door alarms or monitoring devices to notify staff when residents try to leave the facility.Consider putting wandering residents on the same unit with a single exit near the nursing station.If applicable, consider the resident for a secured unitStress During AdmissionIdentify barriers to effective communication (e.g., hearing loss, aphasia, language barrier, dysarthria , etc.).Make sure the resident has all prescribed assistive devices (e.g., glasses, hearing aid, dentures, walking aids, etc.).Obtain information from family and friends on the resident's prior behavior, personal preferences, and routines.Determine the resident's need for assistance in mobility (transfers, gait, or wheelchair mobility) and the ability to follow and remember instructions.Consider teaming the new resident with another resident who is comfortable and oriented in the facility (i.e., the buddy system).Interventions to Reduce StressWhenever possible, maintain the resident's familiar routine.Adjust bedroom and bathroom to resident's functional capacity.Use personal items, photographs and familiar objects from home, to make the new environment less strange.Encourage visits by the family members and friends.Orient the resident to the daily routine.Allow the resident to participate as much as possible in daily decision making.Allow time for new information to be absorbed.Acclimate resident to the new environment.Provide reassurance and support. Physical PlantAll facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts. Examples of these devices:Wanderguard System (locking or alarming)Placement of the residents' device to alarm the system will be verified each shift and documented on a treatment or other flow record.Function of the resident's device will be verified at least daily and documented on a treatment of other flow record.Function of the alarm system will be verified each week and documented in a maintenance log. Keypad exit magnetic locksKeyed AlarmsSecured UnitOr a combination of the aboveAll other exits not considered fire exits will be locked when not occupied by staff members.All exit devices will be maintained by the manufacturer's recommendations and function of each door device will be verified weekly and a log maintained.Staff TrainingStaff will receive training during their orientation process and then annually regarding: Elopement prevention Operation of all exit devices Actions to take if elopement occursThis was determined to be an IJ on 07/31/25. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 07/31/25 at 11:55 AM.The Plan of Removal was accepted at 10:28 AM on 08/01/25 and reflected the following:Plan of RemovalProblem: Elopement InterventionsResident #2 was immediately assessed and placed on 1:1 supervision until discharged from the facility on 6/24/25.All windows on the secured unit were inspected and repaired by the maintenance director. Completed on 7/17/25All exit doors in the facility were checked by the Maintenance Director and Administrator for proper alarming and functioning. No issues were identified. Completed on 6/5/25.Elopement risk assessments for all residents in the facility were completed and reviewed by the DON/ADON/Regional Compliance Nurse on 6/6/25. Completed on 6/6/25.All residents that were determined high risk for elopement based on the assessments had their care plans reviewed and updated by DON, Regional Compliance Nurse and ADON for appropriate interventions to prevent elopement. Care plans will be reviewed and updated upon admission, quarterly, and as needed by the DON, ADON or MDS Nurse. Completed on 6/6/25.The Charge Nurse on shift will be responsible for completing elopement risk assessments on all residents upon admission, quarterly, and residents who demonstrate exit seeking behavior or verbally express the desire to elope from the facility. The resident will be placed on 1:1 supervision as delegated by the charge nurse. The charge nurse or designee will notify the administrator or DON immediately for further guidance on appropriate interventions to ensure the safety of the residents. The resident's care plan will be reviewed and updated with the appropriate interventions. Completed on 6/6/2025 and will continue indefinitely.Elopement Risk Assessments for all new admissions, quarterly assessments, and residents who demonstrate exit seeking behavior or verbally express the desire to elope from the facility will be reviewed by the Interdisciplinary Team daily during the morning clinical meeting to ensure that appropriate supervision and interventions were implemented. The administrator and DON will be responsible for ensuring that any late and/or incomplete assessments are completed immediately after the meeting. Completed on 6/6/2025 and will continue indefinitely.New Process: If there is a window or any area in the facility that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, DON or ADON will be notified immediately by the charge nurse or designee. If repairs cannot be completed immediately by the maintenance director, interventions specific to the hazard will be implemented to ensure the safety of the residents. The administrator will contact the Area Director of Operations to assist in hiring any third-party contractors to complete repairs immediately or as soon as possible. Completed on 7/17/25 and will continue indefinitelyThe Regional Compliance Nurse in-serviced the DON and Administrator 1:1 on the following policies below. Completed on 7/17/25.Abuse and Neglect: failure to repair a broken window immediately could result in a missing resident, neglect, and be a potential safety hazard to staff and residents.Elopement Prevention and Response Policies: to include properly functioning windows and doors to prevent residents from eloping or harm.Behavior Management Policy: a resident who is exit seeking or expressing a desire to elope will remain on 1:1 supervision until the Administrator or DON is notified to give further guidance to ensure the safety of the resident.New Process: If there is a window or any area in the facility that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, DON or ADON will be notified immediately by the charge nurse or designee. If repairs cannot be completed immediately by the maintenance director, interventions specific to the hazard will be implemented to ensure the safety of the residents. The administrator will contact the Area Director of Operations to assist in hiring any third-party contractors to complete repairs immediately or as soon as possible.The Medical Director was notified of the immediate jeopardy citation on 7/31/25 by

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and that the resident's environment remained as free of accident hazards as possible for one (Resident #1) of five residents reviewed for elopement on the facility's secured unit. The facility failed to adequately supervise, monitor, and implement interventions to prevent Resident #1 (who was assessed with severe cognitive impairment and as being at risk for elopement) from eloping from the facility unsupervised on [DATE] where he remained unaccounted for overnight. The resident was located on [DATE], 2.6 miles from the facility. The facility failed to ensure the door to the secure unit was properly functioning as the door did not fully close and/or lock consistently. On [DATE] at 5:25 p.m. an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for injury and/or death from elopement-related harm, including vehicular accidents, falls, missing medications, and extreme weather exposure. Findings included: Review of Resident #1's active physician orders dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cocaine abuse, intracerebral hemorrhage (type of stroke, interruption of blood flow to a part of the brain either by a blockage or rupture of a blood vessel) and encephalopathy (encephalopathy-a group of conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes, and/or coma in the most severe form). Review of Resident #1's quarterly MDS assessment, dated [DATE], revealed he was ambulatory without the use of a device, required supervision and/or physical assistance with hygiene, dressing, and toileting. The MDS assessment reflected the resident's BIMS score was a 3 indicating severe cognitive impairment. Review of Resident #1's care plan with a review date of [DATE] revealed the resident's risk for elopement due to poor safety awareness was addressed. Goals included the resident would not leave the facility or the property unattended. The only intervention was to house the resident on the secured unit for safety. The care plan addressed the resident's elopement on [DATE] but did not include any additional interventions. Review of Resident #1's current Elopement Risk Assessments dated [DATE] and [DATE] reflected the resident had been assessed to be at risk for elopement. Observation on [DATE] at 11:20 a.m. of the secured unit entrance door located on Hall 200 revealed no code was required for entry. Entrance only required pressing the crash bar on the door. A code was required to exit and there was no alarm on the door. In an interview on [DATE] at 2:45 p.m. the Administrator stated Resident #1 exited the secured unit and eloped from the facility on the evening of [DATE]. She stated she was notified at approximately 10:00 p.m. on [DATE] that the resident was missing. The police were notified, and staff searched inside, outside the facility, and the surrounding neighborhood. The search continued through the morning of [DATE] and the resident was located at approximately 11:00 a.m. on [DATE], 2.6 miles from the facility. Resident #1 was assessed and evaluated at the hospital without injury. The Administrator stated the resident possibly exited the secured unit as staff were entering or leaving the unit without closing the door. The Administrator stated the crash bar on the door to the secured unit that leads to Hall 200 had been previously checked and according to the installer the door was functioning properly. She further stated staff had to make sure the door closed and locked when exiting and entering the secured unit. In an interview on [DATE] at 3:30 p.m. LVN A stated he was the charge nurse on duty during the evening shift on [DATE] when Resident #1 eloped from the facility. He stated he last saw the resident at approximately 6:30 p.m. sitting in the secured unit dining room. LVN A stated he went to pass medications to residents residing outside the secured unit on Hall 200 at approximately 6:00 p.m. After he completed his medication pass, he went outside for a 15-minute break and returned to the unit. He stated at the time he took his break he could not say who remained on the secured unit to supervise the residents. He stated when he heard the alarm (unable to recall what time) he did not know what the sound was and was not going to leave the residents on the unit as the evening CNA (CNA G) was late and had not arrived yet. When the evening CNA arrived (unable to recall what time) she told him the alarm was a door alarm. He confirmed he did not go check to see what door was alarming but provided no explanation when asked why he did not go check. LVN A stated he noticed Resident #1 was missing sometime around 8:00 p.m. or 9:00 p.m. The staff searched the inside and outside of the facility. After staff were unable to locate Resident #1, he called the code for missing resident (code purple) and notified the DON. All staff began searching all areas in the facility. LVN A stated while he was providing care on Hall 200 outside the secured unit it was possible that someone could have entered and/or exited the unit and not ensured the door fully closed and locked. He further stated there was no issue with the secured unit door when exiting, but when entering the secured unit from Hall 200 there was a problem with the crash bar and the door did not always automatically close or lock. He stated everyone in the facility was aware of the problem with the door to include administrative staff. LVN A stated there should always be someone on the secured unit at all times, but he had to take care of residents on Hall 200. In an interview on [DATE] at 10:18 a.m. LVN B stated she had worked at the facility since 01/2024 and the door to the secured unit had always had problems of not closing and locking. She stated at times the door would close and lock and at times it would not. LVN A stated staff had to be sure to physically close the door and ensure it locked. LVN A stated two men had repaired the door earlier in the day. Observation on [DATE] at 10:26 a.m. a visitor entered the secured unit to speak with the charge nurse (LVN B). When the visitor exited the door, the door remained ajar and unlocked. The nurse immediately closed the door and the lock engaged. Observation revealed the door was still not functioning properly. Observation on [DATE] at 10:29 a.m. the DON entered the secured unit to speak with the charge nurse, LVN B. The DON left the unit without the nurse reporting that the door was still not functioning properly. In an interview on [DATE] at 10:33 a.m. LVN C was queried about how long the door to the secured unit had not been closing and locking. She stated the door had not closed and locked properly since it had been installed last year. She stated all staff were aware of the problem with the door and had reported the problem to the Administrator. LVN C further stated the Administrator told staff to always check to ensure the door closed and locked. In an interview on [DATE] at 10:38 a.m. LVN E, the charge nurse for Hall 100, stated she occasionally worked the secured unit. She was aware that sometimes the door to enter the secured unit from Hall 200 would not always fully close or lock. She stated she made sure to check the door when entering/exiting and pulled or pushed the door to ensure it closed all the way. She stated she never reported the problem with the door to the administrative staff but had informed the unit charge nurses in the past. LVN E was unable to recall when or what charge nurse she reported the problem to. In an interview on [DATE] at 10:45 a.m. CNA D stated she had worked at the facility for four days. She stated she was told by facility staff to check to ensure the door to the secured unit closed and locked. She stated she noticed the door would at times bounce back and not fully close or lock. She further stated she did not report the door because all staff seemed to be aware and had told her about the door. Review of staff training records dated [DATE] and [DATE] provided by the Administrator on [DATE]. The records reflected staff received training related to the facility's elopement policy/procedure to include what to do when a resident was missing, observed attempting to leave the facility, and what to do when a missing resident returned to the facility. The training addressed reporting, assessments, and care planning for elopement risk. Review of staff training records dated [DATE] and an undated training record revealed staff received training related to the secure unit doors remaining closed and locked at all times. Training records dated [DATE] reflected topics included the secured unit, but no information related to what was included in the training. Review of training records dated [DATE], [DATE], and [DATE] revealed the procedure for responding to door alarms was addressed. In an interview on [DATE] at 11:54 a.m. the Administrator stated she had no in-service training related to the secure unit door not closing or locking consistently. She stated she had not been informed of any problems with the door. She further stated the facility's contractor was last in the building [DATE] and he had checked several things in the facility including the door to the secured unit and it was Ok. When queried about why the contractor had checked the secured unit door, she stated the contractor was in the facility to conduct warranty checks and randomly checked other things in the facility. The Administrator stated she made rounds in the facility and had never seen any problems with the door. In an interview with the Environmental/Maintenance Supervisor on [DATE] at 12:04 p.m. revealed he had worked at the facility for approximately one month. He stated the facility's contractor visited the facility in [DATE], adjusted the latch and the tension of the closer on the secured unit door to help the door close and lock. He stated in the past several nurses and CNAs had reported to him that the door did not always close and lock properly. He stated he reported the issue to the Administrator, and the Administrator contacted the contractor. He stated there had been no other reports related to problems with the door and he had not seen any problems with the door. Review of current maintenance logs revealed they were dated from [DATE] to [DATE]. There was nothing listed in the logs related to the secured unit door. In an interview with the Environmental/Maintenance Supervisor on [DATE] at 12:28 p.m. revealed there were no additional maintenance logs other than what was provided ([DATE]-[DATE]). He stated he performed no routine checks of the secured unit doors. He only made note of issues when he saw an issue on the secured unit. In an interview on [DATE] at 12:32 p.m. CNA F stated she was on duty during the evening of [DATE] when Resident #1 eloped. She stated she was assigned to Hall 200 and arrived to work at approximately 6:30 p.m. When she entered the facility through the side door on Hall 100, she could hear an alarm sounding very low. When she entered the secured unit, the sound was louder but did not last long so she thought someone must had turned the alarm off. The charge nurse was at the desk (LVN A) on the secured unit, and she proceeded to take residents out to the patio for their 15-miunte smoke break. She stated alarms sounded in the facility often at random times. When queried about checking on the alarm she stated she thought the charge nurse (LVN A) would check on the alarm. She stated staff had reported to the charge nurses and to the Administrator multiple times that the door to the secured unit did not always close or lock and the door had been that way since she began working at the facility one year ago. CNA F further stated there were times when visitors and other residents entered the secured unit without checking to ensure the door closed and locked behind them. Observation rounds on the secured unit with Region 3 LSC Program Manager revealed the following: At 12:45 p.m. when the crash bar on the secured unit door was pushed the door opened, closed, and locked without difficulty. At 12:56 p.m. facility staff were entering and exiting the secured unit. Staff physically pushed and pulled with force to ensure the door closed and the lock engaged behind them. On [DATE] at 1:05 p.m. the LSC Program Manager informed the Administrator that the door to the secured unit should close and lock all the time and staff should not have to turn around and physically close the door. In an interview on [DATE] at 3:00 p.m. CNA G stated she worked the evening shift on [DATE] when Resident #1 eloped. She stated she had worked at the facility for one week and [DATE] was the first time she had worked on the secured unit. CNA G stated she arrived to work late at approximately 8:00 p.m. and was informed by staff that Resident #1 had possibly eloped. Staff searched all over the facility to include inside and outside. She stated some staff drove around in their cars searching for the resident. During the evening of [DATE] she saw one of the residents on the secured unit going towards the secured unit door and noticed the door was partially open. She stated she redirected the resident and closed the door. She stated she phoned the Maintenance Supervisor, told him about the door and he came to the facility. The Maintenance Director told her he had to contact the company that installed the door. She did not know how long the door had not been closing and locking. In an interview on [DATE] at 3:19 p.m. CNA H stated she had worked at the facility for three days and the only time she had worked on the secured unit was during the day shift (6:00 a.m. to 6:00 p.m.) on [DATE]. She stated she left the faciity on [DATE] at approximately 6:02 p.m. and Resident #1 was sitting in the day area. She further stated no one was on the unit with the residents when she left but as she was leaving the charge nurse (LVN A) was coming inside the facility through the front door. CNA H further stated the door to the secured unit did not always close and lock. She never reported the problem with the door to anyone because all staff were aware and had told her about the door. When queried about leaving the residents on the unit unsupervised, CNA H stated she did not feel comfortable but had to leave. She stated if she had not seen the nurse coming inside, she would have gone back to the unit. CNA H stated she did not know if the nurse went directly back to the unit. In an interview on [DATE] at 3:58 p.m. Staff I stated she was the OTA and had worked in the facility since February 2024. She stated she was working in the therapy gym on the evening of [DATE] when Resident #1 eloped. She stated she heard the door alarm sounding sometime after 6:30 p.m. but before 7:15 p.m. and the alarm had been sounding for approximately 15-20 minutes. She stated she was busy at the time but as soon as she could she went to the side door near the therapy gym where the door alarm was sounding but did not see anyone. Staff I stated she went outside, looked around but still did not see anyone. When she came inside, she saw Resident #2 in the hallway and the resident told her he saw a tall man leaving out of the side door and he believed it was a family member. She then went to the secured unit but did not see any staff. Staff I stated she did not call out to anyone but walked down the hall about halfway and did not see any staff on the unit. Staff I stated there had always been problems with the door to the secured unit closing well and she had noticed the door did not always close and lock. She never reported it because she felt administrative staff were aware as facility nurses told her about the door when she stared working at the facility in February 2024. In an interview on [DATE] at 4:15 p.m. Resident #2 stated his room was located on Hall 200 next to the side door where Resident #1 left the facility. He stated the therapy gym was also near the same door. He stated on the night of [DATE] at approximately 7:00 p.m. a tall Black man carrying a bag walked past his room and shortly after the door alarm sounded. He stated he thought the man was a visitor leaving through the wrong door by accident. Resident #2 stated a lady from therapy came out and asked if someone had gone through the door and he told her he thought it was a family member. He stated the alarm sounded for approximately 10-15 minutes before the lady from therapy turned it off. He stated he had been on the secured unit before because that was where his Hall 200 nurse was located. He had observed the door to the unit not always closing and locking. In an interview on [DATE] at 11:58 a.m. the DON stated she had worked at the facility since February 2024, and sometimes if the crash bar on the secured unit door was not hit hard enough it would not close or lock. She stated the problem with the door had existed for at least two months. The DON stated she thought she had reported the problem with the door to the Administrator sometime in [DATE]. The DON further stated the door installer had come out to check the door and he said the door was, Ok. The installer felt staff were not hitting the crash bar hard enough. She stated she had no further concerns related to the door. Staff were aware to check the door to make sure it closed and locked. In an interview on [DATE] at 12:56 p.m. the facility's Medical Director stated he was not familiar with the staffing patterns on the secured unit. When informed that the nurses and CNAs assigned to the secured unit were also assigned residents who resided outside of the unit, he stated it would be best to have one CNA designated for the unit. When queried why this would be better, he stated it would be better so that staff would not have to leave the unit to provide care. Observation on [DATE] at 1:25 p.m. revealed Resident #1 was ambulating on the secured unit speaking unintelligently to staff. In an interview on [DATE] at 1:43 p.m. medical records staff stated he was on duty and working on Hall 100 during the evening of [DATE] when Resident #1 eloped. He stated just before he heard the alarm, he saw two dietary staff going out of the side door on Hall 100 and thought they had caused the alarm to sound. He stated the alarm only sounded for a couple of minutes and someone had to have manually silenced it. In an interview on [DATE] at 6:00 p.m. The DON stated it was important that there were staff on the secured unit at all times. She stated residents on the secured unit did not have the mental capacity to make safe judgements and if no staff were on the unit to supervise the residents the residents would be at risk for harm. The DON stated it was important for the door on the secured unit to close and lock properly to prevent residents from leaving because the locked door was a safety measure put into place to maintain safety of the residents. The DON stated if the secured unit door did not close and lock properly residents could exit, get lost and be harmed. Review of the facility's policy/procedure entitled Wandering Residents/Secure Unit Resident revised [DATE] revealed every effort would be made to prevent wandering episodes while maintaining the least restrictive environment for residents who were at risk for elopement. Interventions would be entered onto the resident's care plan and medical record. The resident would be placed on the secure unit after receiving a physician's order and obtaining consent. The policy/procedure reflected if an elopement incident occurred, contributing factors would be investigated and remedied to prevent a reoccurrence. Review of the facility's policy/procedure entitled Safety and Supervision of Residents revised [DATE] revealed employees would be trained on potential accident hazards, demonstrate competency on how to identify/report accident hazards, and try to prevent avoidable accidents. Resident supervision was listed as the core component of the systems approach to safety. The type and frequency of resident supervision would be determined by the individual resident's assessed needs and identified hazards in the environment. Risk and environmental hazards included unsafe wandering. Review of the facility's undated procedure entitled Door Alarms revealed staff were to go outside and walk around the facility to check for a resident if an alarm sounded. If no resident was located outside, the charge nurse was to be notified that an alarm was going off and the outside had been checked. The charge nurse should complete a total head count of residents. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:25 p.m. The Administrator was informed of an IJ in the area of accidents/supervision and was provided with the IJ template via email on [DATE] at 5:28 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 1:25 p.m.: On [DATE] Elopement Risk Assessment completed for each resident in the facility, All residents identified to be at risk for elopement orders have been verified and secure unit placement confirmed. To remedy concerns regarding resident elopement at the facility implemented the following changes, 1. In-service for all staff initiated by the Administrator on [DATE] to educate staff on proper response to ensure resident safety when facility door alarm sounds. 2. Staff who have not signed in-service will be contacted and are not allowed to work until signatures and education is complete. 3. Administrator and Maintenance Supervisor met at facility on [DATE] after notification of missing resident. Each door was checked and worked as intended. 4. Facility implemented Policy and Procedure with specific staff instructions on guidance for Elopement Procedure if Alarm Sounds or it is identified we have a missing resident. 5. Administrator and RDO checked the following exit doors on [DATE] to ensure proper functioning of door alarm, mag lock, code alert or keypad, and push bar on Secure Unit Doors on 200, Hall Large Dining Room, and 200 Hall Secure Unit Entrance will be replaced. 6. Secure Unit Doors for 200 Hall Large Dining Room and 200 Hall Secure Unit will be continuously monitored by staff until push bars are replaced. The facility is anticipating arrival of new push bars on [DATE] in the late afternoon. Plan is to have the new push bars installed [DATE]. 7. The DON completed a head count of all secure unit residents on [DATE] at 5:40 and all residents were accounted for. 8. A new order was added [DATE] for all residents on the Secure Unit which will require visual checks along with documentation that every resident is present and accounted for on Secure Unit. The facility Medical Director was notified on [DATE]st of facility action plan and to offer any suggestions. This plan was implemented [DATE]. This action plan will be monitored through personal observation by the Administrator and verbal reports to the Regional Director of Operations. Review of in-service training material and logs dated [DATE] and [DATE] revealed education included the facility's elopement policy/procedure, maintenance logs, door alarm response procedures, and that there should be staff on the secured unit at all times. Staff were provided training related to visual checks of residents on the secured unit and new orders for all residents on the secure to document residents were present and accounted for each shift. Interviews were conducted with facility staff from various shifts on [DATE] from 5:00 p.m. to 5:45 p.m. Staff interviewed were LVN B, LVN C, CNA J, CNA K, LVN L, CNA M, LVN N, dietary aide O, and the Dietary Manager. Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on responding to all alarms to ensure resident safety, how to check the panel on the halls to determine what door alarm was sounding, conducting a resident head count, full searches inside/outside of the facility, and ensuring they searched each side of the building outside. Nurses were aware that all residents on the secured unit had new physician orders to check and ensure the residents were accounted for each shift. Staff verbalized understanding that both the CNA and nurse could not be off the secured unit at the same time under any circumstance to ensure residents were being supervised at all times. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 6:20 p.m. The facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 11 of 11 residents (Resident #1, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12) residing on the secured unit. 1. The facility failed to assign designated staff for the secured unit, frequently leaving Resident #1, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 who were all cognitively impaired and at risk for elopement, unattended for indeterminate amounts of time when assigned staff provided care to residents in other parts of the building. 2. The facility failed to ensure staff was available to supervise residents on the secured unit when Resident #1 eloped from the facility on 04/30/24. On 05/02/24 at 10:51 a.m. an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on 05/02/24, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk of inadequate supervision, an unsafe environment, falls, serious harm, injury, abuse, and death. Findings included: 1. Review of Resident #1's active physician orders dated 05/2024 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included cocaine abuse, intracerebral hemorrhage (type of stroke, interruption of blood flow to a part of the brain either by a blockage or rupture of a blood vessel), and encephalopathy (encephalopathy-a group of conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe form). Review of Resident #1's quarterly MDS assessment, dated 03/12/24, revealed the resident's BIMS score was 3 indicating severe cognitive impairment. Review of Resident #1's care plan dated reviewed 04/30/24 revealed the resident's risk for elopement due to poor safety awareness was addressed. Goals included the resident would not leave the facility or the property unattended. The only intervention was to house the resident on the secured unit for safety. The care plan addressed the resident's elopement on 04/29/24 but did not include any additional interventions. Review of Resident #1's current Elopement Risk Assessments dated 10/26/24 and 04/30/24 reflected the resident had been assessed to be at risk for elopement. Observation on 05/02/24 at 1:25 p.m. revealed Resident #1 was ambulating on the secured unit speaking unintelligently to staff. 2. Review of Resident #3's undated admission Record revealed the resident was an [AGE] year-old male with admission dates of 05/01/23 and 04/15/24. His diagnoses included Alzheimer's disease. Resident #3's current MDS assessment dated [DATE] reflected a BIMS score of 8 indicating moderately impaired cognition. Review of Resident #3's care plan revised 04/30/24 revealed the resident's risk for elopement was addressed. Goals included the resident not leaving the facility or the property unattended. The only intervention was to house the resident on the secured unit. Review of Resident #3's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. 3. Review of Resident #4's undated admission Record revealed the resident was a [AGE] year-old male with an admission date of 04/24/24. His diagnoses included dementia (a progressive or persistent loss of intellectual functioning). Resident #4's current MDS assessment dated [DATE] reflected a BIMS score of 2 indicating severe cognitive impairment. Review of Resident #4's care plan revised 04/30/24 revealed the resident's risk for elopement due to poor safety awareness was addressed. Goals included the resident not leaving the facility or the property unattended. The only intervention was to house the resident on the secured unit. Review of Resident #4's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. Observation on 05/02/24 at 2:06 p.m. Resident #4 was ambulating on the secured unit, assisted to the bathroom by CNA M, and much encouragement was required. The CNA stated the resident was incontinent at times. 4. Review of Resident #5's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included traumatic brain injury (happens when a sudden, external, physical assault damages the brain). Resident #5's current MDS assessment dated [DATE] reflected cognitive skills for daily decision making were severely impaired. Review of Resident 5's care plan revised 05/02/24 revealed the resident's risk for elopement due to poor safety awareness was addressed. Goals included maintaining the resident's safety and interventions included housing the resident on the secured unit. Review of Resident #5's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. Observation on 05/02/24 at 2:22 p.m. Resident #5 was resting in bed and noted to be incontinent of urine. 5. Review of Resident #6's undated admission Record revealed the resident was a [AGE] year-old female with admission dates of 02/13/24 and 02/21/24. Her diagnoses included Alzheimer's disease. Resident #6's current MDS assessment dated [DATE] reflected a BIMS score of 2 indicating severe cognitive impairment. Review of Resident 6's care plan revised 04/30/24 revealed the resident's risk for elopement due to poor safety awareness was addressed. Goals included the resident not leaving the facility or the property unattended. The only intervention was to house the resident on the secured unit. Review of Resident #6's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. Observation on 05/02/24 at 2:10 p.m. Resident #6 was ambulating on the secured unit. The resident had experienced an incontinent episode and was combative and resistant to care. 6. Review of Resident #7's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia. Resident #7's MDS assessment dated [DATE] reflected the resident's cognitive skills for daily decision making were modified independence. Review of Resident 7's care plan revised 04/30/24 revealed the resident's risk for elopement was addressed. Goals included the resident not leaving the facility or property unattended. The only intervention was to house the resident on the secured unit. Review of Resident #7's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. 7. Review of Resident #8's undated admission Assessment revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia. Resident #8's current MDS assessment, dated 03/08/24, reflected the resident's BIMS score was 1 indicating severe cognitive impairment. Review of Resident 8's care plan revised 04/30/24 revealed the resident's risk for elopement due to poor safety awareness was addressed. Goals included the resident not leaving the facility or the property unattended. Interventions included the resident was housed on the secured unit for safety. An intervention dated 05/02/24 was that the resident would be present and accounted for on the secured unit. Review of Resident #8's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. 8. Review of Resident #9's undated admission Record revealed the resident was an [AGE] year-old male with an admission date of 02/14/24. His diagnoses included dementia. Resident #9's current MDS assessment dated [DATE] reflected the resident's cognitive skills for daily decision making were moderately impaired. Review of Resident #9's care plan revised 03/12/24 revealed the resident's risk for elopement was addressed. The goal was that the resident would not leave the facility or property unattended. The only intervention was to house the resident on the secured unit. Review of Resident #9's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. 9. Review of Resident #10's undated admission Record revealed the resident was a [AGE] year-old male with admission dates of 11/10/23 and 02/07/24. His diagnoses included encephalopathy. Resident #10's current MDS assessment dated [DATE] reflected a BIMS score of 9 indicating moderately impaired cognition. Review of Resident #10's care plan revised 04/30/24 revealed the resident's risk for elopement was addressed. The goal was that the resident would not leave the facility or property unattended. The only intervention was to house the resident on the secured unit. Review of Resident #10's current Elopement Risk assessment dated [DATE] revealed the resident had been assessed to be at risk for elopement. 10. Review of Resident #11's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease and dementia. Resident #11's current MDS assessment, dated 04/12/24, reflected the resident's BIMS score was 2 indicating severe cognitive impairment. Review of Resident #11's care plan revised 05/19/23 revealed the resident's risk for elopement due to poor safety awareness was addressed. Goals included the resident not leaving the facility or the property unattended. The only intervention was to house the resident on the secured unit for safety. Review of Resident #11's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. 11. Review of Resident #12's undated admission Record revealed the resident was a [AGE] year-old female with admission dates of 11/29/23 and 06/24/23. Her diagnoses included dementia. Resident #12's current MDS assessment dated [DATE] reflected a BIMS score of 2 indicating severe cognitive impairment. Review of Resident #12's care plan revised 04/30/24 revealed the resident's risk for elopement was addressed. Goals included the resident not leaving the facility or the property unattended. The only intervention was to house the resident on the secured unit. Review of Resident #12's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. Observation on 04/30/24 at 11:20 a.m. of the secured unit entrance door located on Hall 200 revealed no code was required for entry. Entrance only required pressing the crash bar on the door. A code was required to exit and there was no alarm on the door. There was one nurse and one CNA working on the unit. In an interview on 04/30/24 at 11:20 a.m. LVN B stated there was one nurse assigned to the secured unit and one CNA. She stated she was also assigned to Hall 200 directly outside the unit and the CNA was assigned to additional residents on Hall 100 outside the unit. LVN B further stated when she left the unit to provide care on Hall 200 the CNA stayed on the unit to monitor the residents. In an interview on 04/30/24 at 2:45 p.m. the Administrator stated Resident #1 exited the secured unit and eloped from the facility on the evening of 04/29/24. She stated she was notified at approximately 10:00 p.m. on 04/29/24 that the resident was missing. The police were notified, and staff searched inside, outside the facility, and the surrounding neighborhood. The search continued through the morning of 04/30/24 and the resident was located at approximately 11:00 a.m. on 04/30/24, 2.6 miles from the facility. Resident #1 was assessed and evaluated at the hospital without injury. In an interview on 04/30/24 at 3:30 p.m. LVN A stated he was the charge nurse on duty during the evening shift on 04/29/24 when Resident #1 eloped from the facility. He stated he last saw the resident at approximately 6:30 p.m. sitting in the secured unit dining room. LVN A stated he went to pass medications to residents residing outside the secured unit on Hall 200 at approximately 6:00 p.m. After he completed his medication pass, he went outside for a 15-minute break and returned to the unit. He stated at the time he took his break he could not say who remained on the secured unit to supervise the residents. LVN A stated he noticed Resident #1 was missing sometime around 8:00 p.m. or 9:00 p.m. The staff searched the inside and outside of the facility. After staff were unable to locate Resident #1, he called the code for missing resident (code purple) and notified the DON. All staff began searching all areas in the facility. LVN A stated while he was providing care on Hall 200 outside the secured unit it was possible that someone could have entered and/or exited the unit and not ensured the door fully closed and locked. LVN A stated there should always be someone on the secured unit at all times, but he had to take care of residents on Hall 200. He stated staffing on the secured unit was always one nurse and one CNA as it was on 04/29/24 . In an interview on 05/01/24 at 12:32 p.m. CNA F stated CNAs assigned to the secured unit were also assigned to provide care to residents residing outside the unit on Hall 100. She stated staff have been asking for an extra person so that the CNA assigned to the unit could remain on the secured unit. She stated, usually the nurse, or the CNA would stay on the unit while the other provided care for their assigned residents residing outside the unit. She stated it was not always possible for there to be at least one staff on the unit at all times. She stated the CNA that worked the secured unit also took care of residents on the bottom section of Hall 100. CNA F further stated after Resident #1's elopement on 04/29/24 the assignment had changed to one CNA assigned and designated to work only on the secured unit. In an interview on 05/01/24 at 3:19 p.m. CNA H stated she had worked at the facility for three days and the only time she had worked on the secured unit was during the day shift (6:00 a.m. to 6:00 p.m.) on 04/29/24. She stated she left the faciity on [DATE] at approximately 6:02 p.m. and Resident #1 was sitting in the day area. She further stated no one was on the unit with the residents when she left but as she was leaving the charge nurse (LVN A) was coming inside the facility through the front door. CNA H when queried about leaving the residents on the unit unsupervised, CNA H stated she did not feel comfortable, but she had to leave. She stated if she had not seen the nurse returning inside the facility, she would have gone back to the unit. CNA H stated she did not know if the nurse went directly back to the unit when she saw him entering the facility. In an interview on 05/01/24 at 3:35 p.m. the Administrator stated facility staffing patterns for all shifts on the secured unit were one nurse who was also the charge nurse for Hall 200. There was one CNA who worked the secured unit and the bottom half of Hall 100. She stated the staffing pattern for the secured unit had changed since Resident #1's elopement on 04/29/24. The new staffing pattern implemented for the secured unit was that one CNA assigned would be solely designated to the unit. The Administrator further stated during a staff meeting today (05/01/24) she had reiterated the importance of there being at least one staff on the secured unit at all times for resident safety . Training records dated 09/28/22 reflected topics included the secured unit, but no information related to what was included in the training. In an interview on 05/02/24 at 11:58 a.m. the DON stated her expectation was that there should be a staff member on the secured unit at all times. The staff on the secured unit should work as a team and cover for each other when one has to leave the unit. The DON further stated staff should make alternate rounds to ensure one staff was present on the unit at all times. Her expectations included nurses making walking rounds when they arrive to work and before they leave. The DON stated there was no documented evidence, but she had verbally informed all staff of her expectations. In an interview on 05/02/24 at 12:56 p.m. the facility's Medical Director stated he was not familiar with the staffing patterns on the secured unit. When informed that the nurses and CNAs assigned to the secured unit were also assigned residents who resided outside of the unit, he stated it would be best to have one CNA designated for the unit. When queried why this would be better, he stated it would be better so that staff would not have to leave the unit to provide care . In an interview on 05/02/24 at 6:00 p.m. the DON stated it was important that there was staff on the secured unit at all times. She stated residents on the secured unit did not have the mental capacity to make safe judgements and if no staff were on the unit to supervise the residents the residents would be at risk for harm. Review of the facility's Assessment Tool dated 06/19/23 revealed staffing on the secured unit was not listed. Review of the facility's policy/procedure entitled Staffing dated revised 10/2017, revealed the facility's policy statement reflected the facility would provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. This was determined to be an Immediate Jeopardy (IJ) on 05/02/24 at 10:51 a.m. The Administrator was informed of an IJ in the area of sufficient staffing and the IJ template via email at 11:12 a.m. The following Plan of Removal submitted by the facility was accepted on 05/02/24 at 4:31 p.m. and reflected: On 5/2/24, the Administrator initiated in-service for all Nursing Staff that there must be a Nursing Employee (RN, LVN, or Aide) on the Secure Unit at all times. On 5/2/24 the DON changed aide assignments to ensure there is 1 Aide Staffed in the Unit at all times. On 5/2/24 the DON initiated in-service with all aides regarding new assignment that an aide must remain on Secure Unit at all times. To remedy concerns regarding Secure Unit Staffing at [facility name] the facility implemented the following changes, 1. Nursing staff who have not signed in-services will be contacted and are not allowed to work until completed 2. Administrator to monitor schedule on a daily basis during facility IDT (Interdisciplinary Team) Meeting to ensure aide is assigned at all times on Secure Unit. The facility Medical Director [physician name] was notified on May 2nd of facility action plan and to offer any suggestions. This plan was implemented May 2,2024. This action plan will be monitored through personal observation by the Administrator and verbal reports to the RDO. Review of in-service training material and logs dated 04/29/24 and 05/01/24 revealed education included the facility's elopement policy/procedure, dedicated staff assigned to the unit, coordination between the nurse and CNA to ensure there would be staff on the secured unit at all times to supervise residents. Interviews were conducted with facility staff on 05/02/24 from 5:00 p.m. to 5:45 p.m. Staff interviewed were LVN B, LVN C, CNA J, CNA K, LVN L, CNA M, LVN N, dietary aide O, and the Dietary Manager . Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on new physician orders to check and ensure and document residents on the secured unit were accounted for each shift. Staff verbalized understanding that both the CNA and nurse could not be off the secured unit at the same time under any circumstance to ensure residents were being supervised at all times. The Administrator was notified on 05/02/24 at 6:20 p.m. that the Immediate Jeopardy was removed. However, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.