**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 assistance devices to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision of Resident #1 who was newly admitted to the facility on [DATE] around 2:00 PM and exhibiting signs of confusion. Resident #1 then eloped from the facility approximately 4 (four) hours later between 6:15 PM and 6:35 PM and was picked up by a Community Member and transported to the local police department. Staff were unaware of Resident #1's elopement when the facility was notified by the police department via telephone on 08/04/25 at approximately 6:50 PM that the resident had been brought to the police station. The noncompliance was identified as PNC. The IJ began on 08/04/25 and ended on 08/08/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of harm, serious injury or death.Record review of Resident #1's face sheet, dated 08/14/25 revealed Resident #1 was admitted to the facility on [DATE] with the following diagnoses: dementia (progressive decline in cognitive functions), cerebral infarction (death of brain tissue due to lack of blood supply), chronic kidney disease, major depressive disorder (persistent feelings of sadness and loss of interest that can significantly impact daily life), hypertension (high blood pressure), and atrial fibrillation (irregular heart rhythm). Record review of the Nursing admission Assessment, authored by LVN B on 08/04/25 at 5:15 PM, revealed Resident #1 was alert and disoriented. Resident #1 was confused due to dementia and exhibited both short-term and long-term memory problems. Nursing admission Assessment further revealed Resident #1 was independently ambulatory, had no mobility limitation, and had no verbal expressions to leave facility. Record review of the Wandering Risk Scale, initiated on 08/04/25 at 2:59 PM and completed on 08/05/25, and also completed 72 hours after admission on [DATE], revealed:Resident #1's admission Wandering Risk score was 18, indicating the resident was above high risk to wander.Resident #1's 72-hour Wandering Risk score was 18, indicating the resident was above high risk to wander. Record review of the Elopement note, authored by LVN B on 08/04/25 at 6:50 PM, revealed: Incident Description: Resident was found wandering down the street from the facility. The resident was picked up by a concerned citizen and taken to the police department. The police department called the facility and informed LVN B of the location of the resident. Police brought the resident back to the facility. The resident was confused and unable to recall the event. The resident was assessed for injury and no injuries were noted. Resident was placed on one-to-one monitoring and notifications were made to ADM, DON, Physician and family. Record review of Resident #1's Baseline Care Plan, dated 08/04/25, revealed the resident was alert and cognitively impaired and used a walker as an assistive device. The Baseline Care Plan further revealed Resident #1 was not an elopement risk. Record review of Resident #1's BIMS score, dated 08/05/25, revealed a score of 0, which indicated the resident's cognition was severely impaired. Record review of the facility's Form 3613-A (Provider Investigation Report), dated 8/05/25, revealed the ADM was notified by LVN B on 08/04/25 at 7:12 PM, of Resident #1's elopement from the facility. Resident #1 had been picked up by a citizen and taken to the police station then escorted back to the facility by police. The resident was assessed and found to have no injuries and did not require medical treatment. A police report was not filed. Resident #1 was placed on one-to-one supervision upon return to the facility and a wander guard device was placed on Resident #1 on 08/06/25. Door alarms were checked and found to be functioning properly. Staff in-services were initiated for ANE, elopement, door alarms, and monitoring of newly admitted residents. Record review of Resident #1's Discharge MDS, dated [DATE], revealed:Section C - Cognitive Patterns - BIMS revealed a score of 0, which indicated the resident's cognition was severely impaired.Section GG - Functional Abilities revealed resident was able to stand from a sitting position and walk 150 feet independently. Record review of Discharge summary, dated [DATE], revealed Resident #1 was discharged to an alternate long term care facility with belongings on 08/08/25. During an interview on 08/13/25 at 1:30 PM, the ADM stated Resident #1 was admitted to the facility on [DATE] around 2:00 PM and eloped approximately 4 (four) hours later. She stated the resident was picked up approximately 400 meters from the facility by a citizen of the community in a private vehicle and was taken to the local police station. The facility was contacted by the police department and an officer escorted Resident #1 back into the facility. The ADM stated Resident #1 was assessed upon return to the facility and was found to have no injuries and had no recollection of leaving the facility. The ADM stated she was made aware of Resident #1's elopement by LVN B via phone on 08/04/25 at 7:12 PM. She stated upon admission, Resident #1 was cognitively impaired and was independently ambulatory. The ADM stated Resident #1 was observed ambulating with her walker around the facility shortly after admission, but Resident #1 did not exhibit exit-seeking behavior by wandering into other rooms, seeking exit doors or verbalizing desire to leave the facility. The ADM stated LVN B took Resident #1 outside to the smoking area with several other residents around 6:00 PM and the residents and staff re-entered the building approximately 15 minutes later, which was the last time Resident #1 was accounted for prior to the elopement. The ADM stated all exit doors to the facility were locked except the front door which was protected by an access code that was not posted. She stated she believed the resident followed a visitor out the front door between 6:15 PM and 6:35 PM. She stated Resident #1 did not look like a resident due to appearing younger than her age and may have been mistaken for a visitor when she exited the facility. The ADM stated one-to-one supervision was implemented for Resident #1 immediately upon return to the facility and the resident was moved to a room closer to the nurse's station for better observation of the resident. She stated in-services were initiated for staff on 08/04/25 for elopement, responding promptly to door alarms, monitoring of newly admitted residents and ANE. She stated in-services continued on 08/05/25 and were completed during a mandatory in-service on 08/08/25. The ADM stated door alarms were checked by maintenance, and all alarms were functioning. She stated the access code was changed on the door as an extra precaution. She stated elopement drills were conducted as part of the in-services. The ADM stated the tool used by the facility to determine a resident's risk for elopement was the Elopement Risk Assessment, which would be used if the resident exhibited exit-seeking behavior. She stated the Wandering Risk Assessment was part of the admission assessment, which was usually completed within 24 hours of admission. The ADM stated the Wandering Risk Assessment alone would not indicate the need for added supervision, unless the resident showed exit-seeking behavior. She stated if there was a concern of a resident being an elopement risk, her expectation of staff would be to ensure resident safety and immediately report the concern to administration. The ADM stated Resident #1 remained on one-to-one supervision until alternate placement was obtained on 08/08/25 and the resident was transferred, with family consent, to an accepting facility with a secured unit. The ADM stated a letter was mailed to all family members on or around 08/07/25 as a reminder to ensure resident safety when exiting the facility and a notice was posted on the front door to remind visitors not to allow residents to exit the building without a staff member present. During an interview on 08/13/25 at 2:31 PM, LVN A stated she was on duty from 6 AM - 2 PM on the day Resident #1 was admitted to the facility. She stated the resident was admitted just before shift change around 1:45 PM and she completed initial vital signs and passed the admission on to the oncoming charge nurse (LVN B). LVN A stated she only had Resident #1 under her care for a brief time (approximately 15 minutes) and felt that the resident may need to be watched for wandering or exit-seeking behavior due to being self-ambulatory and appearing confused. LVN A stated during the time Resident #1 was under her care, family members were present in the room, and she did not observe the resident exhibiting exit-seeking behavior. LVN A stated she believed the Wandering Risk Assessment, which was included in the admission assessment, was to be completed within 24 hours of admission, but she was unsure of the exact timeframe. LVN A stated when she returned to duty the next day (08/05/25), Resident #1 was on one-to-one supervision and remained under continuous supervision for the duration of the week until being discharged . LVN A stated she did not observe Resident #1 exhibit exit-seeking behavior at any time during her stay at the facility. LVN A stated she was in-serviced on ANE, elopement, door alarms and monitoring of newly admitted residents upon her return to duty on 08/05/25. During an interview on 08/13/25 at 2:50 PM, LVN B stated she worked weekdays from 2 PM - 10 PM and was on duty the day Resident #1 was admitted to the facility. She stated LVN A obtained Resident #1's vital signs and passed the admission process on to LVN B, due to it being shift change. LVN B stated she entered Resident #1's room at approximately 2:45 PM and observed the resident sitting in the room holding a baby doll with family member present in the room. She stated she completed the physical assessment of Resident #1 before beginning medication pass. She stated Resident #1 was observed ambulating in the hallway during the medication pass. LVN B stated the resident looked younger and had good mobility and did not have the appearance of a resident. She stated she spoke with the ADM in the hallway and discussed that Resident #1 looked like a visitor and was ambulating throughout the facility but had not exhibited exit-seeking behavior. She stated Resident #1's tray went to her room and her family member left just prior to the meal being served but did not inform staff he was leaving. She stated after the evening meal, around 6 PM, Resident #1 was still ambulating in the facility, so she took Resident #1 outside with her and another resident to smoke. She stated the residents, and staff re-entered the building approximately 10 - 15 minutes later and Resident #1 was seen ambulating near the nurse's station. LVN B stated she had another admission and went into a room to check on another resident. She stated CNA C was down the hall and had just started her shift (6pm-6am) and should have been told in report by CNA D to check on Resident #1, but she could not say if the information was passed on or not. LVN B stated sometime after 6:30 PM she received a phone call from the local police department that Resident #1 had been brought to the police station and that the resident would be escorted back to the facility by an officer. LVN B stated she immediately notified the ADM, the physician and Resident #1's family member. No new orders were received. Resident #1 was returned to the facility, accompanied by a police officer. LVN B stated she assessed Resident #1, and she was found to have no injuries, and her vital signs were stable. She stated Resident #1 did not recall leaving the facility. Resident #1 was immediately placed on one-to-one supervision and did not show signs of exit-seeking following the elopement. LVN B stated she did not believe that Resident #1 knew where the exit doors were located in the facility, and she did not observe the resident to go to a door or verbalize the desire to leave the facility. LVN B stated she completed an Elopement Risk Assessment when the resident returned to the facility and she completed the admission assessment the following day, which was within 24 hours of admission. LVN B stated Resident #1 was on continuous one-to-one supervision during the duration of her stay and a wander guard device was added once the order and consent were obtained. LVN B stated she was in-serviced on ANE, elopement, door alarms and monitoring of newly admitted residents on 08/04/25. During an interview on 08/13/25 at 5:14 PM, the ADON stated Resident #1 was admitted in the afternoon on 08/04/25. She stated the facility got three admissions that day and she and the DON assisted to enter Resident #1's medications and diagnoses into the computer but she did not personally observe or assess Resident #1 on the day of admission. The ADON stated she was made aware of Resident #1's elopement by the DON via phone call at approximately 7:30 PM on 08/04/25. She stated she was not aware of any staff member having concerns about Resident #1 wandering or being a flight risk. She stated she did not direct staff to implement added supervision of Resident #1 and, to her knowledge, no one else in administration directed staff to add extra supervision, because the resident was not trying to leave the facility. The ADON stated she was responsible for conducting staff in-service training following the elopement and she began in-services immediately with direct care staff on 08/04/25 and continued on 08/05/25. She stated a mandatory in-service was held on 08/08/25 at approximately 2:30 PM to in-service the remainder of staff on the following: ANE, elopement, responding to door alarms promptly, and monitoring newly admitted residents. During an interview on 08/13/25 at 5:27 PM, the DON stated Resident #1 was admitted from home on [DATE] around 2:00 PM. She stated LVN A was on duty when the resident admitted to the facility, but she only got the resident's vital signs then passed the care of the resident on to LVN B due to shift change. She stated she observed Resident #1 in her room later that same day but did not personally observe Resident #1 ambulating outside the room. The DON stated she was not made aware of any staff concerns for Resident #1 wandering or exit-seeking and she did not direct staff to implement checks that were more frequent than the standard two-hour checks, per facility policy. She stated she was informed of Resident #1's elopement via phone call from LVN B in the evening of 08/04/25. The DON stated Resident #1 was immediately placed on one-to-one supervision upon return to the facility and a CNA was called in to assist with supervision that evening. The DON stated Resident #1 did not exhibit exit-seeking behavior following the elopement and remained on continuous supervision until her discharge on [DATE]. During an interview on 08/13/25 at 6:06 PM, CNA C stated she worked the evening shift on the day Resident #1 was admitted . She stated she was told in report by CNA D to watch the new resident and she observed the resident walking in the hallway sometime after 6 PM, when the resident came in from the smoking area with LVN B. CNA C stated she informed LVN B she was going to shower a resident. She stated she did not see Resident #1 again until she returned to the facility with the police, and she was not told by LVN B to conduct more frequent checks on Resident #1. CNA C stated she did not know whether LVN B told CNA D to conduct more frequent checks on Resident #1. She stated she did not observe Resident #1 wandering into other rooms and did not observe any exit-seeking behavior by the resident. She stated she would have informed her charge nurse if she had seen Resident #1 trying to get out. CNA C stated she observed Resident #1 on one-to-one monitoring with another CNA when she returned to the facility and she had been in-serviced on elopement, door alarms, ANE and monitoring new residents on 08/05/25. During an interview on 08/13/25 at 7:40 PM, CNA D stated she was on duty on the day shift on 08/04/25 when Resident #1 was admitted . She stated she was on break when the resident first came in and initially saw her in her room. CNA D stated she observed Resident #1 ambulating in the hallways with her walker, carrying a baby doll. She stated the Resident #1 interacted with others who spoke to her when she was walking in the hallways, but she did not observe the resident enter other resident's rooms or look for the exit door. CNA D stated she did not hear Resident #1 verbalize the desire to leave the facility and she observed LVN B checking on Resident #1 frequently. She stated she was told by LVN B to look out for the resident and make sure she is OK, but she was not instructed by LVN B to do more frequent checks on the resident. She stated there was no extra documentation or extra checks implemented on Resident #1 until after the elopement. CNA D stated she told CNA C in report to keep an eye on the new resident but did not state that the resident needed to be monitored at set times. She stated Resident #1 was confused but did not exhibit exit-seeking behavior and stated she was surprised when she was informed Resident #1 had left the facility. CNA D stated in order for her to do more frequent checks on a resident and document the checks, she would need to be instructed by her charge nurse or the DON or ADON to initiate the checks. CNA D stated she observed Resident #1 on one-to-one supervision when she returned to work the following day. She stated she was in-serviced on ANE, door alarms, elopement and monitoring of new residents upon reporting to work on 08/05/25. During a phone interview on 08/14/25 at 10:18 AM, the Community Member stated she was driving at approximately 6:35 PM on 08/04/25 about a block or two from the nursing facility when she saw Resident #1 walking with her walker down the street and carrying a blanket and a baby doll. She stated she turned around and asked the resident if she needed a ride and the resident stated, I need to go home. The Community Member stated Resident #1 got into the back seat of her car and she put her walker in the trunk and drove the resident around the block looking for her house. The Community Member stated Resident #1 had no idea where her home was, so she called the police department and was told to bring the resident to the station. She stated an officer met them in the parking lot and had placed a call to the nursing facility prior to their arrival at the station. She stated the officer followed her to the facility and escorted the resident back into the facility. The Community member stated the resident did not appear to be in distress or overheated when she picked her up and the resident remained in the air-conditioned vehicle from the time she picked her up until she was escorted back into the facility by the officer. During a follow-up interview on 08/14/25 at 11:28 AM, the DON stated the Wandering Risk Assessment was initiated for Resident #1 on 08/04/25 and was completed on 08/05/25, which was within the expected 24-hour time frame. She stated a high score on the wandering assessment would not indicate the automatic need for extra supervision of a resident. She stated she did not feel that Resident #1 would have required more than q 2-hour checks, even if her Wandering Assessment score was high, because the resident was not actively seeking to exit. She stated each resident was assessed on an individual basis and her expectation of staff would be to assure resident safety and report to nursing administration if there was a concern for any resident to be a flight risk and to complete an Elopement Risk Assessment if the resident was exhibiting exit-seeking behavior. The facility implemented the following interventions from 08/04/25 - 08/08/25: Record review of Resident #1's Comprehensive Care Plan, dated 08/05/25, revealed:Focus: Resident #1 is an elopement risk/wanderer related to history of attempts to leave facility unattended, impaired safety awareness; resident wanders aimlesslyGoal: The resident's safety will be maintained through the review date.Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Identify pattern of wandering. Intervene as appropriate. Record review of the facility document for Missing Resident/Elopement Monitoring revealed daily monitoring of door locking mechanism and alarm functioning on exit doors from 08/04/25 through 08/13/25. Record review of the facility in-service training on 08/04/25 for Verbal/Exploitation/ Neglect/ Abuse Policy and Protocol/Resident Rights reviewed ANE definitions and reporting and was signed by 23 staff members. Record review of the facility in-service training on 08/05/25 reviewed reporting any potential ANE to the ADM or DON immediately and was signed by 23 staff members. Record review of the facility in-service training on 08/05/25 reviewed Elopement and Exit Seeking Protocol and was signed by 30 staff members. Record review of the facility in-service training on 08/05/25 reviewed Door Alarm Protocol and was signed by 26 staff members. Record review of the facility in-service training on 08/05/25 reviewed Monitoring New Admits and was signed by 31 staff members. An observation on 08/13/25 at 1:26 PM revealed the front door required a keypad access code for entrance or exit to and from the facility. The access code was not visibly posted and required a staff member to enter code. During an observation on 08/13/25 at approximately 4:30 PM, the ADM tested staff response to the front door alarm sounding. Surveyor observed several staff members respond to the front door area within one minute of alarm sounding and check to see if any residents were in the area near the door. Record review of an undated letter which was sent on 08/07/25 via USPS mail to all family members revealed a reminder when visiting the facility, to be aware of residents near the doors who may be attempting to exit the facility unsupervised. The letter further reminded family members not to share the door access code, and to ensure the door closes securely when exiting. Record review of documentation of one-to-one monitoring for Resident #1 from 08/04/25 - 08/08/25 revealed staff signed for whereabouts of Resident #1 every 15 minutes beginning on 08/04/25 at 7:30 PM through 08/08/25 at approximately 5:00 PM, when Resident #1 was transferred out of the facility. During an interview on 08/13/25 at 1:30 PM, the ADM stated on 08/05/25, all residents who were known to have exit-seeking behavior were reviewed and monitored through elopement assessments and wander guard system checks. She stated wander guard drills were conducted as part of the in-services for elopement. During an interview on 08/13/25 at 5:14 PM, the ADON stated she was responsible for conducting staff in-service training following the elopement and she began in-services immediately with direct care staff on 08/04/25 and continued on 08/05/25. She stated a mandatory in-service was held on 08/08/25 at approximately 2:30 PM to in-service the remainder of staff on the following: ANE, elopement, responding to door alarms promptly, and monitoring newly admitted residents. The ADON stated all disciplines of staff were in-serviced and any staff on leave would be in-serviced prior to returning to work. During an interview on 08/13/25 at 2:31 PM, LVN A - day shift, stated she had been in-serviced by the ADON on 08/05/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. During an interview on 08/13/25 at 2:50 PM, LVN B - evening shift, stated she had been in-serviced by the ADON on 08/05/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. During an interview on 08/13/25 at 6:06 PM, CNA C - evening shift, stated she had been in-serviced by the ADON on 08/05/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. During an interview on 08/13/25 at 7:40 PM, CNA D - day shift, stated she had been in-serviced by the ADON on 08/05/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. During an interview on 08/14/25 at 3:05 PM, the Director of Rehabilitation stated he had been in-serviced by the ADON on 08/08/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. During an interview on 08/14/25 at 3:39 PM, CNA E - day shift, stated she had been in-serviced by the ADON on 08/05/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. During an interview on 08/14/25 at 3:48 PM, CNA F - day shift, stated she had been in-serviced by the ADON on 08/05/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. During an interview on 08/14/25 at 3:54 PM, CNA G - day shift, stated she had been in-serviced by the ADON on 08/08/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. Record review of the facility's policy titled Wandering and Elopements, Revised March 2019 revealed: Policy StatementThe facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.4. When the resident returns to the facility the director or nursing services or charge nurse shall: a. examine the resident for injuries; b. contact the attending physician and report findings and conditions of the resident; c. notify the resident's legal representative (sponsor); . f. document relevant information in the resident's medical record. The noncompliance was identified as PNC. The IJ began on 08/04/25 and ended on 08/08/25. The facility had corrected the noncompliance before the survey began.

**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 assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents, hazards, supervision. The facility failed to ensure Resident #1 received supervision and assistive devices to prevent accidents. Resident #1 was exit seeking and was able to elope and had fallen in the parking lot by the street. Staff were not aware of Resident #1's elopement and was found by Occupational Therapist that was off the clock. An Immediate Jeopardy (IJ) was identified on 03/21/25 at 3:32 PM. The IJ template was provided to the facility on [DATE] at 3:32 PM. While the IJ was removed on 03/22/25 at 5:36 PM; however, the facility remained out of compliance at No actual harm, with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for injuries due to not receiving the appropriate level of supervision. Findings included: Record Review of Resident #1's face sheet dated 03/20/25 revealed a [AGE] year-old male with an original admission date of 08/02/2024 and a readmission date of 01/10/25 with the following diagnoses: bacterial pneumonia (a serious lung infection caused by bacteria), metabolic encephalopathy (an acute condition of global cerebral dysfunction in the absence of primary structural disease), type 2 diabetes mellitus, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), high blood pressure, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia, abnormalities of gait and mobility, lack of coordination, repeated falls, muscle weakness, acute kidney failure, psychotic disorder with hallucinations. Record review of Resident #1's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed: He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. He felt tired or had little energy listed as 2-6 days. He was listed as using a manual wheelchair. He needed partial/moderate assistance to go from sitting to standing. Record review of Resident #1's Care Plan, dated 01/10/25, revealed that Resident #1 was not care planned for wander guard. Review of Resident #1's Care Plan updated 8/13/24 revealed: Showed to be (dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits, Immobility. Record review of Resident #1's TAR for month of March 2025, revealed: Resident #1 was placed on 1:1 observations from 03/12/2025-3/21/2025, but no wander guard was listed on TAR. Record review of Resident #1's progress note dated 03/10/2025 at 2:59 PM, stated: 1300 Resident was at front door trying to get out of building. Wander guard applied to right wrist. Resident continues wandering throughout the building. Family called and notified. Recored review of Resident #1's progress note dated 03/10/2025 at 3:30 PM, stated: New order obtained from NP to place patient on one on one due to exit seeking behaviors. Record review of Resident #1's Head to Toe Skin Assessment, dated 03/13/2025 at 6:32 PM, stated: right and left forearm and right elbow. During an interview on 03/20/25 at 11:23 AM, Occupational Therapist A stated that she had seen Resident #1 outside around 3 pm. Occupational Therapist A stated that she had parked on the opposite end of the building, had made a left turn on the road, and then had seen someone standing with a walker in the parking lot. Occupational Therapist A stated that she had seen Resident #1 out of her peripheral vision. The Occupational Therapist A stated that he did not look like a visitor. The Occupational Therapist A stated that as she was parked, she had noticed Resident #1 had lost his balance and had seen him fall. The Occupational Therapist A stated that she had ran into the building and yelled out to Occupational Therapist B to assist. The Occupational Therapist A stated that she had ran to Resident #1 because he was in the street but barely on the side of the street. The Occupational Therapist B and Occupational Therapist A went to help Resident #1 up and at that point Physical Therapist came out with Resident #1's wheelchair. The Occupational Therapist A and Physical Therapist helped Resident #1 into the wheelchair and back into the building. The Occupational Therapist A stated that once they were back into the building, she wrote a statement. The Occupational Therapist A stated that she was off of the clock when this incident occurred. The Occupational Therapist A stated that her and the Physical Therapist C helped Resident #1, and she left after writing the statement. The Occupational Therapist A stated that she had not worked with Resident #1. The Occupational Therapist A stated that this was the second time that she had caught him. The Occupational Therapist A stated that the first time was around lunch, and she was on her way back from lunch. The Occupational Therapist A stated that Resident #1 was right at the door (outside of it, he just needed to let the door go). The Occupational Therapist A stated that Resident #1 did not have his walker at that time. The Occupational Therapist A stated that she had yelled for help from LVN D. The Occupational Therapist A stated that at that time they took him to get a wander guard. The Occupational Therapist A stated that was around noon and Resident #1 had not attempted to elope before that. The Occupational Therapist A stated that the first time that Resident #1 attempted to elope, he was not coherent, but he did make a comment saying something about needing a locker. The Occupational Therapist A stated that Resident #1 did not have a wander guard the first time he attempted to leave but on the second attempt, noticed a wander guard on Resident #1 because when Occupational Therapist A and Physical Therapist C brought Resident #1 back inside the wander guard went off. The Occupational Therapist A stated that she was not aware of any other elopements with residents. The Occupational Therapist A stated that she was not aware of any additional residents that exit seek. The Occupational Therapist A stated that she had not had any training regarding Resident #1's elopement. The Occupational Therapist A stated that she knows what it sounds like when the wander guard alerts and had been trained to go to the sound, each time the sound goes off and had been trained to go to the front door. During an interview on 03/20/25 at 11:35 AM, LVN D stated that the steps to do a wander guard depended on the resident if they are an elopement risk. LVN D stated that they would have to do a wandering assessment. LVN D stated that the wandering assessment will let you know if the resident is high risk. LVN D stated that the nurse initiates the risk assessment. LVN D stated that Resident #1 was wanting to get out the day he eloped and that he was trying to get to the door. LVN D stated that she put a wander guard on him when he tried to get out the first time that day. LVN D stated that she was unsure of the actual date. LVN D stated that she used PCC (point click care) for the assessment. LVN D stated that Resident #1 was in his wheelchair, and he was rolling around right after lunch. LVN D stated that Resident #1 was already agitated that day. LVN D stated that Resident #1 was saying that he was looking for his wife before lunch and after lunch he had stated that he needed to get to his car. LVN D stated that Resident #1 does not usually ambulate using his wheelchair on his own but on this day, he was independently rolling on his own. LVN D stated that Resident #1 was going to the front door, and she had redirected him and brought him to the desk. LVN D stated that she had told Resident #1 that the weather was bad to try and distract him. LVN D stated that she cannot remember if she offered to call his daughter that day to distract him. LVN D did the assessment on Resident #1 and put a wander guard on him. LVN D stated that she did the assessment on Resident #1, and it showed that he needed the wander guard. LVN D stated that she put the wander guard on Resident #1 first and she kept him with her the remainder of her shift. LVN D was not sure what time she had gotten off work. LVN D stated that she had kept eyes on him. LVN D stated that she reported to LVN E that Resident #1 had a wander guard. LVN D stated that she had put a wander guard on Resident #1's right wrist. LVN D stated that she had made the DON, Administrator, and ADON aware that she had placed the wander guard on Resident #1 around lunch time. LVN D stated that no one ever reported to her that Resident #1 had attempted to get out, but she did her assessment based on what she observed. LVN D stated that she did not observe Resident #1 get out of the facility but was told when she was leaving that he had gotten out. LVN D stated that Resident #1 was found outside and had fallen in the front. LVN D stated that she was not sure where at in the front Resident #1 was found. LVN D stated that she had last saw Resident #1 when she was giving report at 2:15 PM during shift change. LVN D stated that she did receive additional training after the incident (elopement drill) and elopement training. LVN D stated that she had been trained to announce it and everyone needs to start looking. LVN D stated that the Charge nurse needs to be the stationary person to report back to. LVN D stated that at that point someone needs to go outside and look. LVN D stated that you would also report to Administrator and DON and then after 15 minutes we need to call the police officers and call family. LVN D later explained that she tested the wander guard against a remote and again against the door prior to placing it on Resident #1. She stated staff member (CNA F) was present when she tested against the door. During an interview on 03/20/25 at 11:36 AM, the Physical Therapist C said she did not see Resident #1's elopement happen. She stated that she was in the front in the therapy area. The Physical Therapist C stated that she was unsure of the time and actual date but does know that it was daytime. The Physical Therapist C stated that earlier in the day before the elopement, the Occupational Therapist A was coming back in and saw Resident #1 standing at the door and she had brought him back inside. The Physical Therapist C stated that during the actual elopement, the Occupational Therapist A had thought that Resident #1 was a visitor and when she had realized that it was Resident #1, she had told nursing immediately what had happened. The Physical Therapist C stated that later that day she was in the therapy office and heard the door open and the Occupational Therapist A yell for the Occupational Therapist B. The Physical Therapist C stated that the Occupational Therapist A was leaving work and Resident #1 had gotten out of the door and off of the curb and had fallen. The Physical Therapist C stated she and the Occupation Therapist A had helped Resident #1 up and nursing had gotten him a wheelchair and brought him back into the building. The Physical Therapist C stated that the alarm did not go off on either the first or second time that Resident #1 eloped. The Physical Therapist C stated that when they hear the alarm, they move. The Physical Therapist C stated that one of them would have gone to check if the alarm had gone off; however, they did not hear it. The Physical Therapist C stated that they were trained to, hop up and get to it. The Physical Therapist C stated that Resident #1 had the wander guard on both times for the attempt and the actual elopement. The Physical Therapist C stated that the wander guard did not go off the first time, but it went off when Resident #1 was coming back through the door after he actually eloped. The Physical Therapist C stated that the wander guard alert system was working intermittently. The Physical Therapist C stated that nursing checks the wander guards, but she was unsure if it was the charge nurse or the DON. The Physical Therapist C stated that Resident #1 seemed unharmed when he actually eloped. The Physical Therapist C stated that when staff was bringing Resident #1 in from the actual elopement, he was telling the staff no that he wanted to go the other way. During an observation on 03/20/2025 at 1:03 PM, State surveyor tested the front door. Alarm sounded. Staff x3 came. During an interview on 03/20/2025 at 1:29 PM, CNA G stated that she was unsure of the exact date and time that Resident #1 was showing behaviors. CNA G stated that Resident #1 tried to get out prior to that actual elopement. CNA G stated that Resident #1 was yelling at staff, being physically abusive, and had bad language. CNA G stated that this was not Resident #1's normal behavior, but he was like this prior to his actual elopement. CNA G stated that she heard LVN D say that Resident #1 tried to leave. CNA G stated that they were watching him but did not do the 1:1. CNA G stated that the first time that Resident #1 tried to get out was when the wander guard was placed on him. CNA G stated that she had received a call while in the restroom and CNA H had stated that Resident #1 was outside. CNA G stated that she went out to help. CNA G stated that breaks are usually around 1:00 pm - 2:30 pm, so that would have to have been around the time Resident #1 was able to get out of the facility. CNA G stated that she was not too sure on the actual timing. CNA G stated that when she went outside, the resident, DON, and the Administrator, were coming inside. CNA G stated that the last time that she saw Resident #1 was approximately 10 minutes before the incident happened. CNA G stated that she did not hear the door alarm. CNA G stated that this had not happened with Resident #1 before, he had always talked about wanting to leave, but this was the first time that he eloped. During an observation on 03/20/2025 at 3:22 PM, Resident #1 observed the wander guard on left arm. He looked at it. Did not say what it was for. During an observation on 03/20/2025 at 4:37 PM-4:45 PM, tested the wander guard at the door near the room where the investigator was and the door down the right side (back) of the facility. The alert on the side and back of the facility have a faint sound. Staff did respond x3 to the side door and x 1 to the back door. During an interview on 03/20/2025 at 6:00 PM, Family Member #1 stated he/she was notified by Family Member #2 that Resident #1 had eloped. Family Member #1 stated that Resident #1 had a wander guard since being admitted . Family member #1 stated that Resident #1 does not get around very well and was not sure how Resident #1 was able to get outside with the wander guard and being as low as Resident #1 was. Family member stated that as a result of the incident they would be trying to place Resident #1 somewhere else. During an interview on 03/20/2025 at 6:05 PM, Physician stated that the facility may have notified his Nurse Practitioner about the elopement. Physician stated that he did not know if Resident #1 had a wander guard. Physician stated that Resident #1 had no elopement issues that he knew of. During an interview on 03/20/2025 at 6:13 PM, Family Member #2 stated she did not know the exact date, but she was told Resident #1 got out the front door. Family Member #2 did not say how far Resident #1 had gotten. Family Member #2 stated that it was told to her in the day that Resident #1 had managed to get out the front door. Family Member #2 stated that she was not sure if it was LVN D or LVN E that notified her. Family Member #2 stated that Resident #1 did not have his wander guard and had not had it for a while, it had been several weeks. Family member #2 stated that she did not know why they had taken the wander guard off. Family member stated that the facility did not notify them of the wander guard being taken off the first time or that they had placed one on Resident #1 the day he eloped from the facility. Family member #2 stated that after Resident #1 had fallen, the day that he eloped and had fallen outside, they had put the wander guard back on Resident #1. Family member #2 stated that it was observed that it was off but had never asked, and just assumed it was because Resident #1 quit wandering and never questioned it. Family member #2 stated that they had noticed the wander guard, but no one had mentioned putting it back on Resident #1. Family member #2 stated that she had seen Resident #1 the next day and noticed that they had placed the wander guard back on. Family member #2 stated that their concern was Resident #1 was at the back of the building. Family member #2 stated that Resident #1 had to walk down a long hallway to get out of the building. Family member #2 stated that no one had paid attention and noticed it, and this was concerning. Family member #2 stated that their parking lot was right by the street. Family member #2 stated prior to this incident they never had concern about Resident #1's care, until this. Family member #2 stated that they were fine with the placement of the wander guard but if they had been told that they were going to take it off they would have declined for the safety of Resident #1, it never was an issue. During an interview on 03/20/2025 at 6:35 PM, NP stated that she was notified on 03/10 that Resident #1 was trying to get out the front door and that he gotten out, right outside the door. NP stated it was her understanding that Resident #1 had not even gotten to the sidewalk. NP stated she was unaware that he gotten to the parking lot near the street. NP stated she received a text stating that they had put a wander guard on Resident #1 on 3/10. NP stated that she does not know if it was before or after he had actually eloped. NP stated her text that she had received stated I put a wander guard on Resident #1 because he was trying to get out of the building after lunch. The NP stated she had not had a text message that had showed that he had gotten out of the facility. NP stated she was unaware if Resident #1 had a wander guard prior to the placement on 03/10. NP stated she had never given an order for a wander guard to be taken off. NP stated they do notify her if they take it off and she has not had any notifications that one needed to be taken off of Resident #1. NP stated that they would have to had justification to take the wander guard off and put on. NP stated that she had a text on August 13 of 2024 that Resident #1 had tried to get out. NP stated that she did not know who texted because the number was not saved. NP stated that she had located the text says Resident #1 had gotten out. NP stated that she thought it was right outside of the door because she received a phone call letting her know they gotten Resident #1 back in. NP stated that when she calls about elopements and wander guard placements she will ask them what symptoms the resident had been having and what is the reason. NP stated that she had not received that information with Resident #1's case. NP stated that it was normal to have placed a wander guard after one attempt especially with Resident #1's case because the doors are unlocked from 7-8 PM. NP stated that it was case dependent in how they respond to elopements. NP stated it was situational. NP stated that in that facility it is almost impossible to actually monitor the front door and where the patient was going. NP stated that there was no way of watching that. NP stated that the wander guard was important because of the layout of the facility. NP stated that Resident #1 cannot walk fast, but fast enough. During an observation at 9:15 AM, The facility is located on [NAME] Avenue with posted speed limit of 55 mph. The cross street is 114 with a posted speed limit of 65 mph. There was an observation of the restaurant across the street that receives business during the day hours. The day that Resident #1 had eloped on 03/10/2025, it was 78 degrees with wind. During an observation and interview on 03/21/2025 at 9:38 AM, Maintenance Supervisor provided his checklist that he used to check the wander guard system. He stated he was required to check it weekly, but he does check the doors daily. He stated that he has not had any issues with the system. During an observation on 03/21/2025 at 10:05-10:08 AM: Tested side door near the room where investigator was. Staff did not come down the hall until 10:08 AM x2. During an interview on 03/21/2025 at 10:17 AM, LVN D stated that she had spoken with Family member #2. LVN D stated that she had told Family Member #2 that she had placed a wander guard on Resident #1. LVN D stated that it was an emergent reason to put the wander guard on because Resident #1 was actively trying to get out. LVN D stated that she was 1:1 with him until got off that day, then the aides took over. LVN D stated that she does not remember if she documented it, and which aides took over. LVN D stated that no one took over her nursing duties while she was 1:1. LVN D stated it was after lunch, and she did not have anything at that moment that she needed to do. LVN D stated that Resident #1 had never had a wander guard. LVN D stated that this was the first time that Resident #1 had a wander guard. LVN D stated that you have to document when you place or remove a wander guard. LVN D stated that you have to notify the doctor to place the order. LVN D stated that she did not know if she had placed it in her note. LVN D stated that there was an order for the wander guard to be checked and changed. LVN D stated that she was there when Resident #1 tried to get out of the door. LVN D stated that Resident #1 was on the right side of the door, and he pushed it. LVN D stated that the door sounded, and she went over there and grabbed Resident #1. LVN D stated that she notified the DON, Administrator, and the ADON. LVN D stated Resident #1 should have been placed on 1:1. LVN D stated that was the protocol for at least 15-minute checks. LVN D stated that she was never instructed to place Resident #1 on 1:1. LVN D stated that she just watched Resident #1 closely based on her nursing experience. During an observation on 03/21/2025 at 10:37 AM, Resident #1 in his room, sleep in his recliner, wander guard on left arm. During an interview on 03/21/2025 at 10:38 AM, CNA I stated that Resident #1 did not have a wander guard before. CNA I stated that she was not sure how Resident #1 had not had his wander guard and why it was taken off. CNA I stated that Resident #1 will wander but he was not looking to get out and Resident #1 will say he needs to go home. During an interview on 03/21/2025 at 11:17 AM, ADON stated that Resident #1 had never had a wander guard before. ADON stated that the wander guard placed in March was the first one. ADON stated that the process for placing a wander guard was if the resident was showing signs an elopement assessment should be completed. ADON stated that the family should be notified of the behavior. ADON stated that the assessment would reveal a score and if the wander guard was needed. ADON stated that the family should be notified, and the documentation should reflect if they agree or disagree and then a consent should be signed if the family agree. ADON stated that if the family was not in agreement of the wander guard, then the resident can be placed on 24 hours observation and the family will try to identify a locked unit. ADON stated that it was not done in this case. ADON stated that she did not observe the placement of the wander guard on Resident #1. ADON stated that it was discussed as a group after Resident #1 had eloped. ADON stated that it had been discussed since Resident #1 was exit seeking and had not displayed that behavior before. ADON stated that labs were obtained with no findings. ADON stated that they discussed Resident #1 being placed on 1:1 and the Administrator had stated that they would need to find 1:1 staff for Resident #1. ADON stated that she did not know why the consent was not obtained or why the assessment was done afterwards. ADON stated that LVN D had reported the POA was called and given a verbal consent. ADON stated there was a call made to the NP. ADON stated she thought they had a consent. ADON stated that they had aids initially watching Resident #1. ADON stated that there was no observation log. ADON stated that the Administrator determined that it was an emergency and that was why the wander guard was placed on Resident #1. ADON stated that they were trained to document the placement of the wander guard and if it was taken off. ADON stated that they have to have justification to put a wander guard on and take it off. ADON stated that if it was not justified then the restraint is not justifiable. ADON stated that she thinks that this could have been prevented because when Resident #1 showed signs to want to leave the first time, the resident should have been monitored more frequently. ADON stated that Resident #1's room was right across from the nurse's station. ADON stated that Resident #1 was not quick and there was no reason someone did not see him. ADON stated that if they remove a wander guard an assessment should pop up in the system. ADON stated that if the assessment showed that Resident #1 no longer exhibited wandering then the nursing judgment would also be considered. ADON stated that the doctor should be called and get an order. ADON stated then the family should be called to remove the wander guard. ADON stated that she was familiar with the policy. ADON stated that the purpose of incident/accident prevention and supervision was safety of the resident. ADON stated that the incident could happen again if the policy was not followed. ADON stated that she did not see Resident #1 when he had eloped. ADON stated that she was told that Resident #1 was by the sidewalk onto the parking lot. ADON stated that the facility was by a busy road. ADON stated that Resident #1 does not have the ability to watch for traffic. ADON stated that she is aware that Resident #1 attempted to get out around lunch time. ADON stated that she was not aware that Resident #1 got out the second time. ADON stated that she was not aware that the wander guard was implemented prior to the assessment. ADON stated that she was not aware that Resident #1 had a wander guard prior to the one placed on 03/10/2025. ADON stated that she did not have any information regarding removal, and it should be care planned. ADON stated that she is not aware of Resident #1's scores from the past wandering assessments. ADON stated that the system to monitor incident/accident prevention and supervision would be to in-service staff and monitor to make sure nursing was following incident/accident policy, ensure that everything was documented, and make sure that there were follow ups and interventions for the resident. ADON stated that she had been trained on incident and accident prevention, supervision, and restraint policy. ADON stated that she would expect policy should be followed and incident and accidents should be prevented. ADON stated that everyone was responsible and there was no reason increased supervision did not occur on the first exit seeking attempt. During an interview on 03/21/2025 at 12:00 PM and continued on 03/24/2025 at 6:17 PM, the Administrator stated that she had been in the facility since November 2024 and that if Resident #1 had a wander guard it would have been documented. The Administrator stated that if Resident #1 were placed on 1:1, it would have been documented and an order for the increased supervision. The Administrator stated that they would have completed an assessment first before placing the wander guard. The Administrator stated that they would also have to have an order to remove a wander guard. The Administrator stated that with Resident #1 eloping successfully, after he had already attempted, could have been prevented. The Administrator stated that Resident #1 had showed signs of wanting to leave and the facility failed to place him on 1:1 supervision. The Administrator stated that she did provide an elopement in-service. The Administrator stated that, Everyone is responsible for keeping the resident safe. The Administrator stated, I was told that they had completed the assessment first and then had called for a wander guard. The Administrator stated that it could be considered a restraint. The Administrator stated that LVN D had documented that Resident #1 had went to the door. The Administrator stated that the assessment would tell you if the Resident needed a wander guard. The Administrator stated that the guard will not stop the resident from getting out of the door, but it is an intervention. The Administrator stated that there is not a reason the assessment is done after the placement. The Administrator stated that she had not had anything on a 24-hour report for Resident #1. The Administrator stated that she did an investigation. In her investigation she had not seen wander guard from any time before. The Administrator had not seen the high risk on all wandering assessments. She stated she did not look at the progress notes or assessments as a part of her investigation. The Administrator stated that she had not talked to the family since the elopement. She stated her team did tell her that they had notified the family. The Administrator stated that she did not follow up to check if the family had been notified. The Administrator stated that even in self-report all that was told to her was that the family was notified. The Administrator stated that she was unaware that the family had not been notified. The Administrator stated that the facility system to monitor incident and accident prevention was to review risk management daily and take the information from morning meetings and address as they are reported. The Administrator stated that she had been trained on incident and accident prevention. The Administrator stated they would have needed need to complete an assessment and then they would have to score a certain score, notify physician, notify family, sign the consent, before it could even be placed. It also would come with restrictions such as how often you would use it or when you remove it. The Administrator stated yes she was familiar with the policy for placing a wander guard. The Administrator stated that she was not aware that the assessment was completed after the restraint was placed on the resident, and once the IJ happened she learned of the situation. The Administrator stated that the system for monitoring for restraints was that she monitors when one is placed and would make sure DON had made her aware when one is placed, and she would follow up and have ADON monitor every week. The Administrator stated that she had been trained in restraints and her staff does complete orientation and annually as well. The Administrator stated that she had observed these residents (Resident #1, Resident #2, and Resident #3) with a wander guard on. The Administrator stated that her expectations in regard to restraint placement was that we are following our policy and that we are completing proper assessments before applying. The Administrator stated it was the responsibility of the charge nurses to apply restraints and complete assessments, and the responsibility of the ADON and DON to monitor. The Administrator stated that everyone was responsible for following the policy. The Administrator stated that there was no reason the assessment was completed after the placement of the wander guard as it relates to Resident #1, she thinks the nurse just wanted to be initiative-taking and was too initiative-taking. During an interview on 03/21/2025 at 12:22 PM, the DON stated that the facility failed to prevent incidents and accidents allowing Resident #1 to get out. The DON stated, I was in my office and was told that he was at the door. The DON stated that the incident prompted the wander guard situation. The DON stated that Resident #1 did not get out of the door, but he was at t[TRUNCATED]