**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 (Res #1) reviewed for elopements in that: Resident #1 had eloped from facility 3 times (7/26/2023, 8/8/2023, 8/26/2023) with a wander guard on. a. staff were not in-serviced following each elopement. b. no elopement assessment was completed for Resident #1 prior to or immediately following the elopements. c.no measurable (dated) care plan for elopement risk. d. an alarm was not in place on Resident #1's window as indicated on care plan. An IJ was identified on 10/07/2023. The IJ template was provided to the facility on [DATE] at 3:28 PM. While the IJ was removed on 10/11/2023, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because the facility is still monitoring their effectiveness of their plan of removal. This could affect residents who are elopement risks and could place them at risk for injuries. The Findings were: Record review of Resident #1's admission Record dated 8/8/2023 revealed she was admitted on [DATE] with diagnoses of vascular dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), severe cognitive impairment, anxiety (a feeling of worry, nervousness, or unease), state and mood disorder (any of a group of mental conditions characterized by persistent disturbance of mood, especially in the form of depression or euphoria or a combination). Record review of Resident #1's admission MDS dated [DATE] revealed she was Cognitively severely impaired. Resident #1 was independent with bed mobility, transfers, walk in room/corridor, locomotion on unit, eating, toilet use and dressing. Resident #1 required limited assistance with her personal hygiene and bathing with 1-person physical assistance. Resident #1 had no impairments for range of motion. Resident #1 incontinent of urinary continence and always continent for bowels. Resident #1's height was 61 and weight was 98. Resident #1 had a restraint and alarms was for Alarms used daily wander/elopement alarm. Record review of Resident #1's baseline care plan dated 6/15/2023 revealed she was independent with walks, transfers, eating, and toileting. Resident #1 required supervision for dressing and her hearing/vision was normal. Resident #1 can verbally communicate with others, she had frequent disorientation, had a wander guard and was an elopement risk. Care plan dated 6/15/2023 revealed cognitive deficit: decision making was impaired related to Dementia. Resident #1 was severely impaired and never/rarely makes decisions. The interventions were not dated. Record review of Resident #1's Care plan dated 6/28/2023 was documented problem was wandering/elopement risk-evidence of attempts to leave facility unattended, resident wanders aimlessly, impaired safety awareness, disorientation to place. Resident #1's interventions was documented in a list that included to assess the cause and effectiveness of interventions, maintain safety, make sure all staff are aware of elopement risk, bracelet alarm for alarm doors, assess for fall risk, monitor for fatigue, and weight loss, keep picture of resident in medical record. Titled-Modify Environment included outside secure courtyard for safe walking, safe walking path Titled-Structure activities to include structured and supervise walking activity, re-orientation to person, place and time as needed, distract resident from wandering by offering pleasant diversion structured activities food, conversations, television, and book. (No dates for the new interventions). Record review of Resident #1's consent for restraint use dated 6/15/2023 was documented ordered wander guard for alert staff of elopement attempts. Record review of in-service on dementia, unsafe behaviors, exit seeking, wandering into other resident rooms dated on 7/25/2023 for twenty-two staff signed by LVN D (trainer). Record review of progress noted dated 7/26/2023 for Resident #1 revealed the ADON on call over weekend, notified the DON and the Administrator. Record review of progress noted dated 7/26/2023 for Resident #1 revealed LVN B documented resident #1 went out the laundry room gate was brought back into facility. Resident #1 was placed on 15 minutes with CNA and the monitoring. The on-call ADON notified DON, Administrator. Record review of an incident report dated 7/26/2023 at 6 PM documented Resident #1 went out the laundry room gate and was brought back by staff and Resident was placed on 15-minute observations for safety. Resident #1 was observed by staff on a continuous basis after she returned to the facility signed by LVN A. Resident #1 was gone from facility less than 30 minutes. LVN A took Resident #1 vitals and head to toe assessment was done with no injuries noted. LVN A notified the MD, Administrator. The city outside temperature was 105/77 Degrees Fahrenheit. Record review of 24-hour report dated 7/26/2023 to 7/29/2023 was documented Resident #1 back in facility every 15-minute checks elopement risk, MD notified and review medications. Record review of progress notes for 8/8/2023 at 7:25 AM was documented Resident #1 in the dining room for breakfast, not found in room, looked inside and outside the facility, no alarms were sounded, notified the DON, called police and family, APS. Resident #1 was seen in dining room for breakfast at 7:10 AM, Resident #1 stated she wanted to go home, wander guard was on her. The staff sent out to look for Resident #1 in cars. At 7:52 am police called facility that Resident #1 was found and return to facility. Staff called Administrator that Resident #1 was found by police. At 8 AM Resident #1 arrived at the facility and brought in by police, Resident #1 ate breakfast and drank fluids, assessed head to toe with no injury and updated APS, family, DON, Administrator and MD. At 8:20 AM Resident #1 wander guard was on her wrist still and tested the front alarm door and worked properly by LVN B. Record review of an incident report dated 8/8/2023 at 7:25 AM documented Resident #1 eloped from the facility last seen at 7 AM, notified police, APS (adult protective service), family no signs of point of exit. Resident #1 had her wander guard on her wrist and was brought back by police signed LVN B. Resident #1 was gone from facility less than 30 minutes. LVN B notified APS, Administrator, DON, and police. LVN B took Resident #1 vitals and head to toe assessment was done with no injuries noted. (There were other exits. 2 doors had wander alarms. The courtyard had locked fences and a back gate that alarmed. If vendors knew the code, they could have let her out by accident). The city outside temperature was 106/78 Degrees Fahrenheit. Record review of 24-hour report dated 8/8/2023 to 8/11/2023 documented Resident #1 back in facility every 15-minute checks elopement risk. Resident #1 eloped at 7:25 am to 8 AM, every 15-minute check, monitor for behaviors and elopement. Record review of Resident #1's Care Plan updated on 8/8/2023 APS and guardian notified of resident #1's elopement and safety to be in placed in a secure unit. No new intervention dated for the other 2 elopements for Resident #1. Record review of progress noted dated 8/26/2023 for Resident #1 was documented the [NAME] C called on the 6-2 PM shift, brought Resident #1 back to the facility. The [NAME] C stated Resident #1 was walking down the street away from the facility. LVN B did the head-to-toe assessment and was stable. LVN B asked Resident #1 how she got out but was too forgetful and confused to remember. LVN B notified Administrator, MD, and guardian. Resident #1's wander guard was on her wrist and the front door worked properly. LVN B noted 2-10 PM sift to state the 15-minute monitoring due to wanderer signed by LVN B. Record review of an incident report dated 8/26/2023 at 2:05 PM documented dietary manager C called the facility by phone saying that she saw Resident #1 walking down the side street away from the facility and brought her back, wander guard was on wrist and was working signed by LVN B. Resident #1 was gone from facility less than 30 minutes. The city outside temperature was 104/76 Degrees Fahrenheit. Record review of 24-hour report dated 8/26/2023 documented Resident #1 back in facility every 15-minute checks elopement risk. Resident #1 eloped at 7:25 am to 8 AM, every 15-minute check, monitor for behaviors and elopement. Record review of Resident #1's Fall risk evaluation dated 9/28/2023 revealed she was oriented x2, had 1-2 falls, was ambulatory, vision adequate, gait normal, administered 1-2 medications, predisposing disease, she scored an 8, documented a high risk would score a 10 or above. Record review of Resident #1's weekly summary dated 9/28/2023 was documented for Cognitive patterns Resident #1 had inattention, disorganized thinking, memory problem short-long-term, and severely impaired. In section for Behaviors Resident #1 wandered. Resident #1's Functional Status she was independent with transfers, bed mobility and toilet use, and did not use a mobility device. Resident #1 for active diagnoses was dementia and had a wander guard bracelet for restraints. The wonder guard bracelet was to alert staff of elopement attempts. Record review of a 30-day notice for Resident #1 dated 9/28/2023 was provided to Resident #1 and temporary guardian. Record review of List of Residents at risk for Elopement (no date) revealed 4 residents to included, Resident #1. The Administrator provided this list. Record review of Resident #1's chart revealed no elopement assessment for each elopement 7/26/2023, 8/8/2023, and 8/26/2023. No prior elopement risk assessments prior to 10/7/2023. Record review of Elopement Risk Assessment dated 10/7/2023 for Resident #1 was documented a score of 25, if the score was 5 or greater, they are at risk. (Does resident have a history of elopements/sundowning- scored 5 for both questions). Elopement precautions on care plan - wander guard bracelet in place-yes. Consider placement in a secured unit-yes. Secure unit available-No. Record review of the in-service's booklet did not have in-services that had staff signatures for elopement risk residents after Residents elopements or attempts. Record review of policy (no date) Protocol for wandering residents was attached to every 15-minute checks sheet for the 3 elopements of Resident #1. Record review of the 3 15 - minute checks were completed and signed by staff for 48 hours, per policy. Record review of Protocol for wandering Residents and Elopement reflected Place resident on a fifteen (15)-minute watch for 48 hours . The following rule states assign staff their time period on the watch and prepare the documentation that needs to be filled out. Record review of Resident #1's 15-minute checks revealed on 7/26/2023 15-minute checks began at 6 PM and ended 7/29/2023 at 5:45 PM. On 8/8/2023 resident 15-minute checks began and ended 8/9/2023. On 8/26/2023 the facility began logging 15-minute checks, on 8/27/2023, 2-10 shift began 30-minute checks. At 10 PM, 15-minute checks resumed each shift through 10/10/2023. Record review of in-service on wandering and elopement precaution care to residents and Resident #1. This included 1:1 (staff to be always close to Resident #1) care, create safe space for activities, finding resident in a timely manner, safe space for staff, document on incidents and follow facility protocol. This in-service was dated 10/6/2023 from 6:30 PM to 7 PM. There was a signature page that included all staff. Record review of list of locked units (no date) that the facility was trying to transfer for safety of Resident #1 to a secure unit. The list included 5 different locked units and denied due to lack of money and Medicaid pending. Record review of paper posted across from nurses' station (no date) near staff timecard, was typed, Attention all staff Members -Make sure that you always monitor Resident #1's whereabouts. Inform charge nurse if Resident #1 is exhibiting signs of wanting to leave facility. Observation on 9/19/2023 at 2:30 PM at entrance revealed the front door had an alarm and was locked with a number pad. Staff came to let surveyor in the facility. Observation on 9/19/2023 at 5:13 PM and 9/20/2023 at 10:14 AM of all exits with the Maintenance supervisor during environment rounds. The front door had an alarm, the smoking section had no exit, and the back door leading out to the courtyard was not locked. So, any resident could go outside and walk around the fenced doors in the courtyard had locks on them that were not easily opened. The courtyard had a back gate that vendors or staff used. This back gate was closed and had a code lock on it. The maintenance supervisor showed surveyor if the back gate stayed open for 3 minutes the alarm in the facility sounded. The back gate if opened lead to a street in neighborhood. The courtyard gate near the laundry room was locked and not easily opened. Observation on 9/19/2023 at 5:17 PM revealed Resident #1 was walking around in the halls, she had a wander guard on her wrist, she went to sit down in the dining room for a meal and saw staff was monitoring her. Observation on 9/20/2023 at 10:15 AM with Maintenance supervisor during environment rounds, in Resident #1's room observed window turn knob locked position, screen on window (window blinds difficult for surveyor to open). Resident #1 was not in room at the time. No observation of an alarm placed in the window. The maintenance supervisor turned the knob down position to open Resident #1's window and then turned the knob up position to close the window. Observations of Resident #1's window with the knob lead to the outside in front of the building, too a 4-lane street separated by middle section. The speed limit was 30 mile per hour and was a business road. Observation of Resident #1 was with staff monitoring and engaging with her in dining room sitting with her. Observation on 9/20/2023 at 10:18 AM revealed staff were with Resident #1. Resident #1 was in the dining room during activity with Activity Director. Observation on 9/20/23 at 12:38 PM with RN supervisor in Resident #1's room window had an alarm on it. Observation on 9/20/2023 at 5:32 PM revealed Resident #1 was in the dining area sitting down with staff talking with them. Observation on 9/22/2023 at 11 AM in Resident #1's room revealed she was in her room in bed sleeping and CNA F was sitting in chair in room. Observation in Resident #1's room window had an alarm on it. Observation on 10/8/2023 at 11:28 AM with Resident #1 was sitting in her wheelchair in her room and had a wander guard bracelet. Observation on 10/8/2023 at noon of sheet of paper posted on (no date) across from nurses' station near staff timecard, was typed, Attention all staff Members -Make sure that you always monitor Resident #1's whereabouts. Inform charge nurse if Resident #1 is exhibiting signs of wanting to leave facility. Interview on 9/19/2023 at 5:18 PM with Resident #1 stated she was at school now and will have to go back home near [NAME] Hwy. Resident #1 was confused when asked how she was doing and how she left the facility. Interview on 9/20/2023 at 10:35 AM with CNA E stated she had worked at facility 4 months on the 1st shift and she picks up hours at times. CNA E stated Resident #1 she remembered did leave the building in the mornings and could not recall what else happened. CNA E stated Resident #1 walked around the inside of building down the halls, but she had not seen Resident #1 get out of the building or the courtyard. CNA E stated she had not heard anyone trying to get out of the window. Interview on 9/20/2023 at 11:08 AM with RN supervisor stated the Maintenance supervisor had told her (on 9/20/23 at 10:15 AM) about the window in Resident #1 was in the locked position and the window was hard to open. The RN supervisor stated she had never seen a window to resident rooms open. Interview on 9/20/2023 at 11:12 AM with LVN D stated Resident # 1 had eloped the 1st time by the back gate, the maintenance supervisor found the gate open. The LVN D stated the maintenance supervisor had replaced the lock with a new one. Interview on 9/20/2023 at 12:14 PM with RN supervisor stated she had called the temporary guardian for Resident #1 and had discussed Resident #1 had to leave the facility and she was waiting for the temporary guardian to find placement. RN supervisor stated Resident #1 was on a 1:1 with staff for 24 hours per day, until they can find placement for her. RN supervisor stated staff had always kept an eye on Resident #1, such as on 2-10 PM the ADON keeps her at the nurse's station with her. Typically, the nurses are aware of Resident #1 and always know where she is in the building. Interview on 9/20/2023 at 1:41 PM with LVN B stated she worked the 1st shift for the last 9 years, and stated 1 nurse per shift 1 treatment nurse, 1 medication aide and 3-4 CNAs per shift. LVN B stated Resident #1 let the building two times while she was on duty (2nd and 3rd elopement). The 1st time was during breakfast, and she was in the dining room looking at her, she turned around to get check a tray, then Resident #1 was gone, LVN B said she had staff looking for her around inside and outside of building. LVN B said she notified the Administrator, and police, LVN B said staff drove around to look for Resident #1, an anonymous person from area called the police and brought her back, LVN B said nurse notified the guardian, and she was not gone for longer than 30 minutes. Resident #1 was brought back by the police, and LVN B did a head-to-toe assessment, LVN B said there were no injuries, and she had her elopement bracelet on, LVN B said she was on 15-minute checks for 3 days. LVN B stated one of the interventions were for the physician to review her medications. LVN B stated the 2nd time Resident #1 left the building was between shifts. LVN B said the nurse had received a call from [NAME] C stating she had found Resident #1 walking down the street away from the facility. [NAME] C brought Resident #1 back to the facility, LVN B stated she asked Resident #1 how she got out of the building; Resident #1 did not reply. LVN B stated she did a head-to-toe assessment with no injuries. LVN B stated she notified the Administrator, family, did an assessment and placed Resident #1 on every 15-minute check for 3 days. LVN B stated for all incidents the nurses complete an incident report, place resident on a 15-minute check for 3 days and document the monitoring on the progress notes and the 24-hour report. LVN B stated the intervention was for staff to monitor Resident#1 closely and to entertain her. LVN B stated she was not aware of any 1:1 monitoring checks for Resident #1. LVN B stated the Maintenance supervisor checked all the gates, fences, all windows to see how Resident #1 left the building, LVN B said the only assumption was that someone left the door open in the courtyard and she left out that door, or maybe out the room window. LVN B stated she checked Resident #1's room window, and it was not open and there were no signs of anyone tampering with the window. LVN B stated or maybe Resident #1 went out the front door and staff did not hear the alarm. LVN B said she was not sure how she left the building. Interview on 9/20/2023 at 2:33 PM with LVN D stated she had worked at the facility since 2014 and had worked all shifts. LVN D stated Resident #1 left the building two times. LVN D said once she was on the way to work, and staff called her to look for Resident #1 and when she arrived at work Resident #1 was in the building. LVN D stated Resident #1 was on a 1:1 for a while and she remembers documenting the monitoring. LVN D remembers every 2 hours staff would check on Resident #1. LVN D stated Resident #1 was exit seeking, and she had dementia, LVN D said Resident #1 would leave in the afternoon, and she would state she needed to go home to be with cats, LVN D said today she continues to be on 1:1 until they could find a safe place for her. Interview on 9/20/2023 at 4:55 PM with LVN A stated she worked at facility for 7 years on the 1st shift. LVN A stated Resident #1's when she left the building, she was down the road and a resident family member saw her and the nurse was able to bring her back to facility. LVN A stated she was gone about 10-15 minutes, LVN A notified the charge nurse and family. LVN A stated she did head to toe assessment with no injuries. LVN A stated she had her wander guard on, and staff were doing 15-minute checks for Resident #1. Interview on 9/22/2023 at 3:55 PM with the DON stated Resident #1 notified APS about Resident #1's safety concerns being in this non-locked facility and looking for placement. The DON stated Resident #1 meet the medical criteria, but not the financial criteria. The DON stated Resident #1 had eloped from facility 3 times and each time APS and the temporary guardian was called to notify, this was an unsafe place for her. The DON stated staff were monitoring Resident #1 on a 1:1 basis, every 15-minute for 24-hour period, since her last elopement on 8/26/2023. The DON stated Resident #1's interventions were 1:1 staff for 24 hours period, medications reviews, alarm bracelet, alarm on window and staff training. The DON stated they had in-services for dementia, incident protocol, but was not sure about elopement in-services. Interview on 10/11/2023 at 11:24 AM with the Administrator stated Resident #1's interventions of placing an alarm on her window to the outside was on 9/19/2023. The Administrator stated Resident #1 had her alarm bracelet on her every time she was brought back to the facility from an elopement. Interview on 10/11/2023 at 2:11 PM with the AA she stated she would stay and keep Resident #1 busy, and she would give her paperwork to do. AA stated Resident #1 if she was busy would take her to AD) to keep Resident #1 busy to take over the 1:1 monitoring. AA stated it has been working out ok, with alternating staff to be with resident #1 on a 1:1, staff with her for 24 hours a day. AA stated the RN supervisor is trying to find placement for Resident #1 but was having trouble because Resident #1 had no income, and she is Medicaid pending. Interview on 10/11/2023 at 3 PM with the ADON stated she had worked at the facility for 34 years. The ADON stated Resident #1 had eloped, was found with wander guard bracelet- (so staff can hear alarm when she exits the facility), had no injuries and staff, family were notified. The ADON stated staff did incidents reports after the incident occurred. The ADON stated the staff had been alternating 1:1 monitoring with Resident #1, Resident #1 wants to leave, and get sundowners (Sundowning is the name for a group of behaviors, feelings and thoughts people who have Alzheimer's or dementia can experience as the sun sets.). The ADON stated they do not usually take resident with elopement risk and the plan was to transfer Resident #1 to a facility with a secure unit. The ADON stated the interventions were medications review for moods and anxiety. This was determined to be an Immediate Jeopardy (IJ) on 10/07/2023 at 3:28 PM. Administrator was notified. Administrator was provided with the IJ template on 10/07/2023. The following Plan of Removal was accepted on 10/11/2023 at 4:30 PM. Plan of Removal Date 10/11/2023 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On 9/19/2023 an investigation was initiated at the facility. On 10/07/2023, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F689 Quality of Care The facility failed to provide Quality of Care for Resident #1 in that it did not in-service staff after each time she eloped, three times, did not have elopement assessment after each elopement and care plans were not measurable for elopement risk. Problem The Facility's Deficient practice revealed facility failed to ensure the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Immediate Corrections Implemented for Removal of Immediate Jeopardy. Facility's Plan of Removal, 10/7/23 Preparation and/or execution of this Plan of Removal does not constitute admission or agreement by the provider of the truth of facts alleged or conclusions set forth in the preliminary finding in the IJ component date 10/7/23. The Plan of Removal is prepared and/or executed solely because the provisions of Federal and State laws require it. Component one: Noncompliance All Staff will be in-serviced immediately on preventing accidents and hazards, namely the risk of Resident #l's elopement from the facility. In-service started 10/7/23 at 5:00 PM. Completed 10/7/23 at 6:20 PM. We have two other residents who are wheelchair bound and even though they have never eloped, we have completed their elopement risk assessments. Resident #l's care plan has been updated with current interventions related to her elopements. The two other residents who are wheelchair bound, and have never eloped, have also had their care plans updated. Component two: Serious injury, serious harm, serious impairment, or death: Resident #1 has been placed on a one-to-one observation by staff on all three shifts (which means one employee was assigned to Resident #1 24 hours a day, seven days a week) since 09/21/2023. Before 09/21/2023, Resident #1 was on a 15-minute watch by staff. No elopement has occurred since 8/26/23 (42 days ago). When the elopements occurred, no injury was sustained by Resident #1. She was not in any danger, she was found nearby, and she was found within an hour. She did not miss any medications and there was no danger from the weather (neither heat nor cold). Resident #1 is alert enough to navigate the neighborhood (walk on sidewalks, cross streets, etc.) without endangering herself. Completed 10/7/23 at 3:28 PM Component three: Need for immediate action: The facility will ensure that all staff were trained on elopement risk patients, in particular Resident #1. The RN Consultant will monitor on a weekly basis. Resident #1 will continue to be on a one-to-one observation by staff on all three shifts (24 hours a day, seven days a week). We have been trying to place Resident #1 in a locked unit. We have been in constant contact with her Guardian about transferring her to another facility, but to no avail. We have contacted at least six facilities with locked units; however, all have refused because Resident #1 does not have any funds and is Medicaid pending. Completed 10/7/23 at 6:20 PM STAFF MEMBERS WHO ARE ON VACATION, SICK OR ARE UNABLE TO BE REACHED, WILL NOT BE ALLOWED TO COME BACK TO WORK UNTIL IN-SERVICED ON ABOVE TOPICS. In-service started 10/7/23 at 5:00 PM. Completed 10/7/23 at 6:20 PM. Plan of removal has been implemented and completed by 10/7/23 at 6:20 PM. Please, accept this plan of removal as our statement of compliance. Plan Of Removal Verification The facility RN supervisor completed a 100% audit of staff in-service and 100% of resident elopement risk assessments and care plans of elopement risk residents were completed. This audit was completed on 10/11/2023. Record review of the staff in-service with signatures by all staff at the facility. The facility RN supervisor provided the one-to-one observations by staff on all three shifts since 9/21/2023. Record review of the 1:1 sheets with staff signatures were provided form 9/21/2023 to current. The facility RN supervisor provided the form she started to monitor staff training on elopement risk residents on weekly basis. Record review of the staff monitoring sheet was started by the RN supervisor. The facility RN supervisor provided the list of facilities contacted with a secure unit but was denied to funding. Record review of a sheet of paper with a list of secure unit facilities were listed and stated denied due to funding. Record review of in-service dated 9/21/2023 from 6-6:30 PM by DON was documented Elopement, educate staff on resident with elopement risk, resident will have letter E placed on the door, Resident #1 was to wear wander guard at all times and battery check weekly, check on 1:1 status. Record review of in-service had the Wandering and Elopement Protocol with each staff person that signed and dated it. Record review of in-service dated 10/7/2023-10/10/2023 for all 3 shifts with staff signatures/phone calls was documented protocol for wandering residents and elopement prevention, Resident #1 must continue to be on 1:1 basis at all times, offer activities she likes, wander guard at all times, and check alarm bracelet. This had 65 staff. (Some staff signed multiple times- staff made sure all 3 shifts signed that they had the in-service). Record review of in-service had the Wandering and Elopement Protocol. Record review of in-service dated 10/9/2023 for 7/26/2023, 8/8/2023, 8/26/2023 by Administrator/Maintenance supervisor was documented check all exits for possible ways Resident #1 could have eloped, in case of elopement place on every 15-minute check or 1:1 status, charge nurse to notify administrator, family, or APS and medical director, and Resident elopement risk wear I badge, and picture in medical record to ID resident. This in-service had 25 staff. Record review of in-service form- meeting with Administrator, RN supervisor, temporary guardian and Ombudsman dated 10/11/2023 regarding Resident #1. They agreed that as soon as the temporary guardian was a permanent guardian. The permanent guardian will place Resident #1's assets for sale. Then Resident 1's assets will not count as a resource for Medicaid, so she can qualify for Medicaid. Temporary guardian and Ombudsman will be looking for placement as soon as possible. Record review of Resident #1's updated care plan completed by RN supervisor stated she updated the care plan with dates. Resident #1's care plan: this was the order the care plan was in. 7/26-8/82023-Staff member to monitor resident #1 every 15 minutes. 8/26/2023-continue a 1:1 intervention (a staff member accompany Resident #1 at all times. 6/16/2023-make sure resident had a wander guard on, with the name at all times. Check wonder guard daily to make sure that it works. 6/16/2023-makes sure the front door alarm is working, and that resident #1 room window was locked, and alarm is on. (This was not on the original care plan). 107/2023-complete an elopements risk assessment, 7/26/2023 document all incidents of elopement and elopement attempts. 6/16/2023-identify pattern of wandering. Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? 6/16/2023-maintain log of interventions that work, offer activities and entertainment she liked: listening to music, walking outside supervised, puzzle, coloring, etc. maintained safety. 6/162023-identification on band on resident, clothing. 6/16/2023 -wander guard for alarm front door. 6/28/2023 Asses for fall risk. 6/16/20223-make staff aware of elopement risk. 7/26/2023-staff to accompany resident wen going to the patio area for activity. 10/7/2023-personalize room with clock, calendar, signs, or pictures. Structured Activates 6/16/2023-structured and supervised walking activities. Reorientation to person. Place and time. 7/26/2023- distract resident form wande[TRUNCATED]