**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 possible and each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 did not elope from the facility without staff knowing from 05/10/25 at 06:03 PM to 05/11/25 at 12:50 AM (approximately 6 hours and 47 minutes). The noncompliance was identified as PNC. The IJ began on 05/10/25 and ended on 05/11/25. The facility had corrected the noncompliance before the investigation began. This deficient practice could place residents at-risk of harm, serious injury, or death. The findings included: Record review of Resident #1's admission Record, dated 06/24/25, reflected Resident #1 was a [AGE] year-old female admitted [DATE] with diagnoses to include vascular dementia (type of dementia caused by brain damage from impaired blood flow) and Alzheimer's disease (a degenerative brain disorder that primarily affects memory, thinking, and cognitive abilities). Record Review of Nursing Admission/readmission assessment, authored by LVN A on 05/10/25 at 03:19 PM, reflected Resident #1 was alert but some disorientation or forgetfulness, able to verbalize needs & wants. It further reflected Resident #1 was not physically able to leave the building on their own so resident did not need an Exit Seeking care plan. Record Review of Resident #1's MDS assessment, dated 05/15/25, reflected a BIMS score of 1 out of 15, indicating severe cognitive impairment. It reflected Resident #1 had a behavior of wandering in the last 1 to 3 days. It reflected the wandering did not place the resident at significant risk of getting to a potentially dangerous location to include outside of the facility. Record review of the Investigation Timeline, undated, created by the ADM, reflected as follows: On 05/09/25: The Admissions Coordinator gave wander guard device to LVN D who then placed it in 600 med cart. The Admissions Coordinator updated community dashboard with Resident #1 admission needs wander guard in the nurses cart On 05/10/25: *At 02:45 PM Resident #1 admitted to community with family and LVN A completed head to toe assessment *At 04:30 PM: video surveillance revealed LVN A opened up 600 hall med cart and took out the wander guard then placed it back. *At 04:35 PM: LVN A went on break and gave report to LVN B without mention of any supervision for Resident #1 *At 05:55 PM: LVN A came back from break *At 06:03 PM: RN C opened the door and let Resident #1 out of the facility. There was no inclement weather and Resident #1 was dressed appropriately. *At 06:45 PM: The nearby hospital called the facility stating Resident #1 was at the hospital. *At 06:59 PM: Head count was done, and all other residents were in the facility. All doors, windows, and wander guard system was checked. Resident with a wander guard were checked for placement and functionality. On 05/11/25: *At 12:50 AM: Resident #1 returned to the community and placed in the secured unit. MD and RP were notified. Head to toe assessment was completed. Record review of the provider investigation report for this incident, dated 05/11/25, reflected, On 05/10/25 at approximately 06:30 PM [Resident #1] who admitted earlier that day exited the community and walked across the parking lot to the neighboring hospital. The hospital staff notified the community that the resident was there and out of an abundance of caution resident was evaluated and discharged back to the facility. Resident's assigned MD and RP were made aware. Upon resident's return to facility, she was assessed and placed on the secured unit and on-going monitoring is in place. Resident is at usual physical and emotional baseline status, no [signs and symptoms] of emotional or physical trauma. IDT has reviewed/update the plan of care accordingly. Observation on 06/24/25 at 10:50 AM revealed Resident #1 was in the secured unit and was not able to provide answers to questions asked. Interview on 06/24/25 at 11:14 AM, the ADM revealed Resident #1 needed to have a wander guard out of precaution because the facility was told Resident #1 wandered in and out of rooms at her previous facility. She revealed LVN A failed to put a wander guard on Resident #1. She revealed Resident #1 was not put in the secured unit because they were told Resident #1 did not ambulate. She revealed RN C let Resident #1 opened the door and let Resident #1 out of the facility. Interview on 06/24/25 at 12:06 PM, RN C revealed she saw Resident #1 waiting by the front door to the facility, opened the door for her, and let her out of the building. RN C revealed she did not know Resident #1 was a resident. Interview on 06/24/25 at 01:15 PM, LVN A revealed she did not remember Resident #1 or any elopement incident that happened in May 2025. Voicemail was left for LVN B on 06/24/25 at 01:43 PM with no call back from LVN. Interview on 06/24/25 at 02:26 PM, the Admissions Coordinator revealed the DON did as assessment for Resident #1 at Resident #1's previous facility and told her on 05/09/25 that Resident #1 needed a wander guard when Resident #1 was going to be admitted on [DATE]. The Admissions Coordinator revealed she gave the wander guard on 05/09/25 to LVN D to put in her med cart and expected LVN D to pass along the information that Resident #1 needed this wander guard to the oncoming shifts until Resident #1 admitted to the facility. The Admissions Coordinator revealed she also updated the dashboard in the electronic medical record (EMR) and staff knew to look at for updates for resident care. Voicemail was left for LVN D on 06/24/25 at 02:45 PM with no call back from LVN. Interview on 06/24/25 at 03:11 PM, the ADM and DON revealed they had assessed Resident #1 at her previous facility and learned Resident #1 was considered a wanderer but was not exit seeking. They revealed this was why they had a wander guard ready for when Resident #1 was admitted . The ADM revealed LVN A knew she needed to put the wander guard on Resident #1 because it was in her med cart and because this direction was reflected on the EMR Dashboard, which nursing staff knew to review when they logged into the EMR. The ADM further revealed LVN A did not work at the facility anymore. They revealed they did not have hospital records for Resident #1 when she was at the hospital on [DATE]. Record review of the facility's policy Resident Safety: Prevention of Responding to Missing Person, and Exit Seeking, revised January 2025, reflected New Admits/Re-Admits should be assessed/re-assessed as clinically indicated by completing the elopement risk/exit seeking assessment UDA in[EMR]. And If assessment deems resident is at risk for elopement and placement on a special care unit or the use of an alert bracelet may be utilized to maintain the resident's personal safety and promote overall well-being. The Administrator was notified on 06/25/25 at 02:48 PM, a past non-compliance IJ situation had been identified due to the above failure. The facility implemented the following interventions. Record Review of Resident #1's care plan reflected a focus of At risk for elopement and/or wandering with unsafe boundaries r/t cognitive impairment/judgement and safety awareness, initiated 05/11/25, with intervention Safety Risk: Monitor resident regularly throughout shift to prevent wandering into other rooms, exit seeking and elopement. Distract & Assist quickly to prevent accidents/injury. Notify the nurse., initiated 05/11/25. Record Review of Resident #1 doctor's orders reflected as of 05/10/25 Admit to Secure unit due to behaviors that may include but not limited to: wandering, exit seeking ., dated 05/11/25, and Resident #1 was being monitored for wandering behavior. Resident #1 was placed on the secured unit on 05/11/25, when the resident came back to the facility. Record review of in-service training, starting on 05/10/25, reflected licensed nurses (to include LVN A, LVN B, and RN C) were educated on the importance of immediately completing the admission assessment/evaluation and exit seeking tool. Record review reflected all staff (to include LVN A, LVN B, and RN C) were educated on 05/10/25 for Elopement Response & Exit Seeking Management and Resident Safety, exit seeking, abuse and neglect and Identifying and Responding to Triggers to Prevent. Record review reflected all staff (to include LVN A, LVN B, and RN C) were educated on 05/10/25 for Process for monitoring, identifying, and reporting resident with exit seeking behaviors or identified risks. Abuse and Neglect (~25% of staff were interviewed on in-servicing on elopements) Record review of facility Incidents and Accidents report for the last 6 months reflected that no other resident had eloped apart from the incident on 05/10/25. Record review of facility's monitoring tool for Elopement/Missing Person Response Drills, dated May and June 2025 dates, reflected the facility was monitored all shifts initially then random shifts, 2-4 times per month x1-2 months. Record review of 4 residents (to include Resident #1) reflected exit seeking tool was completed on 05/10/25. Interview on 06/24/25 at 03:11 PM, The ADM revealed there was not an official training or policy for letting visitors in and out of the building but she let the staff know how to tell the difference between a visitor and a resident so a resident would not be accidentally let out of the building. Interview on 06/25/25 at 10:48 AM, the DON revealed on 05/10/25 they re-assessed all residents with the exit seeking tool to ensure they were filled out properly. Interview on 06/24/25 at 10:58 AM, CNA K (typically worked 6AM-2PM, but worked other times as well) revealed he was trained on preventing elopements to include what residents were at high risk for elopements, responding to door alarms, checking on residents regularly, doing headcounts, and more. He revealed if a resident were to elope, he would follow the resident out and contact the ADM immediately. Interview on 06/24/25 at 11AM, LVN P (worked 6AM-6PM) revealed she was trained on elopements and would follow a resident who exited the building for safety. She revealed she would respond to any alarm to make sure residents were safe. She revealed they performed resident head count checks to make sure all the residents were in the building. She revealed she would report abuse, neglect, or elopements to ADM right away. Interview on 06/24/25 at 12:06 PM, RN C (worked 6AM-6PM) revealed after this incident she was trained on being able to identify who was a visitor and who was a resident. She revealed she would check in with the front desk, who oversaw letting people in and out of the building. She revealed visitors also had name tags to show they were visitors. She revealed she was trained on elopement to include checking on residents regularly and to respond to the wander guard alert if a resident were to get to the front door. She revealed for new admissions they assessed residents to include seeing how oriented they were in the facility. She revealed if a resident was confused, they would monitor resident to ensure they did not wander. She further revealed they would also have to assess if resident needed to be in the secured unit. Interview on 06/24/25 at 12:25 PM, Receptionist O (worked 8AM-5PM) revealed anyone who leaves the building needed to check out with her. She revealed when anyone enters the building, they also checked in with her. She revealed if she did not know if a resident was supposed to leave for the day, she would check with the nursing staff before letting them out because they needed to sign something first. Interview on 06/24/25 at 02:26 PM, the Admissions Coordinator (worked 8AM-5PM) revealed she was trained on how to tell the difference between a resident and a visitor to include asking specific questions. She revealed she was trained on preventing elopements like redirecting residents who were trying to exit the building. She revealed if a resident were to exit the building, she would follow them. She revealed their wander guard alarm system would alarm if a resident with a wander guard was trying to exit the front door. She revealed she made sure that staff had wander guard as needed if a resident assessment showed a resident needed a wander guard. Interview on 06/25/25 at 08:37 AM, CNA E (worked 10PM-6AM) revealed she was trained on preventing elopements. She revealed for Wander alarms, if the alarm went off, they would run to stop the resident, redirecting them away from the exit. She revealed she would follow the resident if they did happen to exit and kept eyes on her residents. She revealed she would report to ADM immediately. She revealed that PCC had a front page for pertinent alerts. She further revealed she was trained to tell the difference between visitors and residents. She revealed the visitors had visitor badges, so the staff knew to look out for this. Interview on 06/25/25 at 08:52 AM, CNA F (worked 10PM-6AM) revealed she was trained on elopement. She revealed she checked on residents in their rooms frequently. She revealed if a resident was not in their room, she would check their restroom, her hallway, speak to the nurse, and contact ADM immediately. She revealed if the door alarm went off, she would redirect resident to the middle of the building and alert the nurse. She revealed if a resident eloped, she would not leave any resident alone due to resident safety. She revealed she was trained on abuse and neglect and reported this along with elopements to the ADM immediately. She revealed visitors had name tags or she would look at the visitor logbook to verify visitors. She revealed she used the home page in the PCC for alerts to include resident pictures for warnings such as if a resident was a wanderer. Interview on 06/25/25 at 08:58 AM, LVN G (worked 6PM-6AM) revealed she was trained on what to do when a resident eloped. She revealed if a resident had a wander guard, the alarm went off and they would respond immediately to get the resident. She revealed she would call ADM and DON immediately if there was a missing resident, and they would search the building to see if resident were hiding somewhere first. She revealed if the doors alarmed, they would go outside right away to search for resident. She revealed she was trained on how to tell the difference between a visitor and resident. She revealed visitors had name tags and she would ask more questions to the visitor or resident to determine who they were. She revealed if a visitor did not sign in, she would ask questions. She revealed she used the PCC Dashboard for pertinent alerts for residents. Interview on 06/25/25 at 09:10A, Receptionist O revealed if a resident were to exit the building, she would stay with them the whole time and call for help. She revealed if any alarm went off (to include the wander alarm or door alarm), she would go to the direction of the alarm, redirect resident, and contact nursing staff. She revealed if someone were to leave, she would contact ADM. Interview on 06/25/25 at 09:15 AM, Dietary [NAME] Q, Dietary Aide R and Dietary Aide S revealed they were trained on elopement. They revealed if they heard any alarm, they would go towards the alarm and make sure the resident was redirected from exiting. They revealed they knew to help locating a missing resident if the whole building needed to find a resident, but they have not been asked to do so yet. They revealed if they saw abuse, neglect, or an elopement, they would contact the ADM as soon as possible. They revealed they knew visitors should have name tags, but they revealed they knew they had to speak with the nursing staff before letting anyone out of the building to ensure it was a visitor. They revealed if they saw a resident exiting the building, they would make sure to follow them, so the resident remained safe. Interview on 06/25/25 at 09:20 AM, CNA J (worked 6AM-2PM) and LVN U (worked 6AM-2PM) revealed they were trained on elopements and had a quick reference attached to their badges. They revealed if they heard an alarm go off in the building, they would go to it right away and make sure the resident would not elope. They revealed they would count residents and go outside if they were not able to locate the resident inside the building. They revealed they do visual checks on residents frequently and were aware of what residents wandered or were exit seeking. They revealed they knew visitors had name tags to identify themselves, but if they questioned if someone was a visitor, they would ask questions or look in EMR to see if they were a resident. They revealed they could also check with the receptionist to identify visitors before letting them out of the building. They revealed they were trained on abuse, neglect, and elopements and would report to the ADM and DON right away. LVN U revealed he was detailed in his assessments and even documented in progress notes if a resident was a wanderer or elopement risk. He revealed if the resident was not capable of contributing to an interview, he would call family, previous nurses, administration, or the previous facility. They revealed they knew to look at the EMR dashboard for pertinent alerts to include if a resident was a wanderer. Interviews on 06/25/25 at 09:26 AM, CNA V (worked 6AM-2PM), CNA K (worked 6AM-2PM), Agency Nurse T (worked 6AM-6PM) revealed they were trained on abuse, neglect, and elopement and to report to ADM and DON immediately. They revealed they checked on their residents frequently and if they had a missing resident, they would search the building and let all nursing staff know. They revealed they would search outside if they could not find the resident inside. They revealed visitors had name tags and they would double check with the nurses before letting someone out of the building. They revealed they used EMR dashboard for any alerts for their residents. Agency nurse revealed that she was detailed in her assessments of residents to include their physical assessment, physical ability, and if a resident were a wanderer or needed monitoring. Interview on 06/25/25 at 10:08 AM, LVN W (worked 2PM-10PM) revealed he was trained on elopements. He revealed he would respond to alarms right away for wander guards or doors. He revealed if they did not find the resident inside the building, they would have to go outside to find the resident. He revealed he would report to ADM immediately. He revealed if resident exited the building, he would follow the resident out. He revealed the visitors had a badge to identify themselves. He revealed EMR had an alert page to know about anything new going on with the residents. He revealed he checked on his residents regularly and if someone was missing, they would have to search for the resident and alert ADM immediately. He also revealed he contacted the ADM immediately if there was any abuse or neglect. He revealed the number one priority was resident safety. He further revealed he recorded detailed information if resident had incident or history of elopement. He revealed they would document any observations or potential triggers. Interview on 06/25/25 at 11:15 AM, CNA X (worked 10PM to 6AM and 2PM-10PM sometimes) revealed she was trained on abuse, neglect, and elopements. She revealed she would report to nurse and ADM immediately. She revealed if any doors or wander guard alarmed, she would do a head count, check doors, and check wander guards. She revealed she redirected residents from going outside. She revealed if they made it outside, she would stay with the resident. She revealed she used the EMR dashboard for alerts. She revealed visitors had name tags and she knew to not let residents out of the building. She revealed she checked residents frequently. She revealed if she had a missing resident, she would let nurses know, do a head count, search for resident, and report to ADM immediately. Interview on 06/27/25 at 01:03 PM, COTA Y revealed she had been trained on preventing elopements. She revealed she would respond to any door alarms or wander guard alarms. She revealed she would help out with searching for any missing residents or any resident that had eloped. She revealed if she saw a resident elope, she would follow the resident for resident safety. She revealed she knew to report abuse, neglect, and elopements to the ADM immediately. Observation on 06/24/25 at 09:06 AM revealed that upon entrance, this surveyor had to be let into the facility by Receptionist, check in via a computer, and get a name tag to identify as a visitor. This observation continued throughout investigation. Observation on 06/26/25 at 06:45PM revealed the front door was locked and needing a staff member to verify this surveyor was a visitor before opening the front door. The noncompliance was identified as PNC. The IJ began on 05/10/25 and ended on 05/11/25. The facility had corrected the noncompliance before the investigation began.