**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for 4 of 6 residents (Residents #33, #40, #290, and #1) and prevent coffee burns for 1 of 2 residents (Resident #2) reviewed for accident hazards and supervision. 1. The facility failed to prevent Resident #33 from eloping from the facility on 04/14/2024, 06/20/2024 and 06/21/2024. 2. The facility failed to prevent Resident #40 from eloping from the facility on 08/09/2024. 3. The facility failed to prevent Resident #290 from eloping from the facility on 06/13/2024. 4. The facility failed to prevent Resident #1 from eloping from the facility on 07/13/2024. 5. The facility failed to ensure Resident #2's coffee lid was placed properly which resulted in her spilling it on herself on 04/04/2024. 6. The facility failed to ensure Resident #2 was served coffee in a cup with a lid on it, which resulted in her spilling it on herself on 06/09/2024. An Immediate Jeopardy (IJ) situation was identified on 08/20/2024 at 4:15 p.m. While the IJ was removed on 08/21/2024, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of serious injury or harm. The findings included: 1. Record review of Resident #33's face sheet, dated 08/21/2024, originally admitted to the facility on [DATE] with a diagnosis which included Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of the quarterly MDS assessment, dated 08/12/2024, indicated Resident #33 made herself understood and understood others. Resident #33's BIMS score was 7, which indicated her cognition was severely impaired. Resident #33 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 12/26/2023, indicated Resident #33 was at risk for wandering and elopement. The interventions included: distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, redirect away from entrances and exits, monitor the location frequently and document the wandering behavior and attempted diversional interventions. Record review of Resident # 33's Elopement assessment, dated 04/14/2024, 06/20/2024, and 06/21/2024, reflected Resident #33 was at risk for elopement. Record review of the event nurse's note dated 04/14/2024 at 11:00 a.m., reflected Resident #33 followed another resident outside through the front door. Resident #33 was observed by a staff propelling in the front parking lot of the facility. Record review of the event nurse's note dated 06/20/2024 at 2:10 p.m., reflected Resident #33 was found outside in the front parking lot. Resident #33 stated she really did not know where she was. Record review of the event nurse's note dated 06/21/2024 at 9:00 p.m., reflected Resident #33 was found by a family member outside by vehicles approximately 50 feet from the entrance door. 2. Record review of Resident #40's face sheet, dated 08/21/2024, originally admitted to the facility on [DATE] with a diagnosis which included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of the quarterly MDS assessment, dated 08/06/2024, indicated Resident #40 made herself understood and usually understood others. Resident #40's BIMS score was 0, which indicated her cognition was severely impaired. Resident #40 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 08/09/2024, indicated Resident #40 attempted to elope and was found in the parking lot to the back of building. The interventions included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, supervise closely and make regular compliance rounds whenever residents in the room. Record review of Resident # 40's Elopement assessment, dated 08/09/2024, reflected Resident #40 was at risk for elopement. Record review of the event nurse's note dated 08/09/2024 at 8:41 a.m., reflected Resident #40 was observed rolling in her wheelchair outside in the parking lot around the building. Resident #40 stated she was going to see a friend at the hospital. 3. Record review of the face sheet, dated 08/20/2024, revealed Resident #290 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of Traumatic brain injury (head injury causing damage to the brain by external force or mechanism), unspecified dementia with agitation (group of symptoms affecting memory, thinking, and social abilities with excessive verbal or physical aggression that causes emotional distress and excess disability), schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and bipolar disorder with psychotic features (serious mental illness characterized by extreme mood swings). Record review of the quarterly MDS assessment, dated 07/23/2024, revealed Resident #290 had clear speech and was usually understood by others. The MDS revealed Resident #290 was able to understand others. The MDS revealed Resident #290 had a BIMS score of 5, which indicated severely impaired cognition. The MDS revealed Resident #290 had disorganized thinking, which fluctuated. The MDS revealed Resident #290 had delusions, but no behaviors, wandering, or refusal of care. The MDS revealed Resident #290 used a manual wheelchair. Record review of the comprehensive care plan, revised on 04/18/2023, revealed Resident #290 was at risk for elopement and wandering because of impaired safety awareness. The goals included: The resident will not leave facility unattended through . and The resident's safety will be maintained . The interventions included: Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes; Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate; and Monitor location frequently. Document wandering behaviors and attempted diversional interventions. Record review of the elopement risk assessment dated [DATE], 06/12/2024, and 06/13/2024, revealed Resident #290 was at risk for elopement. Record review of the event nurses' note, dated 06/13/2024, revealed Resident #290 exited out the front door of the building and was witnessed in the parking lot by vehicles. Resident #290 told staff she was going to work. 4. Record review of the face sheet, dated 08/20/2024, revealed Resident #1 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of intracranial injury (head injury causing damage to the brain by external force or mechanism). Record review of the quarterly MDS assessment, dated 07/29/2024, revealed Resident #1 had unclear speech and was usually understood by others. The MDS revealed Resident #1 was usually able to understand others. The MDS revealed Resident #1 had a BIMS score of 0, which indicated severe cognitive impairment. The MDS revealed Resident #1 had disorganized thinking, that fluctuated. The MDS revealed Resident #1 had no behaviors, wandering, or refusal of care. The MDS revealed Resident #1 used a wheelchair. Record review of the comprehensive care plan, revised 07/15/2024, revealed Resident #1 was at risk for elopement and wandering. The goals included: The resident will not leave facility unattended . and The resident's safety will be maintained . The interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate.; If the resident is exit-seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc.; Provide structed activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes.; . Resident redirected back into facility, educated on the dangers of being in parking lot and ongoing monitoring in place. Record review of the elopement risk assessments dated 12/28/2023, 03/29/2024, 06/29/2024, and 07/13/2024 revealed Resident #1 was at risk for elopement. Record review of the event nurses' note, dated 07/13/2024, revealed Resident #1 exited out the front door and was found, by a family member, sitting in his wheelchair behind an employee vehicle. Resident #1 stated he was enjoying the sunshine. Record review of the facility's policy titled, Elopement Prevention, revised 10/27/2010 indicated, .every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement .2. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team . Physical Plant .1. All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts .2. All others exit not considered fire exits will be locked when not occupied by staff members .3. All exit devices will be maintained by the manufacture's recommendations and function of each door device will be verified weekly and a log maintained . During an observation on 08/19/2024 at 8:15 a.m., the front door had an automatic sliding door and no alarm had sounded upon entrance to the building. The facility was located on a busy highway. During an interview on 08/19/2024 at 4:12 PM, LVN K said if a resident was a high risk for elopement, they redirected them. LVN K said interventions for residents at risk for elopement were redirecting them, and they had the two double doors before the door to exit that acted as an intervention to stop them. The double doors were not locked. LVN K said the door to the exit had a button you had to push for it to open, but it was not locked either. LVN K said it would be hard for a resident to reach the button in a wheelchair. LVN K said the door to the exit did not have an alarm. LVN K said they did not have a wander guard system or anything like it to put on the residents that wandered. LVN K said elopement risk assessments were completed on admission, every three months, and if a resident had an elopement attempt. LVN K said if a resident attempted to elope 1-2 times they would be moved to the secure unit. During an observation on 08/20/2024 at 7:15 a.m., the front door had an automatic sliding door and no alarm had sounded upon entrance to the building. No staff members were observed in the lobby. During an observation on 08/20/2024 beginning at 7:21 a.m., Resident #33 was wheeling herself down the B-Hall during breakfast time. The only staff member on the hallway was a housekeeper, who was in another resident's room cleaning. Resident #33 started from the nurses' station and slowly wheeled herself down to the therapy gym. Resident #33 wheeled herself around the therapy gym, then sat in the doorway wheeling herself back and forth. During an interview on 08/20/2024 beginning at 9:38 a.m., the DON stated residents at risk for elopement, not on the secured unit, had no special monitoring. The DON stated the direct care staff were made aware of the residents at risk for elopement and were instructed to keep a close eye on them. The DON stated there were no set timeframes for monitoring the residents, they should have been monitored according to their judgment. The DON stated the facility did not use a wander guard system or alarms. The DON stated the facility tried to keep the double doors leading into the lobby closed and a staff member in lobby to slow residents who were at risk for eloping down. The DON stated if residents actually eloped, then the residents were redirected into the building. The DON stated if residents were not easily redirected, they were placed on the secured unit. The DON stated labs were ordered on a case-by-case basis to determine if an acute illness was causing wandering behaviors or if placement on the secured unit was necessary. The DON stated residents were placed on the secured unit pending labs. The DON stated after an elopement, residents were placed on 72-hour monitoring. The DON stated the IDT usually met after an elopement to discuss and update the care plan. The DON stated Resident #40 started wandering during the evening times. The DON stated Resident #40 was able to go outside without staff supervision as long as a staff member was sitting in the lobby. The DON stated Resident #40 was easily redirected into the building and 72-hour monitoring was performed. The DON stated she did not believe Resident #40 had been evaluated for the secured unit. The DON stated Resident #290 and Resident #33 had been on the secured unit previously but had to be taken out of the secured unit because they were having combative behaviors with other residents. The DON said there was no special monitoring in place for Resident #290 or Resident #33. The DON stated Resident #33 wandered constantly around the building and have instructed staff to ensure she was watched. The DON stated after Resident #290 and Resident #33 eloped they were placed on 72-hour monitoring. The DON was unsure if labs had been completed. The DON stated Resident #1 was able to wheel himself around the facility. The DON stated Resident #1 was probably at risk for elopement related to past attempts. The DON stated Resident #1 was placed on 72-hour monitoring and reeducated on the dangers of wandering outside. The DON stated the risk for residents eloping would depend on the time of the day, but they were at an increased risk for injury or elopement. During an interview on 08/20/2024 beginning at 2:03 p.m., The Administrator stated the preventative measures put in place currently for residents at risk for elopement who do not reside on the secured unit included: staff monitoring and closing the double doors in the front lobby to slow the residents down. The Administrator stated she had been asking corporate to get the facility a locked keypad for the front door and it was supposed to have been a work in progress. The Administrator stated the facility did not have a wander guard system or alarms for the front door. The Administrator stated if a resident eloped the facility implemented 72-hour monitoring. The Administrator stated incident and accidents were reviewed regularly but she was unsure if any trends had been identified. The Administrator stated she asked for the door keypad around the time the resident elopements had started. Record review of a printed screen shot, provided on 08/20/2024 with a time of 2:31 p.m., revealed the Administrator had asked the corporate office for a keypad entry and exit for the front door on 05/07/2024. Record review of a printed copy, provided on 08/20/2024, revealed a submitted proposal on 05/23/2024 for a keypad entry and exit for the front door. The owner had not signed. 5. Record review of a face sheet dated 08/20/2024 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety (deterioration of memory, language, and other thinking abilities without behaviors), cerebral infarction (stroke), and glaucoma (eye disease that can cause vision loss or blindness). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 usually understood others and was usually able to make herself understood. Record review of the MDS assessment indicated Resident #2 had a BIMS score of 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #2 required supervision or touching assistance with eating, substantial/maximal assistance with toileting hygiene, and was dependent for showering/bathing and personal hygiene. Record review of Resident #2's care plan last reviewed 07/25/2024 indicated Resident #2 was at risk of burns due to hot liquids with interventions which included coffee and other hot liquids should not be served if over 140 degrees, educational in-service was given to staff about making sure cup lid was on properly to prevent spillage, if hot liquid was spilled on self, staff should pour room temperature or lower temp liquid on the affected area of the resident, resident to use spill proof cup with lid for coffee, should be seated in upright position with table or overbed table when hot liquids were being consumed, and staff to provide observation and verbal assistance when resident had hot liquids. Record review of the Order Summary Report dated 08/21/2024, indicated Resident #2 had an order for a fortified/enhanced diet, mechanical ground texture, regular consistency, and liquids by straw. Record review of an Event Nurses' Note - Burn dated 04/04/2024 indicated Resident #2 was in the dining room and had a burn caused by coffee, tea, or other hot liquid to the left abdomen and left lower breast. Details of injury indicated she had an 8x9 cm red area, no blistering, slight pain to touch. Nursing Description of the event indicated, CNA stated she was bringing another resident to the dining room and resident was saying help me, when CNA went to her, she noted that her shirt was wet and the resident stated she spilled her coffee. Resident had her personal cup with lid. Unknown who fixed coffee for resident as she is not able. Resident Statement indicated, Resident stated that she did not know who got her coffee but the lid was not on it like it was supposed to be and she spilled it. Initial treatment/new orders indicated, No treatment at this time, will monitor and offered pain med and was refused. Interventions initiated by nurse indicated, Lid on cup/mug/glass. Signed by Treatment Nurse H. Record review of an Injury Nurses' Note 12 hr dated 04/05/2024 12:09 AM, indicated Resident #2 had no injury. Record review of an Event Nurses' Note - Burn dated 06/09/2024 indicated Resident #2 was in the dining room and had a burn caused by coffee, tea, or other hot liquid to the left breast and under left breast. Details of injury indicated she had a burn injury slightly red, approximately 4 cmx2 cm to under left breast and 6 cmx5 cm to left breast. Nursing Description of the event indicated, CNA observed residents blouse being wet, and when she checked she seen the redness underneath. Resident Statement indicated, Resident stated leave me alone. Initial treatment/new orders indicated Zinc oxide (ointment used for skin) BID x 3 days. Interventions initiated by nurse indicated, Lid on cup/mug/glass. Signed by LVN P. Record review of an Injury Nurses' Note 12 hr dated 06/10/2024 12:43 PM, indicated Resident #2's redness related to the burn was gone. During an observation on 08/20/2024 at 7:20 AM, Resident #2 was observed sitting in the dining room drinking coffee from a covered cup with a straw. During an interview on 08/20/2024 at 7:44 AM, the Food Service Supervisor said Resident #2 was the only one who had spilled coffee on herself that she could think of, and she believed it was only once. The Food Service Supervisor said there had not been any further incidents after June 2024. The Food Service Supervisor said if the residents needed therapy ordered a spill proof cup, and Resident #2 required a spill proof cup for her coffee. The Food Service Supervisor said Resident #2 had to be served her coffee, but the residents that were able to, served themselves coffee. The Food Service Supervisor said they checked the coffee temperature daily and ensured it was at 140 degrees to prevent burns. The Food Service Supervisor said she monitored coffee was available during the day while kitchen staff were present. During an interview on 08/20/2024 at 9:32 AM, LVN L said residents had access to coffee in the dining room all day. LVN L said residents were allowed to get coffee on their own. LVN L said Resident #2 required a special cup because she had spilled coffee on herself a couple of times, and the cup was needed to prevent future burns. LVN L said if she noticed a resident was having issues holding a cup, she would let the nurse manager know and they would get with therapy to get the devices the residents needed. During an interview on 08/20/2024 at 9:56 AM, CNA O said the residents usually had coffee available to them all day. CNA O said the residents were able to get it themselves. CNA O said Resident #2 had a special cup for coffee that had a lid on it, and she was the only one that she knew of. CNA O said Resident #2 required the cup because her grip was not good, and to prevent her from spilling the coffee on herself and getting burned. During an interview on 08/20/2024 at 10:01 AM, the DON said on 04/04/2024 when Resident #2 spilled coffee on herself Resident #2 said the lid was not on tight enough. The DON said Resident #2 was supposed to be using the cup with the lid on it at that point. The DON said she educated the staff to make sure the lid was properly secured to prevent spillage. The DON said she provided an in-service. The DON said they were unable to determine what degree burn she had gotten from the spilled coffee but there was redness, no blister, and had resolved by the next day. The DON said on 06/09/2024 when Resident #2 spilled coffee on herself Resident #2 did not have the coffee cup with the lid on it. The DON said Resident #2 was unable to get coffee herself that somebody had given it to her. The DON said the staff was reeducated again on ensuring Resident #2 had her special cup. The DON said the education was provided verbally and she did not have documentation of it. The DON said they were doing the coffee logs to ensure the coffee was at safe temperatures. The DON said there was not anything implemented to see if any of the other residents were at risk for burning themselves with hot liquids. The DON said they did not complete hot liquid assessments. During an attempted phone interview on 08/20/2024 at 10:31 AM, LVN P did not answer the phone. During an interview on 08/20/2024 at 2:04 PM, the Director of Rehab said they did not have a particular screen to assess residents for their abilities to handle hot liquids. The Director of Rehab said if they noticed or were told by the staff a resident was having issues feeding themselves or required adaptive equipment therapy would evaluate and address the need. The Director of Rehab said she believed when Resident #2 was burned she was already receiving occupational therapy and they ordered a cup with a lid for her. During an interview on 08/20/2024 at 2:14 PM, the DON said the nurses should be assessing the residents needs for their abilities to feed themselves and on admission therapy screened the residents for any special needs. During an interview on 08/22/2024 at 6:48 PM, the Administrator said Resident #2 did not want to sit still with her coffee, and they discussed getting her a cup that would assist with spills. The Administrator said residents were assessed by the nurses on a resident-by-resident case for their abilities to handle hot liquids. The Administrator said anytime there was a change of status the residents were supposed to be assessed. The Administrator said there was always a risk for an accident to happen. Record review of the Coffee Temperature log for February 2024, March 2024, April 2024, June 2024, indicated the coffee temperature was 140° daily. Record review of a Record of Inservice Education dated 04/04/2024 with a subject of Coffee cup for Resident #2 indicated, Resident #2 has a cup for coffee with a lid to help prevent spills. It is very important that you make sure lid is on correctly why you make her coffee. Record review of the undated Guidelines on Serving Coffee in the Nursing Facility indicated, .3. Any residents who have risk factors for coffee burns, such as significant cognitive impairment or extreme shaking may be evaluated for additional safety precautions using a hot beverage risk assessment. Safety precautions may include but are not limited to additional supervision when consuming coffee, insulated or non-insulated coffee mugs with sippy lids, coffee service at lower temperatures, or restricted coffee availability . This was determined to be an Immediate Jeopardy (IJ) on 08/20/2024 at 4:15 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 08/20/2024 at 4:19 p.m. During an observation on 08/20/2024 at 5:00 p.m., the speed limit sign in front of the facility changes from 45 to 55 miles per hour. During an observation on 08/21/2024 at 7:15 a.m., the front door had an automatic sliding door and no alarm had sounded upon entrance to the building. During an interview and observation on 08/21/2024 beginning at 9:18 a.m., the Administrator was standing at the front door with a technician. The Administrator stated she had not realized the alarm system had not been functioning. The Administrator stated the technician had disabled the alarm system the last time he worked on it. The Administrator stated the technician was working on the system and adding another contact alarm that would alarm when the front door was opened. The doors had automatically slid open and the alarm had sounded. Beeping was heard at the nurse's station. The following plan of removal submitted by the facility was accepted on 08/21/2024 at 4:27 p.m. and included the following: Interventions: 1. On 8/20/24, Residents #33, Resident #1 and Resident #290 will be transferred to a sister facility for appropriate supervision. All 3 residents will be placed on 1:1 supervision until transferred. Both residents have been screened and do not meet the criteria to be placed on the secure unit. Other interventions such as alarms, increased staff, wander guards have been reviewed. All doors and alarms have been tested and are functioning properly. All doors with existing alarms were tested and in operation 8/20/24. Front door had an alarm installed the morning of 8/21/24 and will be monitored every shift. 2. On 8/20/24, Resident #40 will be transferred to the secure unit inside the facility. 3. Elopement risk assessments for all residents in the facility were completed and reviewed by the DON/ADON/Designee on 8/20/24. No additional concerns were identified. 4. All elopement risk care plan interventions were reviewed on 8/20/24 by the Regional Compliance Nurse, DON, and ADON. All interventions are in place and care planned. 5. The Administrator, DON, and ADON were in-serviced 1:1 by the ADO and Regional Compliance Nurse on 8/20/24 on the following: A. Elopement Prevention Policy- This in-service includes implementing interventions for residents at risk for elopement. - Completing the elopement risk assessment to determine at risk residents. This in-service also includes reporting to the Charge Nurse, Administrator, or DON any resident who is attempting to elope. The policy includes interventions to assist in preventing elopements, environmental modifications, and staff training. B. Elopement Response Policy- Nursing personnel must report and investigate all residents who attempt to elope. This includes when a resident is observed leaving the premises. A response plan will be implemented immediately. The resident's care plan will be modified to include interventions to prevent further elopement attempts. C. Abuse and Neglect- Neglect includes the failure to prevent, supervise, monitor, and/or intervene when a resident has eloped from the facility. Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. o The Elopement Risk Assessment will be completed upon admission by the charge nurse. The assessment will be completed by reviewing the resident's medical history and social history. Information may be obtained by reviewing current medical records, if available, interview with resident/family, or conference with the interdisciplinary team member. The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, upon new exit seeking behavior, and upon change of condition. The Elopement Risk Assessment will be completed by the charge nurse or designee. The DON will be responsible for ensuring the completion and review of the assessment. This will begin 8/20/24. o All residents who are at risk for elopement will be assessed by the interdisciplinary team. This will begin 8/20/24. o The resident's care plan will be modified by the DON, MDS Coordinator, or designee to indicate the resident is at risk for elopement with appropriate interventions to prevent elopement attempts. This will begin 8/20/24. 6. Medical Director notified of the immediate jeopardy on 8/20/24. 7. An ADHOC QAPI meeting was conducted on 8/20/24 to discuss the immediate jeopardy citation and subsequent plan of correction. In-services: The Regional Compliance Nurse, Administrator, DON, and ADON will in-service all staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. A. All staff were in-serviced on the Elopement Response Policy by the Compliance Nurse, Administrator and DON on 8/20/24. Nursing personnel must report and investigate all residents who attempt to elope. This includes when a resident is observed leaving the premises. A response plan will be implemented immediately. The resident's care plan will be modified to include interventions to prevent further elopement attempts. B. All staff were in-serviced on Elopement Prevention by Compliance Nurse, Administrator and DON on 8/20/24. This in-service includes implementing interventions for residents at risk for elopement. - Completing the elopement risk assessment to determine at risk residents. This in-service also includes reporting to the Charge Nurse, Administrator, or DON any resident who is attempting to elope. The policy includes interventions to assist in preventing elopements, environmental modifications, and staff training. C. All staff were in-serviced on Abuse and Neglect by the Compliance Nurse, Adm[TRUNCATED]