Based on observations, interviews, record review, and facility document and policy review, the facility failed to provide supervision to prevent accidents related to elopement for 2 (Resident #59 and Resident #38) of 3 residents reviewed for elopement. Specifically, Resident #59 eloped from the facility on 02/24/2024 and was pushing their wheelchair when it was hit by a car. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 02/24/2024 at approximately 8:00 PM when Resident #59 eloped from the facility. On 03/28/2024 at 3:34 PM, the facility Executive Director (ED) was provided with the completed IJ template and notified of the existence of an IJ for accidents. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency (SSA) on 03/29/2024 at 7:13 PM. The IJ was removed on 03/29/2024 at 8:15 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of D, which was not immediate jeopardy for F689. In addition, based on observations, interviews, record review, and facility document and policy review, the facility failed to provide supervision for Resident #38. Resident #38 eloped from the facility on 06/20/2023, around 8:30 PM, when nursing staff discovered the resident was not in their room. Resident #38 was found by emergency services and brought back to the facility around 11:40 PM. Findings included: A review of a facility policy titled Elopements and Wandering Residents, revised in June 2023, revealed, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The policy further indicated, 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 1. A review of Resident #59's Face Sheet revealed the facility admitted the resident on 12/11/2023 with diagnoses that included cerebral infarction (stroke), aphasia (difficulty with speech), dysphagia (difficulty understanding language), and Wernicke's encephalopathy (a neurological disorder). A review of Resident #59's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/15/2023, revealed Resident #59 did not have a Brief Interview for Mental Status (BIMS) or a Staff Assessment for Mental Status completed. The MDS indicated disorganized thinking was present continuously. The MDS indicated Resident #59 did not exhibit any wandering behavior, ambulated with a walker or wheelchair, and required supervision or touching assistance with walking. The MDS revealed no wandering/elopement alarm was used. A review of Resident #59's Care Plan revealed a Problem area with a start date of 02/20/2024, which indicated the resident was at risk for elopement related to Wernicke's encephalopathy. The Care Plan indicated the resident had exit-seeking behaviors and would kick the door off the tracks to get it open. Interventions included to ensure the departure alert system was in place and functioning properly and indicated the resident had two departure alert system devices, one on the inside of an article of clothing and one on the back of the resident's wheelchair. Further review of the interventions revealed that company vans had been moved to the back of the facility (out of sight) after an elopement attempt on 02/20/2024, elopement monitoring every 30 minutes for an elopement attempt on 02/21/2024, and one-on-one supervision for an actual elopement on 02/24/2024. A review of Resident #59's nursing Progress Notes, dated 12/17/2023 at 9:25 AM, revealed Resident #59 was found in a facility van outside the facility, and a departure alert system device was placed on the resident. A review of Resident #59's physician's Progress Notes, dated 01/09/2024 at 3:37 PM, revealed Resident #59 was severely agitated and attempting to escape from the building. A review of Resident #59's nursing Progress Notes, dated 02/20/2024 at 10:48 AM, revealed the departure alert system alerted a nurse to check outside the facility. The note revealed the front door was pushed open off the track, and Resident #59 was found attempting to get inside the facility transport vehicle. The note revealed two staff members safely brought the resident back into the facility, and all company vehicles were moved to the back of the building as an intervention. A review of Resident #59's nursing Progress Notes, dated 02/20/2024 at 1:57 PM, revealed Resident #59 attempted to leave the facility twice on that shift. The note revealed that the first time, the resident was able to be redirected at the front door; about thirty minutes later, the resident was found outside the facility. The note revealed the resident had on a departure alert system device that locked the doors, but the resident had forced the doors open. A review of Resident #59's physician's Progress Notes, dated 02/20/2024 at 3:27 PM, revealed the Medical Director (MD) found the resident outside in the cold parking lot. The MD indicated that he felt Resident #59 required a locked memory care unit for safety. A review of Resident #59's nursing Progress Notes, dated 02/24/2024 at 3:20 PM, revealed that on this date, Resident #59 had attempted to elope multiple times. A review of Resident #59's nursing Progress Notes, dated 02/24/2024 at 8:15 PM, revealed that during the night shift, Resident #59 left their room, crossed the road, and a car collided with the resident in their wheelchair. The note revealed Resident #59 was taken to the hospital, evaluated, and returned to the facility about an hour later. The note revealed that after 30 minutes, Resident #59 attempted to leave the facility again, and staff followed the resident to the front door. The note revealed the resident became very combative, but staff were able to redirect the resident. A review of a document titled Follow-Up Investigation Report, dated as submitted by the ED on 02/28/2024 at 7:15 PM, revealed camera footage was reviewed, and Resident #59 had pushed through the front door at 7:46 PM, exited the building, and walked down the parking lot. The report revealed that at 7:52 PM, the resident was pushing a wheelchair ahead of them, and the wheelchair was struck by a car. The Follow-Up Investigation Report further revealed Resident #59 had minor cuts and scrapes to their hands, with blood visible on their fingers. The report revealed the resident was sent to the local emergency room (ER) for further evaluation, and no additional injuries were identified. The report revealed the resident was placed on one-to-one continuous staff supervision upon return to the facility. During an interview on 03/26/2024 at 7:42 PM, Registered Nurse (RN) #19 stated staff needed to always keep their eyes on an elopement risk resident. RN #19 said elopement risk residents had a departure alert system device on their wrist or ankle, and some also had a device on their wheelchair. RN #19 stated that usually, when the resident would get close to the front door, an alarm would sound, and the doors would lock. She stated if any of the side doors were opened, an alarm would sound. She stated when the door alarms sounded, staff were not able to hear them. RN #19 said that on the day of the elopement, upon arrival at work, she was made aware that Resident #59 had tried to elope earlier in the day. RN #19 stated that on the night of the elopement, a certified nursing assistant (CNA) had taken Resident #59 to the bathroom, and RN #19 had gone to administer medication to another resident. RN #19 stated that when she came out of the other resident's room, she noticed Resident #59's door was open, which was unusual. RN #19 stated that she asked the aides if they had seen Resident #59, and they all said no. RN #19 stated that the aides went running down the hallway. RN #19 stated she heard the alarm, went running towards the front door, and saw police cars. RN #19 said Resident #59 had a departure alert system device placed on their wrist or ankle and on their wheelchair. RN #19 indicated Resident #59 had kicked open the front door and walked across the street, and their wheelchair was hit by a car. RN #19 stated she went out to speak with the police to give them all the information about the resident. She stated Resident #59 was taken to the hospital. RN #19 stated that after the 02/24/2024 event, there was a booklet on elopements that staff had to read and sign that explained what to do if a resident tried to elope. RN #19 said new alarms were also put in place but did not ring overhead and were still unable to be heard. RN #19 said the alarm only sounded on the 400 hall. She further stated the two-way radio walkie-talkies only said wanderer. RN #19 stated she did not think the alarms were what alerted staff that the resident was out of the building. RN #19 stated she thought when staff first realized the resident was missing, they went to the front door and realized the alarm was sounding and the resident was out of the building. During an interview on 03/26/2024 at 8:07 PM, Certified Nursing Assistant (CNA) #21 stated she was present on the night Resident #59 eloped. CNA #21 stated that she did not recall hearing any alarms sounding because she and another CNA were in resident rooms and too far from the front door. CNA #21 said after the incident on 02/24/2024, walkie-talkie radios were put in place, and Resident #59 was put on one-to-one continuous staff supervision. CNA #21 said Resident #59 already had a departure alert device in place but discovered how to push the door open. She stated that after the incident, a booklet with information on elopement was passed out for staff to read and sign. During an interview on 03/27/2024 at 8:18 AM, the CNA Coordinator stated she worked the day Resident #59 eloped. The CNA Coordinator said she was assigned one-on-one with Resident #59, and the resident spent a lot of time with her. The CNA Coordinator stated that on the day of the incident, she was off work but came to the facility due to the resident being very agitated. The CNA Coordinator stated she came in around 11:30 AM and was with the resident until around 3:30 PM. She stated Resident #59 was completely fine when she left for the day. The CNA Coordinator said she never witnessed the resident make it outside. She stated Resident #59 was always in the hall when the alarm would sound, and she would redirect the resident and spend time with the resident. During an interview on 03/26/2024 at 12:49 PM, CNA #11 stated she was not working on the day Resident #59 eloped but said the resident would take their wheelchair, put it against the door, and open the door. CNA #11 said Resident #59 had a departure alert system device, but she was not sure where it was placed. During an interview on 03/26/2024 at 1:13 PM, CNA #5 indicated if a resident was trying to elope, she would try to redirect them. CNA #5 stated if that did not work, she would try to approach the resident in a different way. CNA #5 stated that all residents who were at an elopement risk wore a departure alert system device. CNA #5 stated the device would be attached to an ankle or wheelchair. CNA #5 stated she checked residents for placement of the device to ensure there was no dangerous situation of the resident going into the street or something. During an interview on 03/26/2024 at 1:26 PM, CNA #13 stated if a resident had on a departure alert system device and got too close to the front door, an alarm would sound in the whole building. CNA #13 said she worked as a one-on-one staff member with Resident #59 for about two weeks. CNA #13 said after the elopement incident, Resident #59 had a departure alert system device attached to their clothing because the resident hated the device being on their body. CNA #13 said walkie-talkies at the nursing stations were also alarmed when one of the residents got near the door. During an interview on 03/26/2024 at 2:27 PM, Licensed Practical Nurse (LPN) #14 stated a resident that was an elopement risk would have a departure alert system device on the resident so when they got close to an exit door, the door would automatically lock. LPN #14 said that staff now had walkie-talkies that would sound since residents in the past had been able to push the doors open once they were locked. LPN #14 said they were not at work when Resident #59 eloped. LPN #14 stated Resident #59 tended to wander a lot and got frustrated because the staff could not really understand the resident. LPN #14 said Resident #59 was the reason a special alarm was put in place for when the front door got knocked off the hinges. LPN #14 stated that prior to the walkie-talkies, there was a faint alarm that staff could barely hear. During an interview on 03/26/2024 at 2:38 PM, CNA #15 stated she could not hear the front door alarm at all. During a follow-up interview on 03/26/2024 at 3:29 PM, CNA #15 stated there had only been one resident to elope since she had been at the facility. She said newly hired staff had not been told what to do when a resident eloped. CNA #15 stated the front door alarm was faint, and she had never heard the walkie-talkie sound. CNA #15 stated she was not in the facility when Resident #59 eloped. During an interview on 03/26/2024 at 2:42 PM, CNA #17 stated that elopement risk residents had a departure alert system device, and staff checked on them every two hours to make sure the device was in place. CNA #17 said if an alarm sounded at the front door, the doors would lock, and that would cue staff to check the doors and find the residents. CNA #17 stated the alarm could be heard from everywhere in the building. CNA #17 stated walkie-talkies were implemented at each nurse's station after Resident #59 eloped and said the walkie-talkies would transmit a message. CNA #17 said after the elopement, staff had to read a packet on preventive measures and other interventions for elopement. During an interview on 03/26/2024 at 3:11 PM, the Business Office Manager (BOM) stated she would hear the alarm sounding. She stated the alarm would be very loud, and she would hear it in her office and the conference room. The BOM stated she was not working during the elopement event for Resident #59 because it was on a weekend. During an interview on 03/26/2024 at 3:34 PM, CNA #16 stated the walkie-talkies' volumes were turned down at the nurses' station due to them being too loud when staff were on the phone. CNA #16 stated the walkie-talkies notified of call light activations and an elopement. During an interview on 03/26/2024 at 7:22 PM, CNA #18 stated for an elopement risk resident, she tried to distract the resident, tried to get them to go back to their room, and keep them from the doors, and completed a safety check every two hours. CNA #18 stated if a resident with a departure alert system device went to the front door, there was an alarm that sounded, and the door locked. CNA #18 said walkie-talkies were also at the nurse's station. CNA #18 said she could hear the alarms if she was at the nurse station but not if she was in a resident room. CNA #18 said she was at work the night Resident #59 eloped but was not aware of the incident until her coworkers told her about it and she saw the police. During an interview on 03/26/2024 at 8:19 PM, RN #22 stated he was not working the night Resident #59 eloped. RN #22 said the alarms were soft and could not be heard, so a louder alarm had been put in place. RN #22 also said the walkie-talkie was connected to the call light system and was supposed to alert staff to both the departure alarm system and the call lights. RN #22 indicated it worked for call light notification, but he was not sure if it was working to alert for the departure alert system. During an interview on 03/27/2024 at 8:55 AM, RN #23 stated they were not at work when Resident #59 eloped, but for elopement risk residents wearing a departure alert system device, an alarm should have sounded when the resident got close to the door. RN #23 said sometimes the alarms did not work. RN #23 stated the front door alarm could not be heard on the 600 hall. During an interview on 03/27/2024 at 10:34 AM, the Social Services Director (SSD) stated she had witnessed Resident #59 exit the building once prior to the elopement on 02/24/2024. The SSD stated that when she tried to get Resident #59 to come back into the building, the resident grabbed her by the neck. The SSD said Resident #59 stopped once she told the resident they were hurting her. The SSD said she had heard the alarm sound when the residents approached the doors. During an interview on 03/27/2024 at 12:00 PM, the MD stated Resident #59 was a severe alcoholic and was found at home after suffering a stroke. The MD said he felt Resident #59 was admitted to the facility prematurely due to the resident being severely encephalopathic and having behaviors that were out of control. The MD recalled seeing Resident #59 right outside the front door one day. He stated when he attempted to get the resident to come back inside, the resident turned around and hit him. The MD said his approach was to get the resident on medications that could stabilize the resident's moods until the resident could be moved to a more appropriate level of care. The MD stated that on the day of the elopement, the recommendation had already been made for the resident to be transferred to another facility. During an interview on 03/27/2024 at 4:23 PM, the ED stated Resident #59 came to the facility for rehabilitation but was switched to long-term care. The ED stated that sometime in January, it was apparent the resident was a wander risk. The ED stated in February, the resident started showing signs of exit-seeking. The ED stated that Resident #59 went out the door a few times. The ED stated that the staff would see the resident but had a hard time redirecting the resident. The ED stated the resident would go toward the facility vans, so as an intervention, the vans were moved to the back of the facility. He stated that the intervention worked for a few days, but then the resident tried again, and it was at that point that communication started with a memory care facility. He stated that the resident displayed more exit-seeking behaviors on the day of the 02/24/2024 incident. The ED stated the resident had gone out to the parking lot, but staff were able to get the resident in. The ED said he was not notified of the initial exiting attempts the resident had on 02/24/2024. The ED said he wished staff would have notified him so that interventions could have been put in place and the entire incident could have been avoided. The ED said the Quality Assurance and Performance Improvement (QAPI) committee initiated a four-step plan to address elopement and how it should be reported. The ED stated he felt there should have been some interventions put in place sooner based on the number of times the resident attempted to elope. The ED said there were a few times that both he and the CNA Coordinator took Resident #59 outside, and the resident never attempted to go to the road. The ED stated the CNA Coordinator was notified on the day of the incident and came in to help calm the resident down. The ED said the departure alert system was tested routinely. The ED stated he installed a new alarm to the front doors on 02/27/2024 that sounded if the doors were pushed off the hinges. He stated that when the alarm was installed, he tested it with and without a departure alert system trigger to ensure the alarm worked appropriately. The ED stated he did not do any testing with the volume of the alarms. He said the walkie-talkies were installed around the same time, maybe the same day, and were connected to the call light system. He stated when they were installed, he tested them to ensure they were functioning and sending out notifications. He stated he went to the front, activated the alarm, and then went to the nurse's station to hear it sound the wanderer alert. The ED stated he made sure the volume was turned all the way up. The ED said no staff had ever mentioned they could not hear the alarms or the walkie-talkie alerts. During an interview on 03/28/2024 at 8:47 AM, the Maintenance Director stated he tested the departure alert system alarms weekly by removing a departure alert system device from the package and taking it to the door to make sure the alarm sounded and the door locked. During an interview on 03/28/2024 at 8:58 AM, the Director of Nursing (DON) stated her expectation was for staff to let her know immediately if an elopement occurred. The DON said if staff were not able to find the resident, the police would be called. She stated once the resident was found, a full assessment would be completed, and if needed, the resident would be sent to the ER. The DON stated the MD would also be notified. The DON stated the staff would then meet as a team to discuss what interventions could be put in place to prevent an elopement from happening again. The DON said all of this would be done after the immediate needs of the resident were taken care of. The DON said she was working on the day Resident #59 eloped. She said the resident had gone out the door earlier in the day, and a CNA was able to get the resident to come back into the facility. The DON stated the CNA Coordinator came in to calm the resident and stayed for a few hours. The DON said when the incident occurred, Resident #59 was taken to the emergency room, and when the resident returned to the facility, they were immediately placed on one-to-one continuous staff supervision. The DON stated they were working on interventions prior to the elopement incident, which included placement at another facility. She further stated once she was made aware that staff could not hear the alarms, the walkie-talkies were put in place. During observations and interviews on 03/26/2024 between 4:40 PM and 5:10 PM, the walkie-talkies were tested. On the 100/200 hall, LPN #14 was at the nurses' station, and the walkie-talkies were at the desk. There was poor audible notification when the call bells were pressed. The walkie-talkies were labeled Do not remove. LPN #14 stated he could not take the walkie-talkie off the base. LPN #14 said he could only hear the walkie-talkie at the nurses' station and that he would not be able to hear the walkie-talkie if he was more than 20 feet from the nurses' station. On the 500/600 hall, CNA #5 stated the walkie-talkie was not on the unit and was with CNA #11. CNA #11 said she normally did not carry the walkie-talkie but took the walkie-talkie because of the morning meeting. CNA #11 was asked to demonstrate how the walkie-talkie was used, and CNA #11 was observed raising the volume. CNA #11 stated when the call bell was pressed, or a departure alert system was breached, a notification was heard on the walkie-talkie. A call bell was then pressed, and the walkie-talkie was very audible. CNA #11 stated the volume was kept low due to the staff meeting. An observation on the 400 hall with CNA #11 revealed a grey box that had an alarm that would be triggered if there was a departure alert system breach. CNA #11 stated the alarm would be very loud on hall 400. CNA #11 stated that due to the low census, the unit was unstaffed and had mainly independent residents on the unit. CNA #11 stated she would not be able to hear the grey box sound if she were on halls 500 or 600. During observations on 03/27/2024, between 1:19 PM and 1:33 PM, the alarms were tested with the ED. At 1:19 PM, the departure alert system alarm was initiated and could only be heard in the lobby area. At 1:21 PM, the departure alert system alarm was initiated again, and the alarms could not be heard on the 300, 500, and 600 halls; a faint alarm could be heard while standing at the nurses' station on the 100 hall. On the 300 hall, the walkie-talkie sounded wanderer. At 1:23 PM, the front door was popped off the hinges, and the alarm could only be heard on the 100 hall. At 1:25 PM, the front door was popped off the hinges again, and the alarm was heard on the 100 hall, but there was nothing on the walkie-talkie. The alarm could not be heard on the 500 hall. At 1:29 PM, the door was popped off the hinges and the alarm was heard on the 100 hall and an unintelligible talking sound was heard on the walkie-talkie. The alarm could not be heard on the 300, 500, and 600 halls. 2. A review of Resident #38's Face Sheet revealed the facility admitted the resident on 06/13/2023 with diagnoses which included metabolic encephalopathy, delirium due to known physiological condition, generalized anxiety disorder, and cognitive communication deficit. A review of Resident #38's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 06/16/2023, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #38 had delusions and had displayed wandering behavior for one to three days during the assessment period. The MDS further revealed the resident used a wander/elopement alarm daily. A review of Resident #38's Care Plan revealed a Problem area with a start date of 06/14/2023 that indicated the resident experienced wandering by moving with no rational purpose, seemingly oblivious to needs or safety. Interventions, with a start date of 06/14/2023, directed staff to ensure the resident had an identification band in place, follow familiar routines as much as possible, redirect to conversation or activity of choice and offer to contact loved ones and provide comfort measures for basic needs when the resident begins to wander and equip resident with a device that alarms on their left wrist. An additional intervention with a start date of 03/14/2024 indicated Resident #38 had a location device on their right wrist due to frequent elopement attempts. A review of Resident #38's physician's Progress Notes, dated 06/14/2023 at 6:07 PM, revealed Resident #38 was seen by the Medical Director (MD) sitting in the front foyer. The Progress Note indicated the resident was waiting on a ride home. A review of Resident #38's physician's Progress Notes, dated 06/19/2023 at 11:33 AM, revealed Resident #38 was seen by the MD. The Progress Note indicated the resident continued to wander around the facility, triggered the alarms often, and required heavy staff involvement to prevent the resident from eloping. A review of an Initial Report, dated as submitted on 06/21/2023, revealed that on 06/20/2023 at 8:30 PM Resident #59's room was checked by a nurse and found to be empty. The report revealed that a thorough search of the facility and outside was conducted. The report revealed that facility management and emergency services was notified. The report indicated that the resident was located at 11:40 PM in the local town. A review of a document titled Follow-Up Investigation Report dated 06/28/2023 revealed camera footage was reviewed, which revealed Resident #38 exited their room at 7:50 PM on 06/20/2023. The report revealed that a visitor was seen walking into the facility around 7:55 PM and Resident #38 was observed walking out of the facility at 7:55 PM. The report revealed Resident #38 walked to the corner of the building and walked outside of the video footage view. The report indicated that the resident had an abrasion on their head and scratches on their face. A review of Resident #38's physician's Progress Notes, dated 06/21/2023 at 11:35 AM, revealed Resident #38 was seen by the MD after the resident had been returned to the facility by the police in the early morning hours. The note revealed the resident had a laceration on their head, and the Director of Nursing (DON) escorted the resident to the emergency room (ER) for further evaluation. The note revealed a computerized tomography (CT) scan of the head, and x-rays were conducted due to complaints of shoulder pain. Results were documented in the Progress Notes as negative. A review of Resident #38's nursing Progress Notes, dated 06/22/2023 at 6:35 PM, revealed a tracking device was applied to Resident #38's shoe. During an observation on 03/26/2024 at 1:08 PM, Resident #38 was observed coming out of their room with a wheelchair and their clothes. When staff asked the resident where they were going, Resident #38 said they were going home. Staff redirected the resident back to their room, and the resident put their belongings back in their room. The resident then returned and stood at the nurses' station with staff. During an observation on 03/27/2024 at 4:06 PM, Certified Nursing Assistant (CNA) #10 was observed with Resident #38. The resident was sitting in a recliner across from the nursing station. Resident #38 got up and walked toward the dining room, and CNA #10 immediately followed the resident. During an interview on 03/26/2024 at 7:22 PM, CNA #18 stated Resident #38 wandered and was often found in other rooms or in the dining room. CNA #18 stated at times it took four to five staff members to barricade the door and redirect the resident. During an interview on 03/27/2024 at 8:55 AM, Registered Nurse (RN) #23 stated there had been multiple complaints to administration about Resident #38. She stated when Resident #38 was first admitted , she begged staff not to put the resident on the 400 hall due to their behaviors. RN #23 stated the resident was put on the 400 hall anyway and the next night, the resident eloped. RN #23 stated that after the elopement, Resident #38 was moved to the 600 hall. RN #23 stated for elopement risk residents wearing a departure alert system device, an alarm should sound when the resident gets close to the door. RN #23 said sometimes the alarms did not work. RN #23 stated the front door alarm could not be heard on the 600 hall. During an interview on 03/27/2024 at 12:00 PM, the Medical Director (MD) stated he did not know much about Resident #38's history and believed the resident had a stroke and had several mental health issues and disabilities. During an interview on 03/28/2024 at 8:58 AM, the DON stated Resident #38 had been at the facility long enough that staff knew what worked for the resident and what did not. She said the most current intervention in place for Resident #38 was one-to-one continuous staff supervision in the afternoon and evening hours because the resident seemed to be fine in the morning hours. The DON stated Resident #38 had a departure alert system device and a tracking device that could be used to locate the resident with a cell phone. She stated a tracker had been used previously, but Resident #38 started taking the tracker off and hiding it, so that was when a different device was used. The DON said extensive conversations had taken place about placement in another facility, but the resident's family had refused. During an interview on 03/29/2024 at 4:38 PM, the DON stated the expectation was for a resident who may be an elopement risk to be assessed for a departure alert system device, for the family and staff to be made aware of the wandering and the placement of the departure alert system device. She stated staff needed to respond immediately if an alarm was heard. The DON said if the staff did not see the resident, they should beg[TRUNCATED]