**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure adequate supervision for 1 resident (R) (R7) of 3 residents reviewed for elopement.R7 was assessed as at risk for elopement and had a WanderGuard on R7's left ankle. R7 lived on the second floor of the facility and had multiple documented attempts of entering the emergency exit stairwell near R7's room. The facility's WanderGuard system did not work with emergency exit stairwell doors. R7 expressed a desire to jump down the stairwell and staff used medical equipment to block the stairwell and divert R7 from the door. On 5/31/25, R7 exited the building via the stairwell and was found outside near an employee parking lot. The facility did not complete an investigation into R7's elopement. The facility also did not update R7's plan of care with person-centered approaches after R7's attempted elopements and actual elopement.The facility's failure to provide adequate supervision for a resident assessed to be at risk for elopement created a finding of immediate jeopardy that began on 5/6/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 7/29/25 at 10:27 AM. The immediate jeopardy was removed on 7/29/25, however the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan.Findings include:The facility's Elopement, Unsupervised Absence, Hazardous Wandering and Missing Residents policy, revised 11/7/24, indicates the facility will implement procedures that strive to identify, prevent, and respond to resident elopement attempts. The facility will follow Centers for Medicare & Medicaid Services (CMS) regulations and guidelines and will conduct assessments of residents on admission as well as periodic re-evaluation of behaviors that may lead to wandering and elopement. An elopement occurs when a resident receiving health care exits the Health Center or licensed healthcare provider, exits the community's property, and is no longer under the supervision or line-of-sight of a team member, volunteer, or family member .Community access allowance or transfer to a more secure level of living may occur for the protection of the resident based upon further assessment or past and future incidents of elopement After an elopement occurs: The means of egress (if known) that the resident used to leave the community or care area should be analyzed to prevent further occurrences. Door alarms, alarm panels, wander prevention systems, and locking mechanisms should be checked for proper functioning by Environmental Services and/or security team members. Accurate, thorough, and timely documentation of all aspects of the elopement will be documented in the resident's record. Documentation should include time frame and notification of physician, responsible party, law enforcement, and all involved parties. An incident report will be completed and the resident's responsible party and physician will be notified. The Director of Nursing and Health Center Administrator will conduct a root cause analysis and review documentation with the Interdisciplinary Team to critically analyze the event and ensure appropriate interventions and care plan updates are in place to prevent future occurrences. Resident's elopement risk will also be reviewed. The facility's Mood and Behavior Management policy, revised 4/17/25, indicates: .6.The Health Center utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Team members will: .c. Monitor the resident closely for expressions or indications of distress .h. Accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record .j. Discuss potential modifications to the care plan. 7. The resident and as appropriate the resident's family are included in the comprehensive assessment process .The care plan shall: .h. Be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition. From 7/28/25 to 7/29/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including dementia with behavioral disturbance, pressure ulcer to sacrum, type 2 diabetes, muscle weakness, and unsteadiness on feet. R7's Minimum Data Set (MDS) assessment, dated 5/30/25, had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R7 had severe cognitive impairment. R7 had an activated Power of Attorney for Healthcare (POAHC). R7 was admitted to the facility after a hospital stay from 3/22/25 to 4/2/25 for a chronic pressure ulcer that R7's previous memory care facility was unable to manage. R7 was admitted from the hospital to the facility's rehab unit which was located on the second floor. R7 discharged to R7's previous memory care facility on 6/2/25. An activities of daily living (ADL) self-care performance deficit care plan, initiated on 4/2/25 and revised on 4/11/25, indicated R7 transferred with the assistance of one staff with a gait belt and walker (revised 4/7/25). A care plan, initiated on 4/11/25, indicated R7 was at risk for falls related to deconditioning, dementia, and use of psychotropic medication.An elopement assessment, dated 4/2/25, indicated R7 was at risk for elopement.A progress note, dated 4/3/25, indicated R7 had a WanderGuard on the left lower extremity.An elopement care plan, initiated on 4/3/25, indicated R7 was at risk for elopement/wandering related to disorientation to place, history of attempts to leave the facility, and wandering aimlessly. The care plan contained interventions (initiated on 4/3/25) to encourage R7 to be in common areas and redirect from doors and to a safe area when necessary. A WanderGuard to the lower left extremity was added on 4/11/25. (The care plan had not been updated since 4/11/25.)A care plan, initiated on 4/3/25 and last revised on 5/20/25, indicated R7 had a behavior problem related to delusions and refused medication, wandered the halls, and wandered into others' rooms. The care plan contained interventions (initiated on 4/3/25) to anticipate and meet R7's needs, approach in a calm and nonthreatening manner, use a calm, slow approach during care, and provide psych services. (There were no interventions added to the care plan after 4/3/25.) (An impaired cognitive function care plan, initiated on 4/10/25, indicted R7 had impaired thought processes related to dementia with agitation and neurocognitive disorder.)A trauma/victimization care plan, initiated on 4/3/25, indicated R7 lived in [NAME] during the war, lost multiple friends and family, was mugged and robbed at home, and was assaulted by a resident in another setting. The care plan contained interventions (initiated on 4/3/25) to assess pain every shift and as needed, direct/assist to groups/activities daily, and identify and model healthy activities to combat boredom and lack of self-stimulation. (A care plan, initiated on 4/30/25, indicated R7 was grieving the loss of a neighboring resident.)A progress note, dated 5/6/25 at 2:43 PM, indicated R7 exited an alarmed door on the fire escape at approximately 1:30 PM. R7 was discovered on the landing attempting to go downstairs. R7 stated R7 needed Family Member (FM)-L. R7 was speaking in German and stated jump. R7 exited the fire door again and set off the alarm at approximately 2:30 PM. Staff located R7 on the landing. R7 said R7 was going to jump and needed to go home and attempted to bite staff during redirection. R7 refused a walker and pushed staff away. A progress note, dated 5/6/25 at 3:53 PM, indicated staff spoke with FM-L about a transfer due to R7's increased wandering. FM-L understood the safety risk and gave consent for referrals which were sent to 2 facilities. A progress note, dated 5/6/25 at 8:28 PM, indicated R7 tried to open the stairway door multiple times and stated R7 wanted to go home. R7 tried to leave through the stairway door and became agitated during redirection. 1:1 supervision was provided due to wandering and behaviors.A progress note, dated 5/7/25 at 9:19 PM, indicated R7 wandered the unit from 2:40 PM to 5:30 PM and tried to open residents' doors. R7 was agitated and combative when redirected. R7 tried to leave unit via an emergency exit door at the end of the hallway. R7 was impulsive, disoriented, and sundowning and was provided 1:1 supervision at times for safety. A progress note, dated 5/9/25 at 2:10 PM, indicated an alarm sounded and R7 exited the unit via the stairwell at approximately 7:00 AM. R7 declined to leave the stairwell for 20 minutes. R7 stated R7 was going to jump, wanted to go home, and attempted to bite staff multiple times. R7 initially declined to take medication and stated staff were lying and trying to poison R7. After speaking with a Nurse Practitioner (NP), R7 agreed to take medication. Staff attempted to obtain a urine sample for a urinalysis and labs were ordered. A Social Services note, dated 5/15/25 at 11:56 AM, indicated a behavior management meeting was held with the Interdisciplinary Team (IDT). R7 was prescribed trazadone, Seroquel, and Namenda. A titration of Namenda was recommended. A progress note, dated 5/18/25 at 1:48 AM, indicated R7 stated a man with a knife was trying to kill R7. R7 attempted to leave the floor via elevator and the stairwell. The physician was notified and R7 was sent to the Emergency Department (ED). A provider note, dated 5/18/25 at 1:23 AM, indicated R7 was agitated and psychotic and was found in the stairwell trying to escape the unit. R7 refused to talk to the provider. R7 was hostile toward staff and stated someone was trying to kill R7. R7 refused to take anything by mouth and stated the nurse was trying to kill R7. R7's diagnoses included metabolic encephalopathy (primary). R7 was referred to the ED for labs and acute management. A follow-up progress note, dated 5/18/25 at 5:35 AM, indicated R7 did not have symptoms of infection and would return to the facility.A progress note, dated 5/19/25 at 7:44 PM, indicated R7 wandered into residents' rooms, wandered the unit, refused medication, and thought a man in the basement was after R7. Staff provided Facetime with FM-L. The NP asked R7 to take Seroquel which R7 did.A progress note, dated 5/19/25 at 10:24 PM, indicated R7 was agitated, wandered the unit, tried to open the stairwell door, and stated R7 needed to go to the basement to kill the man who hurt R7. Reassurance, redirection, and reorientation were ineffective. R7 had a butter knife and fork and tried to stab staff with the utensils. R7 declined to give up the utensils and stated R7 needed to kill the man with the knife. Staff redirected R7 away from the stairs. 1:1 supervision was provided. The NP was notified and R7 agreed to take Seroquel. A progress note, dated 5/27/25 at 9:00 AM, indicated R7 was agitated and aggressive with staff, threw a walker at R7's window, and attempted to dismantle an air mattress to use the motor to break the window. R7 also attempted to barricade R7's self in the room and moved furniture around to block the doorway. The NP told staff to request a psych consult and continue to encourage R7 to adhere to R7's medications regimen. A psych consult was requested on 5/28/25.A progress note, dated 5/31/25 at 4:19 PM, indicated R7 used the L wing fire escape door to elope from the facility and was found outside near the employee entrance at approximately 2:00 PM. R7 expressed suicidal ideation and was resistant to return to the facility. Therapeutic communication was eventually effective and R7 was assisted back inside with with 3 staff. R7 returned to unit and tried to strangle R7's self with a gait belt. Staff intervened and no injuries were sustained. The police department and crisis team were on site from approximately 2:45 PM to 3:30 PM. 1:1 supervision was provided. A progress note, dated 6/2/25, indicated R7 was found in a secured courtyard (during the elopement on 5/31) and was discharging back to R7's secured memory care facility on 6/2/25.On 7/28/25, Surveyor observed R7's room on the second floor which was the last room in the hallway before an alcove. The alcove contained 4 rooms and an emergency stairwell exit door. On 7/28/25, Surveyor requested incident reports for R7. Surveyor was provided with an incident report for a fall on 5/16/25 but was not provided with any incident reports related to elopement.On 7/28/25 at 10:43 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who verified R7 repeatedly attempted to get in the stairwell. LPN-G stated staff put equipment in front of the stairwell door to keep R7 from going down the stairwell. On 7/28/25 at 11:45 AM, Surveyor interviewed LPN-E via phone who verified R7 wandered frequently and often got into the emergency stairwell near R7's room. LPN-E indicated LPN-E wrote a progress note when R7 eloped from the building toward the end of R7's stay and was found outside near the employee entrance. Surveyor read the progress note (dated 5/31/25 at 4:19 PM) to LPN-E and informed LPN-E of the progress note on 6/2/25 that indicated R7 was in a courtyard. LPN-E indicated R7 was outside the building but not in a courtyard. LPN-E indicated 3 staff brought R7 back inside and thought one was a kitchen staff. LPN-E did not hear an alarm when R7 left the unit and did not recall completing an incident report. LPN-E thought LPN-E completed an elopement evaluation after the incident, however, R7's medical record did not contain an elopement assessment. LPN-E indicated the protocol was to notify the Director of Nursing (DON), the on-call nurse, and in some situations, the Nursing Home Administrator (NHA) which LPN-E did. LPN-E indicated there was a lack of support in keeping R7 safe and stated staff had asked for a 1:1 caregiver for R7 many times. Messages in the scheduling system asking if staff wanted to help went unanswered so staff tried to provide 1:1 supervision with the staff they had. LPN-E indicated it was difficult to manage and keep R7 when R7 exhibited behaviors. LPN-E indicated the alarm on the emergency stairwell sounded when the door opened but stopped when the door closed. LPN-E stated LPN-E contacted crisis after R7 attempted to strangle R7's self with a gait belt and expressed suicidal ideation. LPN-E stated crisis responded and recommended 1:1 supervision. LPN-E indicated R7 was on 1:1 supervision after the incident but was not aware of any care plan updates or new interventions.On 7/28/25 at 1:33 PM, Surveyor interviewed CNA-F who was working on 5/31/25 when R7 eloped from the facility. CNA-F indicated CNA-F returned from break, noticed R7 was not in R7's room, and started looking for R7. CNA-F checked the stairwell and R7 was not there. CNA-F looked out a window and observed R7 outside on a sidewalk in an area where employees park. CNA-F indicated it was difficult to get R7 back inside and could not recall who was there to assist. CNA-F was not sure how long R7 was gone and thought the incident occurred after lunch. CNA-F was not interviewed by the facility as part of an elopement investigation. CNA-F indicated R7 went into the stairwell almost every time CNA-F worked and verified R7 was on 1:1 supervision after the incident. CNA-F indicated staff put equipment in front of the door to prevent R7 from going down the stairwell, however, R7 moved the equipment.Following the interview, Surveyor walked down 2 flights of stairs in the stairwell and out the L exit door and paced to where R7 was found. When the door opened, Surveyor observed a sidewalk that was approximately 20 paces to the main sidewalk. Surveyor turned right and walked approximately 20 paces to where CNA-F indicated R7 was standing. Surveyor noted there was a parking lot but no courtyard in the area. Surveyor noted if R7 continued to walk on the sidewalk for approximately 50 more paces, R7 would have arrived at the employee entrance. On 7/28/25 at 11:56 AM, Surveyor tested the L wing stairwell door with LPN-G who indicated the WanderGuard system does not alert when the stairwell door opens. LPN-G also indicated staff do not carry pagers if a door alarm is set off. The door contained a magnet alarm on the left side and a box on the upper right side. When LPN-G opened the door, the magnet alarm emitted a high-pitched sound. The alarm stopped when the door closed. There were no other audible alarms. LPN-G was not aware that R7 had eloped but confirmed R7 frequently got into the stairwell.On 7/28/25 at 11:58 AM, Surveyor descended 2 flights of stairs in the stairwell to the first floor and noted there were 2 doors on the lower level, including a door that went into a first floor resident area and an egress door that contained a sign that stated Push until alarm sounds. Door can be opened in 15 seconds. Surveyor asked Maintenance Staff (MS-M) to test the exit door. MS-M pushed the door which opened right away. The door did not alarm and there was not a delayed 15 second locking mechanism. MS-M indicated the alarm would sound on the main fire panel. MS-M and Surveyor walked to the front entrance of the facility and observed the alarm panel which indicated the system was normal and no alarm was sounding. MS-M then contacted Maintenance Director (MD)-J. On 7/28/25 at 12:06 PM, Surveyor showed MD-J the L wing exit door that opened without alarming and without a delayed lock. MD-J opened the door and confirmed the door opened immediately and did not alarm. MD-J was not sure the sign on the door that stated Push until alarm sounds. Door can be opened in 15 seconds was appropriate for the door. MD-J pointed to an alarm box on the door, stated the alarm went to a panel behind a desk, and pushed the button on the box (which did not sound). Surveyor and MD-J then went to the panel and noted the alarm was not sounding and the panel did not indicate an alarm had been activated. Surveyor asked 2 nursing staff in the lobby if they carried pagers or phones that alerted them of an alarm. The staff indicated they do not hear anything except the magnet alarm which stops when the stairwell door is closed. On 7/28/25 at 12:18 PM, Surveyor and MD-J tested the K wing stairwell door. When MD-J opened the door, the alarm sounded, the door did not open, and a red light blinked on the handle. The door opened after 15 seconds of MD-J pushing on the door. MD-J confirmed the L door did not do that and did not contain a blinking light on the push bar. MD-J turned off the alarm with a key. MD-J also indicated a pager should sound, however, MD-J was not wearing a pager. MD-J and Surveyor went to the panel behind the secretary's desk on the second floor and noted a red blinking light for the K door but not the L door. MD-J indicated the L door should be lit up as well, however, there was no alarm sounding. MD-J attempted to disarm the alarm by entering several codes in a key pad but was unsuccessful. There were no staff at the desk. Surveyor observed the alarm panel on the wall behind the secretary's desk and noted the secretary's back would face the alarm panel. MD-J confirmed if staff did not watch the panel, they would not know an alarm was triggered since there was no audible sound. MD-J also confirmed the only audible alarm sound tested was the magnet alarm on the stairwell exit door which only sounds when the door is open. MD-J indicated there is a second alarm on the door that needs to be reset with a button, however, the alarm would not sound for nursing staff to hear. On 7/28/25 at 1:38 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-K who indicated ADON-K was told R7 got down the stairwell and was found in a courtyard. ADON-K indicated R7 had a history of trying to leave the unit and frequently needed redirection and 1:1 supervision. ADON-K was not sure if an elopement investigation was completed and did not recall interviewing staff or checking doors. ADON-K was not aware that staff used equipment to block the stairwell door and confirmed equipment should not be used to block an exit door. ADON-K confirmed R7's care plan and interventions should have been updated to ensure safety and monitoring. ADON-K was aware the WanderGuard system did not work with stairwell doors, but was not aware the L wing exit door did not work properly. ADON-K was also not aware that staff indicated R7 was observed outside the building on a sidewalk near the employee entrance/parking lot. ADON-K indicated there was not a formal process for behavioral management and stated it was more of a collective of ideas for brainstorming with social workers and providers. ADON-K indicated the facility has a psychiatrist and verified care plans should be updated in clinical meetings. On 7/28/25 at 1:52 PM, Surveyor interviewed DON-B who indicated staff informed DON-B that R7 was found in an enclosed courtyard but was not sure how R7 got there. DON-B was not sure who found R7, who reported the information, or if an investigation was completed. DON-B indicated R7 got down the L stairwell and stated all stairwells have an exit door. Surveyor indicated the L stairwell leads to an employee parking area and not a courtyard. DON-B was not aware the WanderGuard system does not work with stairwell exit doors. When Surveyor informed DON-B that the L stairwell lower level exit door did not work correctly when Surveyor tested the door, DON-B did not recall testing stairwell doors as part of an elopement investigation. DON-B confirmed staff should not block exit doors with equipment and confirmed precautions should have been implemented, assessments should have been completed, and care plans should have been updated when R7 expressed suicidal ideation and repeatedly attempted to exit the facility. On 7/28/25 at 2:06 PM, Surveyor interviewed NHA-A who confirmed a thorough investigation should have been completed for R7's elopement and R7's plan of care should have been updated with appropriate interventions to keep R7 safe. NHA-A was not aware staff used equipment to block an exit door to try to deter R7 from going down the stairwell. Surveyor informed NHA-A that the magnet alarm was the only audible alarm staff heard upstairs and it only sounded when the door was open. Surveyor informed NHA-A that the panel that lights up if a door is opened is located behind the secretary's desk which is between the east and west units and staff are only at the desk during the day from Monday through Friday. Surveyor also informed NHA-A that the panel did not audibly alarm which meant staff had to physically see the light to know if a door was open. NHA-A confirmed all doors should be working and nursing staff should be alerted timely when a door alarms.On 7/29/25 at approximately 8:30 AM, Surveyor interviewed Plant Manager (PM)-I via phone who indicated PM-I checked the L wing exit door after Surveyor's observation. PM-I confirmed the L exit door was not working and stated the facility contacted a vendor who was coming to repair the door. PM-I indicated there was a power surge over the weekend that may have caused the panel on the L door to burn out. PM-I confirmed each stairwell door has a magnet alarm that audibly sounds when the door is opened and stops when the door is closed, and a second alarm box called the Pal-care system which, if triggered, has to be reset by pushing a button on the box. PM-I indicated the Pal-care system also alarms at the panel and via pagers. PM-I indicated first and second shift maintenance staff carry pagers as well as a rapid responder for the whole community. PM-I indicated a rapid responder located in a building near the independent living section of the campus carries a pager on the third shift. Surveyor explained the concern of floor staff not getting alerted when a door is triggered, except for the magnet alarm that only sounds when the door is open and the alarm panel that is not audible and not in a location where nursing staff can keep an eye on it when staff aren't at the desk. PM-I indicated on the evening of 7/28/25, the facility downloaded the door alarm program onto nursing laptops so staff are alerted if a door is triggered. The facility provided Surveyor with a door alarm report for the L door from 6/28/25 through 7/28/25. Surveyor requested to review the door alarm report that covered 5/31/25, however, PM-I indicated the door report only went back 30 days. PM-I also provided a bi-annual inspection report of all doors completed on 5/12/25 that indicated all doors passed inspection. The facility's last elopement drill was completed on 11/1/24 with 12 staff. The facility also provided door inspections that were completed on 5/21/25, 6/11/25, and 7/9/25 with no concerns noted.On 7/30/25 at 3:09 PM, Surveyor interviewed Social Worker (SW-H) via phone. SW-H recalled R7 and indicated the facility had a behavior management meeting once per month in which all residents taking psychotropic medication and/or had behaviors were reviewed. SW-H did recall discussing R7 at the meetings and would have placed a note in the chart. When Surveyor read the progress note (dated 5/6/25) that indicated R7 wanted to jump in the stairwell and discussed R7's repeated attempts to enter the stairwell and exit the building, SW-H was not aware that R7 expressed a desire to jump down the stairwell on 5/6/25. SW-H indicated SW-H would have contacted the physician, updated the care plan, and met with the team to put interventions in place for R7's safety. SW-H did not recall discussing formal 1:1 supervision for R7 or moving R7 away from the stairwell door or to the first floor. SW-H indicated all of the options would have been on the table to discuss with the team had SW-H been aware of R7's suicidal ideation. SW-H did recall R7's elopement on 5/31/25, but thought R7 was found in a courtyard. SW-H was not sure who informed SW-H and indicated SW-H did not take part in an investigation.The failure to supervise a resident with a history of accessing a stairwell, expressing a desire to jump, and attempting to elope from the facility and the failure to ensure exit doors alarmed appropriately created a reasonable likelihood for serious harm that led to a finding of immediate jeopardy. The immediate jeopardy was removed on 7/29/25, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harms/isolated) as the facility continues to implement the following action plan:Equipped direct care team members with emergency notification devices (i.e., tablets, cell phones) connected to each stairwell and egress door.Educated staff on the following: The revised notification process when a stairwell door is accessed and prompt response to the alarm: Not to block emergency exits with equipment; Emergency preparedness procedures related to the loss of utilities.Corporate staff educated the NHA and DON on conducting a thorough investigation following an elopement.Reviewed residents at risk for elopement or change in condition at daily clinical meetings for 3 months to ensure safety.Implemented bi-weekly exit and egress door audits.