Failure to Supervise Cognitively Impaired Resident Resulting in Unnoticed Elopement
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment to prevent unsafe wandering and elopement for a cognitively impaired resident. The resident was admitted with diagnoses including esophageal cancer, severe protein‑calorie malnutrition, adult failure to thrive, and a history of immunosuppression therapy. Therapy and clinical evaluations shortly after admission documented moderate cognitive impairment, decreased insight, poor judgment, and decreased safety awareness. A Speech Language Pathology evaluation showed moderate cognitive‑communication deficits with impaired short‑term memory, problem solving, and executive functioning, and a SLUMS score indicating moderate cognitive impairment. The admission MDS BIMS score also indicated moderate cognitive impairment, and the care plan identified cognitive loss/dementia and fall risk. Multiple nursing and provider notes over the following weeks documented intermittent and worsening confusion, treatment‑interfering behaviors such as repeatedly pulling out IV/PICC lines, disorientation, and statements reflecting confusion. Despite this documentation, the facility’s Elopement Risk Evaluation completed on 11/6/25 concluded the resident was not at risk for elopement. The Unit Manager who completed the tool answered “No” to questions about cognitive impairment, poor decision‑making, exit‑seeking behaviors, wandering oblivious to safety, and history of elopement, while acknowledging the resident was independently mobile and able to exit the facility. On 11/19/25, a psychiatric APRN formally evaluated the resident for capacity at the request of the primary physician and documented that the resident lacked capacity to make decisions related to healthcare or long‑term placement, was significantly disoriented, and could benefit from a guardian or POA. Another APRN note the same day described significant disorientation and fluctuating mental status, with risk of delirium and unsafe behaviors. Nonetheless, the facility did not update the elopement risk assessment or care plan to reflect this change in condition and did not implement elopement‑specific interventions. On the day of the incident, staff notes and the facility’s own timeline show that the resident was last seen at the nursing station around mid‑morning, when he denied needing anything. The front desk receptionist left the front desk unattended to go to the kitchen, and the front door, which could be opened without staff intervention, was left accessible. Around that time, EMS exited the building with another resident, and the facility asserts the doors closed and locked, but the receptionist later stated that a visitor likely opened the front door, allowing the cognitively impaired resident to leave unnoticed. The resident walked out the front door, crossed a two‑lane road, and traveled approximately half a mile over uneven terrain and near multiple water retention ponds to a nearby college dormitory. College staff found him in the dorm, describing him as confused, disoriented, unsteady, shaking, disheveled, and unsure of where he was. EMS documentation noted he did not remember where he was supposed to be and believed he was in a different city. The facility did not become aware that the resident had left until contacted by campus security after EMS had been called, and there was no documentation in the clinical record that the resident had exited the facility without staff knowledge or supervision. Interviews with the Unit Manager indicated she was told not to document the incident and that no elopement re‑evaluation or care plan update was completed afterward. The facility’s failure to recognize and act on the resident’s documented cognitive impairment and lack of capacity, to accurately assess elopement risk, to maintain supervision at the front entrance, and to document the elopement led to the determination of Immediate Jeopardy under F689. The resident’s family member reported being very upset that they were not notified of the incident until 24 hours later and expressed concern about what could have happened while the resident was unsupervised outside the facility. The Administrator and DON acknowledged in interviews that the resident left the facility without staff knowledge and supervision, but the Administrator repeatedly resisted characterizing the event as an elopement, instead describing it as the resident going for a walk and forgetting to sign out. The Administrator also stated that she would allow residents she considered cognitively impaired but without a formal incapacity statement to leave unsupervised and was unaware of the psychiatric APRN’s documented incapacity determination at the time. The DON confirmed that she did not direct staff to make a late entry documenting the incident and did not order a new elopement risk assessment, stating she believed the resident was alert and oriented and that a new evaluation was only done when a resident newly expressed a desire to leave and “did not make sense.” These actions and inactions, in the context of extensive documentation of confusion and impaired safety awareness, contributed directly to the unsafe elopement and the cited deficiency for failure to prevent accidents and provide adequate supervision.
Removal Plan
- Resident #900 no longer resides at the facility and was successfully discharged home as planned.
- Resident #900 was immediately placed on 1:1 staff observation.
- A licensed nurse performed a complete skin inspection for Resident #900 with no new skin concerns identified.
- Resident #900’s cognitive status was re-evaluated using the BIMS assessment.
- The Administrator/Designee re-educated all staff on Missing Resident Drill and Elopement policy, emphasizing responding to door alarms, using the elopement binder, performing a resident headcount, and Administrator/DON notification.
- The Administrator modified the receptionist process for residents exiting the facility and added it to new hire education, including use of a binder with blue (requires supervision) and white (safe for unsupervised LOA) sheets, clinical team determination of supervision, and resident sign-in/sign-out for each LOA; front door opened by remote or keypad.
- The contracted vendor removed the automatic open option on the front double doors so doors remain locked with access by staff remote or keypad entry/exit only.
- The facility extended receptionist hours to 7:00 a.m.–9:00 p.m., 7 days/week.
- The front desk coverage process was updated to establish coverage when the receptionist is on break/steps away and to define the process for 9:00 p.m.–7:00 a.m. for assisting residents with LOA and/or visitors entering/exiting.
- Residents admitted in the last 30 days were re-evaluated for accuracy of new admission assessments and documentation related to cognitive status and elopement risk by the DON/Designee.
- The Administrator confirmed the LOA process is included in the new admission packet.
- The DON/Designee completed a new elopement risk assessment on all current residents in the electronic medical record system.
- The receptionist on duty for the event was re-educated on ensuring residents exiting the facility were approved by clinical staff prior to exit and on the binder/blue-white sheet LOA process and door access process.
- The DON/Designee re-educated all employees on F689 (including CMS definition of elopement), the updated facility elopement policy, documentation of resident incidents in the clinical record, and the new receptionist process for resident exiting (binder/blue-white sheets, clinical team determination, sign-in/sign-out, remote/keypad door access).
- All licensed nurses were educated on communicating physician changes to a resident’s capacity and notifying the DON and/or Administrator at the time of determination to ensure timely re-evaluation of elopement risk.
- An ad hoc QA meeting was held with the facility Medical Director in attendance via phone.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility failed to keep the environment free of accident hazards when a resident’s room contained an unattended shaving razor on the sink and additional razors in a nightstand, despite leadership stating razors were not permitted in resident rooms. An LPN disposed of unused lancets in regular trash instead of a sharps container, contrary to acknowledged policy. On two occasions, an unattended housekeeping cart on an upper floor had germicidal wipes left on top and easily accessible, even though housekeeping leadership and staff stated that chemicals and disinfectant wipes were to be kept locked in the cart for safety.
A resident with severe cognitive impairment, dementia, a history of falls, and dependence on staff for transfers was observed using a lift reclining chair even though the care plan and physical device review did not identify that device. Therapy staff lowered the chair and placed the remote next to the call light on the resident’s lap, and staff stated they were not aware of any formal assessment for safe use of the lift chair. The DON stated the resident should have had an assessment to determine whether she was safe to have the lift chair.
A resident with severe cognitive impairment, dementia with behavioral disturbances, and fall risk interventions in place was transferred by staff using methods that did not match the care plan and Kardex. Staff used a transfer belt for some transfers, then later used a Hoyer lift from mattresses on the floor to a wheelchair, but used a green sling even though the resident required a yellow sling based on weight. The RN, LPN, DON, and PT verified the resident’s transfer status and sling instructions were not updated to reflect current needs.
A resident with nicotine dependence was care planned as a smoker who could go out to smoke at designated times or with family, with an intervention that a smoking evaluation be completed quarterly. The last documented smoking safety evaluation showed the resident could safely smoke with supervision, but no additional evaluations were completed for several months, contrary to facility policy requiring smoking assessments at admission, readmission, with significant change, and quarterly by a licensed nurse, even though the resident continued to smoke under staff and family supervision in the courtyard.
Failure to supervise smokers and secure smoking materials. Surveyors found that 27 smokers were not adequately monitored and that residents were able to keep cigarettes and lighters in their possession despite care plan directions to return them after smoking. One resident with severe cognitive impairment, dementia, schizophrenia, and continuous oxygen use was observed with cigarettes and a lighter while on oxygen, and staff confirmed she was an unsafe smoker requiring direct supervision.
Code Alert System Failed to Prevent Resident Elopement: The facility failed to keep the code alert system functioning as intended and did not follow the manufacturer’s weekly testing and inspection guidance. Two residents with significant cognitive impairment were able to get through the main doors, and one resident exited the building before staff followed outside. The report also states that multiple residents with code alert devices did not have adequate elopement or wandering assessments and care plan interventions, and several attempts to leave were not documented in the record.
Failure to Control Razors, Sharps, and Chemical Wipes Creating Accident Hazards
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and safe handling of potentially hazardous items. On one floor, a shaving razor was observed on the sink in a resident’s room. When questioned, the resident stated the razor on the sink was not his and showed the surveyor separate razors he kept in his nightstand. The resident’s record showed admission with malignant neoplasm of overlapping sites of the bladder and care plans for ADL self-care deficits related to activity intolerance, generalized muscle weakness, bladder cancer, and a history of gross hematuria, with interventions including encouraging and assisting with bathing, personal hygiene, and oral care. Facility leadership, including the ADON, Administrator/Risk Manager, and DON, stated that residents were not allowed to keep shaving razors in their rooms and that razors were to be kept in the supply room. Additional observations showed that staff did not consistently follow safe disposal practices for sharps and did not secure chemical products as required by facility policy. An LPN performing a blood glucose check discarded unused lancets into the medication cart trash instead of a sharps container, despite acknowledging that lancets were to be disposed of in a sharps-resistant container. On two separate observations, a housekeeping cart on the second floor was left unattended with a container of germicidal wipes placed on top of the cart and easily accessible. Corporate housekeeping staff and the Housekeeping Director stated that all chemicals that could harm residents should be locked in the cart’s compartment, and housekeeping staff reported that disinfectant wipes and cleaning supplies were to be kept locked in the cart for resident safety. The facility’s written “Nursing Home Accident Prevention and Safety Policy” stated a commitment to maintaining a safe, hazard-free environment and identifying and correcting safety risks promptly.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. The facility continues to ensure that the resident environment remains free of accident hazards as possible. IMMEDIATE CORRECTIVE ACTION Resident #29 was not adversely affected by the alleged deficient practice. Razor was immediately removed and disposed of from resident's room by nurse on 5/11/26. Germicidal wipes were immediately secured in a locked housekeeping cart on 5/11/26. Staff E was provided with 1:1 education by the Director of Nursing regarding the importance of providing an environment free from hazards and accidents with emphasis on keeping hazardous items like razor secured on 5/11/26. Staff G was provided with 1 to 1 education by House Keeping Director regarding ensuring that all housekeeping chemical products are secured in a locked housekeeping cart when not in use on 5/12/2026. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. The Director of Nursing and/ designee conducted a facility-wide observation audit to ensure that hazardous items are locked and secured and that staff are disposing of Sharps in a Sharp Resistant Container on 05/15/2026. The Housekeeping Director conducted a facility-wide observation on 5/15/2026 to ensure that all housekeeping chemical products were secured and locked inside the housekeeping cart when not in use. No residents were adversely affected by the alleged deficient practice. SYSTEMATIC CHANGES Director of Nursing initiated ongoing in-service education with staff on standards of maintaining an environment free from hazards/accidents with emphasis on keeping hazardous items like razor secured and properly disposing of sharps in sharps resistant container on 5/20/26. The Housekeeping Director and/or designee initiated ongoing in-service education on standards of maintaining an environment free from hazards/accidents with emphasis on keeping housekeeping chemical products secured and locked in a housekeeping cart when not in use on 5/20/2026. MONITORING The Director of Nursing and/or designee will conduct random observation audits to ensure that hazardous items are locked and secured and sharps are disposed in sharps resistant container weekly for 3 months. The Housekeeping Director and/or designee will conduct random observation audits to ensure that housekeeping chemical products are secured and locked in a housekeeping cart weekly for 3 months. The Director of Nursing, Housekeeping Director and/or designee will report findings of observation/audits to the quality assurance committee monthly for 3 months to ensure continued substantial compliance is achieved and maintained.
Failure to Assess Safe Use of Lift Reclining Chair
Penalty
Summary
The facility failed to ensure a resident was safe to have a lift reclining chair. The resident had severe cognitive impairment, lower extremity impairment on one side of the body, a history of falls, dependence on staff for transfers, and diagnoses including dementia, disorientation, anxiety, muscle weakness, and a right pubis fracture. The resident’s care plan identified high fall risk related to impaired mobility, confusion, and dementia, and directed staff to keep the call light within reach and encourage use of it. The care plan also stated the resident required two staff to assist with transfers using a standing lift as needed, but it did not identify use of a lift reclining chair. The physical device review also did not identify an electric recliner chair or other lift type reclining chair. During observation, the resident was transferred into the lift chair by therapy staff, who lowered it from an upright position to a seated and then reclining position. The remote for the lift chair and the call light were both placed on the resident’s lap next to each other. The PTA stated she was not aware of any assessment for safe use of the lift chairs, and nursing and therapy staff stated they were not aware of any formal lift chair assessment for the resident. The DON stated therapy worked with residents who had lift chairs and was not aware of any formal assessment, and later stated the resident should have had an assessment completed to determine if she was safe to have a lift chair. The DON also stated the resident was cognitively impaired and could accidentally use the lift chair remote when intending to push the call light.
Failure to Follow Transfer and Sling Size Interventions
Penalty
Summary
The facility failed to ensure staff followed fall risk interventions for one resident identified as at risk for falls. The resident had severe cognitive impairment, delusions, behaviors directed at others, dementia with behavioral disturbances, anxiety, an affective disorder, diabetes, and hearing loss. The resident’s care plan and Kardex identified the resident as a fall risk and stated the resident was independent for transfers, while also noting that if a Hoyer transfer was required, a yellow/medium sling was to be used. During observation, nursing assistants transferred the resident from a wheelchair to the toilet using a transfer belt, then later transferred the resident from the wheelchair to mattresses on the floor using a transfer belt and two staff members. Staff stated they normally used a Hoyer lift to lift the resident from the mattresses on the floor, but the resident’s Kardex did not identify the mattresses on the floor or clarify when a Hoyer should be used for transfers. Staff also stated the resident was not independent with transfers and required one to two staff for wheelchair-to-toilet transfers and two staff with a Hoyer for transfers to and from the mattresses on the floor. On a later observation, two nursing assistants used a Hoyer lift to transfer the resident from the mattresses on the floor to a wheelchair, but used a green sling even though the resident weighed 155 pounds and the manufacturer’s chart indicated a yellow sling was required. Staff stated the green sling was too big for the resident and that the correct sling size was important for safety. The RN, LPN, DON, and PT all verified that the resident’s care plan and Kardex were not revised to reflect the resident’s current transfer abilities and the correct sling size and transfer method for the resident’s current setup.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
The facility failed to ensure resident safety related to smoking by not completing required smoking safety assessments at the prescribed frequency for one resident. A resident with a diagnosis that included nicotine dependence was observed smoking in the courtyard with his daughter present, and later in the presence of Activities staff who remained outside with the residents while they smoked. The resident’s care plan, dated 2/4/25, identified him as a smoker who could go out to smoke at designated times or with family and specified that a smoking evaluation would be completed quarterly. Record review showed the most recent Smoking Safety Evaluation had been completed on 11/6/24 and indicated the resident could safely smoke with supervision, but no further evaluations were completed until 4/30/26, despite facility policy requiring smoking assessments upon admission, readmission, with significant change, and quarterly by a licensed nurse.
Failure to Supervise Smokers and Secure Smoking Materials
Penalty
Summary
The facility failed to adequately supervise 27 identified smokers and failed to secure resident smoking materials, including lighters and cigarettes. Surveyors found that the facility’s smoking policy required smoking-related privileges, restrictions, and concerns to be documented in the care plan and communicated to personnel, and required residents with restricted smoking privileges to be monitored under direct supervision while smoking. Resident #15 was observed sitting up in bed with oxygen in use, and later was observed on the smoking patio sitting in a wheelchair with a plastic bag containing cigarettes and a lighter in her lap. Staff confirmed she was identified as an unsafe smoker and required a smoking apron while smoking. Her record showed severe cognitive impairment with a BIMS score of 6, diagnoses including dementia and schizophrenia, and continuous oxygen at 2 liters per minute via nasal cannula for COPD. Review of the records for all 27 smokers showed care plan interventions requiring them to return smoking materials to the Activities Department after re-entering the building from the smoking patio. Interviews with the Activity Director, LPN, MDS staff, CNA, DON, Administrator, and Medical Director showed conflicting descriptions of where smoking materials were kept, but multiple staff acknowledged that residents kept cigarettes and lighters in their possession and that residents were expected to turn them in after smoking. The Medical Director stated residents were not permitted to keep cigarettes or lighters and that residents with low BIMS scores or those receiving oxygen should not have access to smoking materials.
Code Alert System Failed to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure the code alert system used for residents at risk for elopement was functioning properly and failed to follow the manufacturer’s recommendations for weekly testing and inspection. The report states that the immediate jeopardy began when R12 was able to exit the building after the main entrance code alert system malfunctioned, and that R19 was also able to get through the main doors because the doors did not lock as required by the system. The manufacturer’s binder in the facility called for weekly testing of the code alert units, regular testing of each detection zone, and quarterly service inspections, but the facility’s logs showed the doors were being tested monthly instead of weekly. R19 was severely cognitively impaired with Alzheimer’s disease. The resident’s assessment identified low elopement risk, and the care plan lacked interventions for elopement and wandering. During observation, R19 wheeled to the main entrance, went through the first door into the vestibule, and the alarm sounded, but the door did not lock. A nursing assistant responded and redirected R19 back to the central TV area. The resident’s progress note did not include the attempt to leave the building. R12 was severely cognitively impaired with non-Alzheimer’s dementia and anxiety. The resident had repeated attempts to leave the facility, but the care plan lacked elopement and wandering interventions, and the most recent assessment also identified low elopement risk with the door alarm band not selected. During observations, R12 repeatedly approached the main entrance, triggered the alarm, and was able to get through the first door into the vestibule; on one occasion R12 exited the building before being followed outside by staff. The report also states that R12’s record lacked documentation of the successful exit and other attempts to leave. In addition, the facility failed to adequately assess and develop care plans for multiple other residents assigned code alert devices, including residents with severe or moderate cognitive impairment and diagnoses such as dementia and Alzheimer’s disease, whose care plans did not include elopement or wandering interventions or, in some cases, the location of the device.
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