Failure to Supervise Resident Leads to Elopement
Summary
The facility failed to ensure adequate supervision for a resident with cognitive deficits, leading to an elopement incident. On the specified date, the resident eloped from the facility around 5:35 PM. A CNA noticed the resident was not in their room around 6:00 PM but did not take action to locate them, assuming the resident had been discharged. It wasn't until 8:47 PM that an LPN realized the resident's whereabouts were unknown and initiated a search. The resident was eventually found by local law enforcement at a grocery store 1.9 miles away from the facility at 8:57 PM. The resident had been admitted for rehabilitation services and had diagnoses including dementia, encephalopathy, and alcohol abuse. The resident's care plan indicated a desire to return home, and staff interviews revealed that the resident had expressed confusion and a desire to go home. Despite these indicators, the resident was not identified as being at risk for wandering or elopement. The facility's policies on elopement and missing residents were not adequately followed, as staff failed to monitor the resident and did not conduct timely checks. Interviews with staff revealed lapses in communication and supervision. The CNA who first noticed the resident missing did not report it immediately, and the LPN on duty did not receive a proper handover from the previous nurse. The facility's previous Director of Nursing confirmed that residents should be checked every two hours, but the resident was not monitored for over three hours. This lack of supervision and failure to follow established protocols led to the resident's elopement and the subsequent finding by law enforcement.
Removal Plan
- The resident was located nearby by local law enforcement and taken to the emergency room for an evaluation upon family request. No injuries noted. The resident discharged home with the RP after the ER visit.
- A one-time head count to verify all current residents were inside the facility was completed by the charge nurse on duty. All residents were accounted for.
- All facility exits were verified by the Administrator and DON to be locked and alarms functional.
- DON/Social Worker completed a new elopement risk User Defined Assessment for all current residents to identify any resident who may have had a change in condition deeming them at risk for elopement. Any residents found to be newly at risk will have their care plan reviewed and revised as indicated.
- The front door will be monitored until all reassessments have been completed.
- All staff will be interviewed to ascertain if there are any residents with wandering behavior that may not be documented. If residents are identified with wandering behavior not previously identified, their assessment and care plan will be updated to reflect the wandering.
- A discharge communication form will be instituted to reflect scheduled discharges each day indicating discharge date/time to effectively communicate between discharge planner and direct care staff. The discharging nurse will sign acknowledging when discharge occurs.
- Facility front door was locked and/or supervised. Facility changed the door system to remain locked at all times with keypad code required for entry/exit. Residents and family members notified and educated of change in entry/exit process by resident council meeting and family notifications by phone and written notification.
- Staff re-educated by DON/Designee regarding reporting of new behaviors such as wandering and elopement policy. Staff also reeducated on steps to take if a resident displays wandering behavior. Charge nurses reeducated regarding documentation of behaviors, specifically wandering with the need to obtain an order for a Wander guard Bracelet if indicated.
- 24-hour report/Nurse-to-nurse communication process updated to a more efficient method of communicating changes from shift to shift. A 24-hour notebook will be utilized rather than 24-hour report form. Staff education was initiated. Staff education on the new process for 24-hour report was completed.
- The facility will utilize elopement risk assessment in Electronic Medical Record that scores residents on a scale of 0-10 according to elopement risk level.
- Staff educated regarding discharge communication form initiated by discharge planner to communicate with direct care staff the scheduled discharges each day. The discharging nurse will sign acknowledging the discharge is complete and return to the DON.
- Facility doors will be checked daily x 1 week and then weekly x 4 weeks to verify that all doors are secured and functioning properly.
- The facility Interdisciplinary Team (IDT) will review nurse's 24-hour report information and discuss new or worsening behaviors in daily clinical meetings 5 x weekly. If a new behavior is reported or documented, IDT will verify that care plan and orders reflect interventions as indicated. DON/Designee will also interview 5 staff members to verify reporting and documentation of any new wandering behaviors. The interviews will be weekly x 4 weeks, then monthly x 2 months.
- 24-hour report/Nurse-to-nurse communication process monitored daily in clinical meeting 5 x weekly X 4 weeks to verify the 24-hour notebook is being utilized and report is thorough.
- Elopement risk assessments (that score residents on a scale of 0-10 according to elopement risk level) will be reviewed on all new admissions X 3 months to verify that assessment is complete, interventions in place and care planned if appropriate.
- The facility IDT will review the discharge communication forms from the previous day to verify each discharge occurred as scheduled and will initiate a new discharge communication form listing the discharges scheduled for the day and will provide the form to direct care nurses on each unit.
- An emergency Quality Assessment Program Improvement (QAPI) meeting was conducted, attendance included the Medical Director.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with multiple medical conditions, including COPD and chronic respiratory failure requiring O2 via nasal cannula, was care planned as at risk for injury related to smoking, with interventions requiring supervision during smoking and storage of all smoking items at the nurse station. During observation, surveyors found an open metal box containing a disposable e-cigarette on the resident’s over-bed tray, and the resident and CNAs confirmed the vape was kept in the room despite staff acknowledging it was not permitted. The DON confirmed the resident was not allowed to keep e-cigarette supplies in the room, and review of the facility’s smoking policy showed all smoking materials, including vapes, were required to be stored in locked boxes at the nurse station or designated area.
A resident with dementia, quadriplegia diagnosis, behavioral issues, and documented fall risk had a care plan calling for a hazard-free room, use of a floor mat or mattress at bedside, and behavioral approaches to reduce injury from falls. Despite this, the resident—who was dependent for ADLs but able at times to scoot and push herself off the bed—experienced an unwitnessed fall, was found face down on the floor with head trauma, and may have struck a nearby tube feeding pole. Observations and staff interviews showed that equipment and furniture such as an oxygen concentrator, wastebasket, bedside table, and feeding pole were positioned near the bed where the resident, known to reach over the side and pull on nearby objects, could hit her head if she fell. The facility did not consistently implement the care-planned environmental and supervision interventions to keep the area free of accident hazards, resulting in a cited deficiency.
The deficiency involves multiple failures to implement ordered or care-planned fall-prevention measures and to conduct a complete post-fall investigation. Several residents with significant medical and functional impairments experienced falls or were identified as at risk, yet interventions such as non-skid floor strips, fall mats at bedside, Dycem on a wheelchair seat, and proper wheelchair foot pedals were not in place as ordered or documented by the IDT. In one case, a dependent resident was lowered to the floor during ADL care and sustained a skin tear, but the facility’s investigation did not clearly determine why the resident was lowered, who did so, or how the injury occurred, and staff accounts were contradictory. These events occurred despite a facility policy requiring prompt, detailed fall investigations and the identification and implementation of appropriate fall-prevention interventions.
The facility failed to maintain safe and controlled smoking areas, as evidenced by heavily littered smoking and entrance areas and residents smoking in a designated non‑smoking zone. Surveyors observed numerous discarded cigarette butts around the secured behavioral unit’s smoking exit and the main entrance, where no cigarette disposal container was present. A resident with multiple psychiatric and medical diagnoses, assessed as an independent smoker, reported routinely smoking at the main entrance, while two other cognitively intact residents, including one with hemiplegia assessed as an unsafe smoker requiring supervision, were also seen smoking there. Staff, including a CNA and an LPN, confirmed that residents smoked at the main entrance despite it being a non‑smoking area and acknowledged the extensive cigarette litter.
The facility failed to prevent an accident hazard in meal service and to document resident falls as required. A cognitively intact resident with multiple chronic conditions was served chicken noodle soup that contained an approximately two‑inch chicken bone, which she discovered while eating alone in her room; dietary staff had used leftover fried chicken that was manually deboned for the soup, and several residents received this soup. In a separate issue, another cognitively intact resident with chronic respiratory and psychiatric diagnoses had unwitnessed falls that were recorded only in Risk Management documents, while IDT notes referenced fall investigations without dates, times, resident condition, or involved staff, and no corresponding nursing notes were entered despite facility policy requiring detailed fall documentation in the medical record.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Unsecured E-Cigarette Supplies Kept in Resident Room
Penalty
Summary
The facility failed to ensure smoking supplies were locked and secured as required by facility policy and the resident’s care plan. One resident, admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, acute and chronic respiratory failure with hypoxia, epilepsy, COPD, alcohol abuse, cannabis use, and tobacco use, had a quarterly MDS indicating intact cognition. The resident’s care plan, dated 02/13/26, identified risk for injury related to smoking, cigarettes, and electronic devices, with interventions specifying that the resident was to be supervised at all times while smoking, wear a smoking apron, and have all smoking items kept at the nurse station. During observation on 03/18/26 at 10:49 A.M., the resident was seen in bed with oxygen via nasal cannula, and an open red metal box containing a disposable e-cigarette (vape) was on the over-bed tray next to the bed. The resident confirmed that he kept the vape in his room in the red box. Two CNAs separately confirmed that the resident had his e-cigarette vape in his room, and one CNA stated he was not permitted to have it there. The DON also confirmed the resident was not permitted to keep e-cigarette supplies in his room. Review of the facility’s “Lionstone Smoking” policy, revised 10/15/24, showed that no smoking materials are permitted with the resident or in their room and that all smoking materials, including vapes, must be kept in lock boxes at the nurse station or designated area. This constituted non-compliance with the requirement to keep smoking materials secured.
Failure to Implement Care-Planned Fall and Hazard Controls for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain care-planned fall and accident-hazard interventions for a resident identified as being at risk for falls and injury. The resident was admitted with multiple diagnoses including unspecified dementia, quadriplegia, delusional disorders, early-onset Alzheimer’s disease, anxiety disorder, major depressive disorder, and epilepsy. On admission, the nursing evaluation identified the resident as at risk for falls, and the care plan documented fall risk related to impaired cognition and decreased safety awareness, with goals to reduce injury risk. Interventions included ensuring the room was free from accident hazards, placing a floor mat next to the bed, and later revising this to a mattress on the floor at bedside. The care plan also documented behavioral issues such as verbal aggression, yelling, throwing legs out of bed, resisting care, socially disruptive and attention-seeking behaviors, including a history of yelling fire and pretending to have seizures, with interventions to approach calmly and re-approach if agitated. The resident’s care plan further identified an ADL self-care performance deficit related to quadriplegia, dementia, fluctuating ADLs, Alzheimer’s disease, and cognitive impairment, with documentation that the resident required one-person assistance for ADLs and a two-person assist with a mechanical lift for transfers. The MDS assessment indicated the resident was cognitively intact, had no impairment of upper and lower extremities, and was dependent for rolling in bed and transfers. Despite being care planned as dependent for mobility and at risk for falls, multiple interviews and observations established that the resident was able at times to move, scoot to the edge of the bed, and push herself off the bed. Staff, the POA, and the NP all reported that the resident could and did intentionally push or throw herself from the bed, sometimes to gain attention, and that she had a history of similar behaviors at a previous facility. The facility’s fall protocol required assessment of history of falls, cognitive/behavioral symptoms, mobility, and development and implementation of a plan of care to reduce falls and minimize injury. The incident underlying the deficiency included an unwitnessed fall in which the resident was found on the floor next to the bed after reportedly throwing herself out of bed, with a hematoma near the left eye and an active nosebleed, requiring EMS transport to the hospital. At the time of this fall, the resident had a fall mat on the floor and a tube feeding pole with a feeding machine next to the bed, and staff reported the resident might have hit her head on the pole. Subsequent observations showed the resident with bruising and steri-strips on her forehead, and later lying in bed leaning over the side with an oxygen concentrator, wastebasket, and bedside table positioned near her head. A CNA immediately identified and removed these items as accident hazards, acknowledging the resident was a fall risk who could hit her head on them if she fell. The DON later acknowledged the resident probably hit the cement floor when she rolled off the bed. These findings demonstrate that the care-planned interventions to keep the room free of accident hazards and to provide adequate environmental protection (such as appropriate placement of mattresses and removal of hazardous equipment and furniture near the bed) were not consistently implemented, resulting in a failure to ensure a hazard-free area and adequate supervision to prevent accidents for this resident. Additional interviews reinforced that the resident frequently reached over the side of the bed, grabbed and pulled on the floor mat, and pulled on nearby equipment such as the tube feeding pole. Staff, including the RN, CNA, NP, and DON, described the resident’s fluctuating physical abilities and behavioral components, including faked seizures, reports of chest pain, and self-propelling off the bed. Despite this known pattern and the care plan directive to keep the environment free of accident hazards and to use protective measures at bedside, the resident continued to have accessible objects and equipment within striking distance of her head while in bed. The facility’s failure to consistently remove or reposition these hazards and to fully implement the individualized fall and behavior-related interventions as care planned led to the cited deficiency for not ensuring the area was free from accident hazards and not providing adequate supervision to prevent accidents.
Failure to Implement Fall-Prevention Interventions and Complete Thorough Post-Fall Investigation
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall-prevention interventions and to conduct a thorough post-fall investigation for multiple residents. For one resident with COPD, severe protein-calorie malnutrition, dysphagia, wheelchair use, and severe cognitive impairment, orders and care plan interventions for non-skid floor strips near the bed and fall mats on both sides of the bed were in place following recurrent falls. However, during observation of the resident’s room, there were no non-skid strips or fall mats at the bedside, and the LPN confirmed these items were not present. Another resident, cognitively intact and largely independent in ADLs except for needing substantial assistance with bathing, experienced a fall and had a post-fall intervention of nonskid strips to the floor documented in an IDT follow-up note. The resident’s fall risk care plan did not include nonskid strips as an intervention, and a separate care plan intervention for a visual reminder to ask for assistance when getting out of bed was not observed in the room on multiple occasions. Nursing staff confirmed that nonskid strips were not on the floor and that the visual reminder, which should have been posted near the bed and in the bathroom, was not in place. A third resident, cognitively intact with a history of cerebral infarction, hemiplegia, traumatic cerebral hemorrhage, heart disease, and alcohol abuse, had an unwitnessed fall after sliding from a wheelchair post-therapy. The IDT determined Dycem should be added to the wheelchair seat as a preventive intervention, but subsequent observation in the therapy department showed no Dycem on the wheelchair, and therapists confirmed its absence despite one therapist stating she had previously placed it. For a resident with anoxic brain damage, COPD, dysphagia, bilateral hand contractures, moderate protein-calorie malnutrition, psychoactive substance abuse, anxiety disorder, and severely impaired cognition, the plan of care identified fall risk and dependence for rolling and other ADLs. A progress note documented that the resident was lowered to the floor during ADL care by a CNA and sustained a skin tear to the right side of the back. The fall investigation concluded that a hospice aide was providing care when the resident fell out of bed and that the suspected root cause was the air mattress and turning the resident, but the investigation did not identify why the resident needed to be lowered to the floor, who lowered the resident, or how the skin tear occurred. The DON later stated that both a hospice aide and a facility CNA were present, that staff accounts were contradictory, that only one witness statement from a unit manager was available, and verified that it remained unclear what happened and how the skin tear was obtained, confirming that a thorough investigation was not completed. Another resident with intact cognition, major depressive disorder, borderline personality disorder, seizure history, and other psychiatric and pain-related diagnoses was care planned as being at risk for falls due to new admission status, potential medication side effects, and seizure history. After the resident fell from bed during a seizure and was found on the floor at bedside, the IDT added fall mats to both sides of the bed as an intervention. On two separate observations, the resident was in bed without fall mats in place, and the DON confirmed that the fall mat intervention ordered after the first fall was not in place. A further resident, cognitively intact with an above-knee amputation, polyneuropathy, muscle weakness, and muscle wasting, fell forward out of a wheelchair while being transported by a company driver to a van for dialysis, with the right leg caught in the wheelchair wheel. The IDT follow-up identified the cause as the absence of the right foot pedal and initiated an intervention that the right foot pedal be in place when the resident was transported. The therapy manager stated that residents with wheelchairs are always given foot pedals, that this resident always used foot pedals, could not remove the pedal independently, and could not self-propel, and the DON confirmed the fall occurred when the resident did not have the right foot pedal on the wheelchair when leaving for dialysis. The facility’s fall prevention and management policy stated that the facility would identify risk factors to minimize falls, obtain information from assessments, diagnoses, and current ADL status, and begin a fall investigation once the resident was safely transferred following a fall. The policy required asking the resident what they were doing when they fell, identifying witnesses and obtaining written statements immediately, attempting to identify why the resident fell before implementing post-fall interventions, and conducting an interdisciplinary review with discussion of the fall, potential causes, existing interventions, and a deep root cause investigation. The findings show that for multiple residents, ordered or care-planned fall-prevention interventions such as non-skid strips, fall mats, Dycem, and wheelchair foot pedals were not in place at the time of observation or transport, and for one resident, the post-fall investigation did not meet the facility’s own policy requirements for a thorough and clearly documented investigation.
Failure to Maintain Safe and Controlled Smoking Areas
Penalty
Summary
The facility failed to maintain a safe smoking environment in both the secured women's behavioral unit and the main entrance area. On the secured women's behavioral unit, surveyors observed numerous discarded cigarette butts lying all over the ground near the exit door to the smoking area and along the sidewalk leading away from the building; a CNA confirmed the presence of these cigarette butts. At the main entrance, which was identified as a non‑smoking area, surveyors observed a concrete pad and awning where residents, visitors, and staff entered the building, and noted numerous discarded cigarette butts scattered across the ground near the front door, throughout the landscaping rocks on both sides of the doors, and around a trash can with a plastic liner. There was no container for discarded cigarettes at this entrance. Multiple residents with documented smoking evaluations and intact cognition were observed smoking in the non‑smoking main entrance area. One resident, with diagnoses including essential primary HTN, antisocial personality, inhalant abuse, schizoaffective disorder, bipolar disorder, anxiety disorder, and psychosis, had been assessed as an independent smoker with no history of smoking safety concerns and reported that he smoked by the main entrance doors often. Another resident, with diagnoses including paranoid schizophrenia, bipolar disorder, essential primary HTN, anxiety disorder, and psychotic disorder with delusions, was also assessed as an independent smoker. A third resident, with cerebrovascular disease, hemiplegia and hemiparesis, hyperlipidemia, depression, anxiety disorder, and epilepsy, had been assessed as an unsafe smoker requiring staff supervision due to left‑sided paralysis. Despite these assessments, surveyors observed these residents smoking directly outside the main entrance in the non‑smoking area, and staff (a CNA and an LPN) verified both the residents’ smoking in this location and the large amount of discarded cigarette butts scattered on the ground and in the landscaping.
Failure to Prevent Food Choking Hazard and to Document Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure meals were free from choking hazards and to maintain required documentation of resident falls. One cognitively intact resident with multiple chronic conditions, including COPD, heart failure, diabetes, hypothyroidism, and major depressive disorder, was observed eating lunch alone in her room with the door closed. After the meal, an approximately two‑inch chicken bone was found in her soup bowl. The resident confirmed she had eaten chicken noodle soup and discovered the bone while eating. A staff member verified the presence of the bone, and the Dietary Manager reported that leftover fried chicken from a recent meal had been deboned by dietary staff for use in the soup. A facility-provided list showed that eight residents were served chicken noodle soup at that meal. The facility’s food and nutrition policy stated that food would be prepared to be nutritious, palatable, attractive, and safe to meet individual needs. The facility also failed to follow its fall policy and document falls in the medical record for a cognitively intact resident with chronic respiratory failure, obstructive sleep apnea, delusional disorders, and anxiety. Interdisciplinary team notes on two separate dates indicated that fall investigations had been completed and interventions reviewed, but these notes did not include the date or time of the falls, the resident’s condition after the falls, or the staff involved. Nursing notes contained no documentation of these falls. Risk Management documents, labeled as not part of the medical record and not to be copied, showed the resident had unwitnessed falls on two dates. The DON confirmed there was no nursing documentation related to these falls in the electronic medical record, and the ADON confirmed that, per the facility’s fall policy, nurses should document falls in the nurse’s notes, including assessments and details of the circumstances of the fall.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
