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F0657
D

Failure to Update Care Plans for Elopement Risk and Smoking Status

Walnut Cove, North Carolina Survey Completed on 08-21-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise and update care plans for two residents in accordance with their current needs and assessments. For one resident with Alzheimer's Disease, the care plan continued to list the use of a wander/elopement alarm as an intervention, despite the resident no longer being at risk for elopement and not having a physician order or device in use. The MDS Nurse confirmed that the intervention was mistakenly left on the care plan during the review process, and the DON stated that the resident previously had the alarm but it was no longer in use. For another resident with major depressive disorder and nicotine dependence, the care plan inaccurately reflected the resident's smoking status. Although the resident had been reclassified as an unsafe smoker and required supervision while smoking, the care plan still indicated the resident was a safe smoker and included interventions appropriate for that status. The MDS Nurse acknowledged awareness of the change but had not updated the care plan, and the DON confirmed that the MDS Nurse was notified of the resident's new status but the care plan was not revised accordingly.

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