Failure to Identify and Address Supervision Deficiencies Resulting in Resident Elopement
Penalty
Summary
The facility's Quality Assurance and Assessment (QAA) Committee failed to identify and address quality concerns related to adequate supervision of residents, resulting in repeated deficient practices. Despite having a QAPI program and holding regular QAA Committee meetings with interdisciplinary attendance, the committee did not effectively track, measure, or prioritize quality deficiencies, nor did it systematically analyze underlying causes. This lack of effective oversight led to ongoing issues with supervision and accident prevention, as evidenced by a history of citations for related deficiencies. On August 4, 2025, the facility failed to provide adequate supervision and effective services to prevent the elopement of a resident with known exit-seeking behaviors. The resident was able to leave the facility undetected through an electronic gate in the front of the building. This incident, along with previous citations for similar issues, demonstrates a pattern of insufficient supervision and failure to implement effective corrective actions, potentially affecting all 191 residents in the facility.