Facility Assessment Failed to Identify and Address Secured Memory Unit
Penalty
Summary
The facility failed to ensure that its Facility Assessment accurately and comprehensively reflected the presence and needs of a secured memory unit located on the fifth floor. The assessment, dated 4/28/2025, did not identify or recognize the secured unit, despite documentation and staff interviews confirming that the fifth floor housed residents with dementia and behavioral health needs who were at risk for elopement. Observations over four survey days confirmed that access to the fifth floor was restricted by a keypad code, which was not provided to residents, and staff consistently referred to the area as a secure or memory care unit. The facility's documentation also showed that 53 residents, approximately 25% of the facility's population, resided on this floor, but this was not reflected in the Facility Assessment. Staff interviews further revealed that the fifth floor had been used as a dementia and behavioral unit for at least three years, with residents identified as elopement risks and not given the elevator code. The Administrator and Director of Nursing acknowledged that the keypad system was installed to prevent wandering and that the residents on this floor were considered at risk for elopement. Despite these facts, the Facility Assessment did not include the secured unit or address the specific needs and protocols required for this population, resulting in a deficient practice regarding the assessment and monitoring of residents' safety and staff training requirements.