F0744

E

Failure to Implement Person-Centered Dementia Care and Supervision for Wandering Residents

Lakewood, Colorado Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate, person-centered dementia care and supervision for multiple residents with dementia who exhibited wandering and territorial behaviors. Facility policy required individualized care plans, least restrictive approaches, thorough clinical assessment, monitoring of mood and behavior, and staff training in dementia care and behavior management. Despite this, surveyors observed residents with known dementia and wandering tendencies roaming hallways without purpose, entering other residents’ rooms, and intruding into others’ personal space and rooms without consistent staff monitoring or redirection. During group activities, several residents wandered the halls unobserved, and one resident repeatedly attempted to exit locked doors and became frustrated without timely staff intervention.

Specific residents with documented dementia, severe cognitive impairment, and care plans addressing wandering and behavioral risks were not managed according to their care plan interventions. One resident with severe cognitive impairment and documented wandering and aggressive behaviors was observed going into other residents’ rooms without staff supervision or redirection, despite care plan directives for early staff-led redirection and immediate intervention when entering others’ rooms. Another resident with dementia and daily documented wandering was seen attempting to exit locked doors and then wandering the unit and trying to exit the front door without staff maintaining line-of-sight supervision, even though the resident had an elopement/wandering care plan. Additional residents with severe cognitive impairment and documented frequent wandering were observed pacing hallways, standing idly, and entering other residents’ rooms without staff monitoring or redirection, contrary to care plan interventions that called for structured activities, reorientation strategies, and redirection.

Residents identified as territorial or prone to aggression when others entered their rooms or personal space were also not consistently protected through care-planned interventions. One resident with dementia and a care plan noting potential physical aggression and territoriality, including triggers such as others entering his room or personal space, was not supervised or protected when another resident rested her head on him and touched his head and hand, and when other residents were in close proximity, without staff monitoring or redirection. Another resident with a history of becoming physically aggressive when others wandered into his room had a care-planned intervention for retractable barrier straps across his doorway, but surveyors observed that these straps were not consistently in place, allowing wandering residents to enter his room unimpeded. Staff interviews confirmed that many or all residents on the secure memory unit wandered and entered other residents’ rooms, that staff relied on red barrier straps to deter entry, and that staff did not consistently prevent residents from going into others’ rooms, with some CNAs unaware of where to find care plans or unable to clearly describe non-restrictive behavior management approaches.

The record reviews further showed a pattern of frequent wandering documented in daily activity tracking for many of these residents, including those whose MDS assessments did not always reflect wandering behaviors, while care plans for elopement and wandering called for identifying patterns, determining purpose of wandering, and providing structured activities and redirection. Despite these documented needs and interventions, surveyor observations over multiple days showed residents repeatedly wandering aimlessly, entering occupied and unoccupied rooms, and intruding on others’ privacy without consistent staff intervention. This mismatch between assessed needs, written care plans, and actual staff practices led to residents with dementia not receiving the individualized, person-centered dementia management and supervision necessary to maintain their highest practicable physical, mental, and psychosocial well-being, particularly in relation to wandering, room entry, and resident-to-resident interactions.

Staff interviews corroborated that wandering and room entry by residents were common and difficult to manage, and that staff did not always know or follow care-planned interventions. One CNA acknowledged that residents frequently wandered into others’ rooms and that barrier straps were used only after complaints, while another CNA admitted not knowing where care plans were located. An LPN stated that all residents wandered, especially one younger resident, and that staff only redirected residents when they saw them enter rooms that were not theirs, which conflicted with observations showing a lack of consistent redirection. Another LPN stated that residents could not be stopped from going into other residents’ rooms and that redirection was difficult, underscoring the facility’s failure to implement effective, person-centered dementia management strategies as outlined in its own policy and residents’ care plans.