Failure of Administrative Oversight Leads to Undetected Elopement of Cognitively Impaired Resident
Summary
Facility administration failed to provide effective oversight and implement processes to ensure resident safety related to unsafe wandering and elopement. A cognitively impaired, ambulatory, and confused resident with poor safety awareness exited the building through an unlocked front door after walking past an unattended front desk. The resident crossed a two-lane road and walked approximately half a mile over uneven terrain and near water ponds to a nearby college dormitory. Facility staff were unaware the resident had left until they were notified by college campus security about the resident’s transfer to a local emergency room via EMS. The resident had multiple documented indicators of cognitive impairment and safety risk prior to the incident. The admission MDS showed moderately impaired cognition with a BIMS score of 12 and a need for partial to moderate assistance with ambulation and activities of daily living. Speech therapy documented moderate cognitive-communication deficits with problems in short-term memory, problem solving, and executive functioning. Nursing and provider notes described intermittent confusion, pulling out IV lines, statements indicating disorientation, and treatment-interfering behaviors requiring close supervision and safety monitoring. A psychiatric APRN documented that the resident lacked capacity to make healthcare and long-term placement decisions, was unable to understand the consequences of not receiving care, and recommended a guardian or POA. Despite this, the admission elopement assessment scored the resident as not at risk for elopement, there were no subsequent elopement reassessments, and the care plan, while noting impaired cognition, did not translate into effective elopement risk management. After the resident left the facility unsupervised, the administration did not consider the event an elopement and did not document the incident or any measures to prevent further unsafe wandering in the clinical record. The Administrator characterized the event as the resident going out for a walk and failing to sign out, and stated the resident was cognitively intact based on a BIMS score obtained upon return, despite prior documentation of incapacity and dementia-level SLUMS scoring. The DON expressed a desire not to label the event as an elopement and acknowledged there was no documentation in the record about the incident, stating she did not want to enter a late note because the Administrator conducted the investigation. A Unit Manager LPN reported being told not to document anything and that the Administrator and DON would handle it. The facility had an elopement prevention policy defining elopement for incapacitated residents and requiring an elopement risk assessment, monitoring device, and care plan when such a resident wanders into an unsafe area or leaves the building, but these processes were not implemented for this resident. The lack of adequate supervision, failure to recognize and classify the event as an elopement, failure to reassess elopement risk, and failure to document the incident and related interventions led to a determination of Immediate Jeopardy under F835.
Removal Plan
- Resident #900 was successfully discharged home as planned.
- The Administrator/Designee completed staff re-education on Missing Resident Drill and Elopement with all staff members, emphasizing responding to door alarms, using the elopement binder, performing a resident headcount, and Administrator and DON notification.
- The Administrator/Designee completed Missing Resident Drills at varying times with staff members participating collectively from each department.
- The Administrator modified the receptionist process for residents exiting the facility and added this to education for newly hired staff, including use of a newly created binder with blue (supervision required) or white (safe for unsupervised LOA) sheets for each resident, requiring residents to sign in/out for LOA each time they leave, and opening the front door by remote or keypad.
- The facility’s contracted vendor removed the automatic open option on the front double doors so doors remain locked with access by staff remote or keypad entry/exit only.
- The facility extended receptionist hours and updated the front desk coverage process for breaks/step-away coverage and for after-hours coverage for LOA/visitors.
- The Chief Nursing Officer re-educated the Administrator and Director of Nursing on the CMS definition of elopement, their roles to ensure resident safety, and the expectation to complete a risk management report for elopement events.
- The facility changed its elopement policy to reflect CMS’s definition of elopement.
- The interdisciplinary team was re-educated on reporting and documenting resident incidents in the clinical record, the alleged deficient practice outlined on the immediate jeopardy template, and federal regulation F835, emphasizing adherence to medical record documentation policies and procedures.
- Residents admitted in the last 30 days were re-evaluated for accuracy of new admission assessments and documentation related to cognitive status and elopement risk.
- The receptionist on duty for the event was re-educated on ensuring residents exiting the facility were approved by clinical staff prior to allowing exit and on use of the LOA binder/blue-white sheets, sign in/out requirement, and door access by remote/keypad.
- The Director of Nursing/Designee completed new elopement risk assessments on all current residents in the EMR.
- All licensed nurses were educated on communicating physician determinations/changes in resident capacity to notify the DON and/or Administrator timely to ensure prompt re-evaluation of elopement risk.
- Staff were re-educated on the CMS definition of elopement, the updated elopement policy, documentation of resident incidents in the clinical record, and the new receptionist process for resident exits (including binder/blue-white sheets, clinical team determination of supervision for LOAs, sign in/out requirement, and door access by remote/keypad).
- An ADHOC QAPI meeting was held with the medical director participating by phone, and the QAPI committee approved the recommendations.
- QA meetings included review of the new receptionist process for residents exiting the facility.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Facility leadership failed to oversee resident care and staff performance effectively. Staff reported a week-long shortage of insulin syringes, during which nurses borrowed insulin pens and vials from other residents and gave them to different residents, while one resident missed insulin and another had delayed blood sugar checks and insulin coverage. Interviews also described an LPN threatening a resident, delayed incontinence care, intimidation of staff who reported concerns, and other allegations of misconduct, while the DON and RN/ADON did not fully investigate several of the reported issues.
The NHA and DON failed to effectively manage the facility to implement sufficient monitoring and supervision to prevent an elopement. Facility records and job descriptions showed the NHA was responsible for maintaining effective systems and overseeing staff, care, supplies, and facilities, while the DON was responsible for nursing management, resident care standards, policy implementation, and supervision of the nursing department. The report states the facility failed to properly supervise a resident and failed to respond appropriately to the elopement.
Administrator Living in Facility and Alleged Alcohol Use Not Addressed: The facility failed to follow its drug-free workplace policy and failed to address repeated concerns that the Administrator was drinking alcohol, appeared intoxicated, and smoked in non-designated areas. Staff reported seeing alcohol in the Administrator’s office, smelling alcohol on his breath, and observing behavior they believed was impaired, while the DON and other leaders learned he was living in a room at the facility. The Area Admin did not investigate the allegations and stated he considered the Administrator exempt from policy during evenings and weekends because he lived at the facility.
Failure to Plan for Facility Closure and Resident Discharge: The facility received an eviction notice but did not have a closure plan for the 30 residents. The ADM said he was out of money, had no specific plan, could not pay for a DON or RN supervisor, and was relying on agency staff while delinquent on supplies and pharmaceuticals. Residents were distressed about being moved, and the ADM had not notified residents or RPs about the eviction.
The NHA and DON failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. The facility did not have working laundry equipment to ensure clean and sanitized linens and laundry, and this was identified as an Immediate Jeopardy for all 67 residents. The NHA and DON confirmed the failure during interview.
A resident eloped from the facility after staff failed to ensure proper supervision, and the event was identified as an IJ for all residents at risk for elopement. The NHA and DON were found to have failed to effectively manage the facility and to fulfill their job duties related to overseeing operations and nursing services.
Leadership and Oversight Failures Affecting Resident Care
Penalty
Summary
The facility failed to demonstrate effective leadership of overall operations to ensure residents received care as ordered and that staff actions were appropriately overseen. Review of job descriptions showed the Administrator was responsible for directing overall operations, the DON for overall management of resident care, and the RN/ADON for assisting with nursing management and training and for ensuring staff understood expectations for resident care. During the investigation, multiple staff interviews and resident statements showed breakdowns in oversight, communication, and response to care concerns across the facility. One major concern involved insulin administration and supply management. An Ombudsman asked the facility whether insulin needles were available for residents who had insulin orders. Staff reported that the facility was out of insulin syringes for about a week. During that time, LPNs stated they borrowed insulin pens or vials from other residents and administered those medications to different residents because they had no syringes available. One LPN stated she notified the RN/ADON that the facility was out of syringes and that nurses were taking and using other residents’ insulin. Another LPN stated she took another resident’s unopened insulin pen and gave it to a different resident. A third LPN stated she took one resident’s insulin vial and gave it to another resident. The RN/ADON stated she was responsible for ordering supplies but said she was not aware nurses were taking and administering other residents’ insulin. The DON stated she learned of the syringe shortage from the Ombudsman and did not interview residents or nurses about whether insulin had been missed or investigate beyond checking whether syringes were currently available. A resident also stated he missed insulin one day because there were no syringes, and on other days nurses took insulin from another resident so he would not miss his dose. The investigation also identified delayed insulin administration for another resident. That resident stated her blood sugar was supposed to be checked at breakfast, lunch, and dinner, but a former LPN did not check her breakfast or lunch blood sugar or give insulin as ordered. The former LPN acknowledged he was several hours late with the lunch blood sugar check and insulin coverage and said he did not contact the DON or physician when he fell behind. In addition, a resident reported an interaction with staff in which an LPN told him to leave the unit and threatened to call the police, while another nurse observed the resident was calm and not behaving aggressively. The RN/ADON stated she did not investigate that incident further after being notified. Additional interviews described prolonged incontinence care delays, intimidation of staff who reported concerns, allegations of inappropriate sexual conduct, theft of a resident’s bank card and jacket, and drug-related allegations involving staff and residents. The RN/ADON also acknowledged that wound care oversight, wound assessments, treatment completion, infection control, supply ordering, and day-to-day operational oversight were difficult to keep up with and that a surgical wound had not been fully assessed or treated as ordered.
Failure to Supervise and Respond Appropriately to Elopement
Penalty
Summary
The facility failed to administer operations in a manner that enabled effective and efficient use of its resources because the NHA and DON did not effectively manage the facility to implement sufficient monitoring and supervision to prevent an elopement. The NHA job description stated that the NHA is responsible for establishing and maintaining systems that are effective and efficient to safely meet resident needs and comply with federal, state, and local requirements, including overseeing staff, medical care, medical supplies, and facilities. The DON job description stated that the DON is responsible for providing nursing management, setting resident care standards for all direct care providers, and providing complete supervision and management for the nursing department, including developing and implementing policies and supervising all aspects of nursing services. Based on the facility records and job descriptions reviewed, the facility failed to properly supervise a resident and failed to respond appropriately to an elopement, and the report states that the NHA and DON failed to fulfill their essential job duties to ensure that Federal and State guidelines and regulations were followed.
Administrator Living in Facility and Alleged Alcohol Use Not Addressed
Penalty
Summary
The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently because it did not ensure the Administrator followed the internal drug and alcohol policy, did not ensure the Administrator had his own residence and did not reside in the facility, and did not ensure Area Admin followed up on reported concerns that the Administrator was drunk, drinking alcohol at the facility, and smoking in areas that were not designated for smoking. On observation, a man identified as the Administrator was seen outside the facility smoking while wearing a blue hairnet and using a walker. Later, a room in the facility appeared occupied even though no resident name was on the door; the room contained a suitcase, clothing on the floor, clothing in a fallen laundry basket, and men’s clothing in the closet. During interview, the DON stated she had been told the previous day that the Administrator had been seen drunk and that corporate was at the facility to investigate. She also stated the Administrator was residing in the room and had been living at the facility since about a week before her arrival. Multiple staff members reported concerns about the Administrator’s conduct. The SW stated she heard a rumor that he had been drunk at the facility, saw a box of alcoholic beverages in his office, and observed him smoking in non-designated areas. The DTA C stated she smelled alcohol on his breath on one occasion and had seen him parked at a local liquor store. The ADON stated she saw a person believed to be the Administrator sitting outside by the dumpster in a red car and later walking into the building appearing impaired, with pinkish color and walking sideways. The Administrator stated he lived at the facility five nights a week because the facility needed him. The Area Admin stated he had been told the Administrator might have been intoxicated at night or on weekends, but he did not investigate and believed the Administrator was exempt from facility policies during non-working hours because he lived at the facility. The facility policy required a drug-free workplace and stated that when a supervisor is notified or suspects a violation, the supervisor must observe the behavior and immediately complete the reasonable suspicion testing checklist.
Failure to Plan for Facility Closure and Resident Discharge
Penalty
Summary
The facility failed to use its resources effectively and efficiently to prevent an eviction and facility closure for 1 of 1 facility reviewed for administration. The facility received a 30-day eviction notice on 05/08/2026, but did not submit a closure plan for the 30 residents who were living in the facility at that time. The eviction notice stated the tenant owed approximately $430,000, including back rent, property taxes, and advanced operating expenses, and the landlord intended to terminate the lease on 07/01/2026. During interviews, the Administrator stated he was on the path of closure and that the previous DON and prior Administrator had resigned. He said he had spoken with nearby facilities about possible discharges if closure occurred, but he did not have a specific plan in place. He stated that providing food and medical supplies, including medication, was a top priority, and that he had an agreement with an agency staffing company to provide staffing. He also stated he was out of money, could not pay for a DON or RN supervisor, and was using an RN to provide supervision every other day for several hours. The Administrator stated he had not notified residents or their responsible parties about the eviction, although word had gotten out. He also stated he was delinquent in payment for supplies and pharmaceuticals and had been cut off by one agency staffing company due to non-payment, while working with another agency to keep direct care staff in place. Residents interviewed described distress related to the move, including one resident who was crying and upset after living in the facility for 19 years, another who said the move was stressful because she did not know where she would be going, and another who was crying and upset about having to move.
Failure to Maintain Infection Control Program
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections from resident to resident. The report states that the facility failed to have working laundry equipment to ensure clean and sanitized linens and laundry, and this was identified as creating an Immediate Jeopardy for 67 of 67 residents. Review of the facility job descriptions showed that the NHA was responsible for leading, directing, and managing overall operations in accordance with applicable standards and for organizing, developing, and directing resources to maintain the highest degree of quality care. The DON was responsible for organizing, developing, managing, and directing nursing services and for working with the Administrator and Medical Director to ensure the highest degree of quality care, while following health, sanitary, and infection control policies. During interview, the NHA and DON confirmed the facility's failure to maintain the infection control program related to the laundry equipment issue.
Failure to Supervise Resident Resulted in Elopement
Penalty
Summary
The Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility by not ensuring proper supervision for Resident R1, who eloped from the facility on 5/10/26. The report states that the resident exited to an unsupervised and unauthorized location without staff's knowledge, and this event was identified by surveyors as creating an immediate jeopardy situation for all residents identified as an elopement risk. The job description for the NHA stated responsibility for leading, directing, and managing overall operations in accordance with applicable policies, procedures, and regulations, while the DON was responsible for organizing, developing, managing, and directing the Nursing Service Department and working with the Administrator and Medical Director to ensure the highest degree of quality care. Based on the findings, the facility failed to ensure proper supervision for the resident, and the NHA and DON were notified on 5/20/26 that they had failed to effectively manage the facility to prevent the elopement.
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