F0607

D

Failure to Supervise High-Risk Resident and Report Sexual and Elopement Incidents

Ashland, Virginia Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

Facility staff failed to implement abuse, neglect, and theft prevention policies and procedures in relation to a resident with severe cognitive impairment and known wandering and exit-seeking behaviors, resulting in elopement and sexual contact incidents. One resident, diagnosed with Wernicke's encephalopathy, dementia, alcohol use disorder, and other conditions, had a BIMS score of 99 indicating severe cognitive impairment and was fully ambulatory. Despite multiple documented episodes of wandering into other residents' rooms, disrupting care, and seeking exits, staff did not consistently apply ordered safety measures such as a Wander-Gard device or supervision. The resident had a physician order for a Wander-Gard dated 11-13-25, but the device was not on the resident during surveyor observation, and documentation showed the resident had removed it on 3-8-26 without replacement.

The same resident had a documented elopement on 12-15-25, when he went to the outside patio/courtyard and pushed open the gate, exiting to the parking lot before being redirected back inside by staff from another unit. This elopement was not reported to the state agency. The facility’s courtyard gate alarm was found by surveyors to be turned off, with the Maintenance Director acknowledging that the alarm had been shut off and that multiple unaccounted-for keys existed. The courtyard exit door lacked an activated alarm, and surveyors observed the gate standing open for approximately five minutes with no staff present and residents in the courtyard. An Elopement Evaluation completed on 2-16-26 documented that the resident’s wandering was not likely to affect the safety or well-being of self or others and not likely to affect the privacy of others, despite prior documented incidents of elopement and intrusion into other residents’ rooms during personal care.

The resident was also involved in multiple sexual incidents. On 2-23-26, staff documented that the resident was found in another male resident’s room on his knees performing oral sex; the cognitively impaired resident later had no recollection of the event. On 3-5-26, the same resident was found sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; this third resident was not identified and the incident was not reported to the state agency. The care plan was updated over time to include behavior and elopement focuses, including a 1:1 monitoring intervention added on 3-9-26 for obsessive-compulsive behavior and a psychosocial problem related to sexual/physical contact with another resident, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR.

The facility failed to follow its abuse/neglect policy and regulatory reporting requirements for allegations and incidents of abuse and neglect. For the 2-23-26 sexual incident, the only documents produced were limited notes, a skin check, unsigned typed interview notes, and a purported final facility-reported incident (FRI) follow-up referencing an initial FRI that could not be located. The interim administrator could not produce the initial report, and there was no fax confirmation showing that the follow-up was successfully sent to the state agency; the state agency had no record of receiving it. No investigation notes or staff witness statements were found, and the facility’s abuse/neglect policy, which mirrored federal and state requirements for timely reporting and 5-day follow-up investigations, was not implemented. Additionally, the elopement on 12-15-25 and the 3-5-26 intrusion into a female resident’s room were never reported to the state agency. The report identifies these failures as neglect, defined as withholding required goods and services, including necessary supervision for a resident known to be a danger to self and others.