Elopement of Wandering Resident and Delayed Call Light Responses
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Penalty
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The facility failed to maintain sufficient nursing staff to meet resident needs and its own staffing plan. PBJ data showed repeated low weekend staffing, and review of staffing postings, assignment sheets, and punch-in records found frequent call-offs and staff leaving early, resulting in staffing levels that often did not match the facility assessment. Staff interviews described CNA/LNA shortages on every shift, especially weekends, and residents reported concerns that there were not enough CNAs to assist with meals and other needs. The DON acknowledged higher turnover and that staffing depended on census and acuity.
The facility failed to provide enough nursing staff to meet resident needs, with staff and residents reporting frequent short staffing, long call light delays, missed showers, and rushed care. During meal observations, a resident spilled food while waiting for help, another could not reach a breakfast tray until a NA repositioned them, and a resident with a paralyzed arm had the tray placed on the wrong side. The report also cited inadequate wound care for a resident with a surgical hip wound and a pressure injury that developed in the facility.
Insufficient staffing led to delayed call light response, delayed incontinence care, and incomplete ADL support. Residents reported long waits for help, including mechanical lift transfers and brief changes, while staff described short aide coverage, uncovered call-offs, and difficulty completing showers, checks, and two-person transfers. Observations showed residents left wet or waiting for care, and an LPN and ADON were observed not completing requested assistance when they entered resident rooms.
Insufficient nursing staffing led to delayed ADL care, late medication administration, and missed ordered enteral feeding. Residents and CNAs reported long waits for incontinence care, help with meals, and response to call lights, especially on the overnight shift. MARs showed repeated late doses for multiple residents, including meds given hours late or after midnight, and an LPN confirmed she forgot to connect a resident’s PEG tube feeding because she had too many tasks and about 30 residents assigned.
Insufficient nursing staff led to missed restorative care for multiple residents. The facility did not use dedicated RNA staff and instead assigned restorative tasks to floor CNAs, who said they were too busy to provide separate 15-minute sessions. Interviews with residents and staff showed omitted ROM, dressing routines, exercise programs, and prosthesis application, while Point of Care entries marked the tasks complete even though they reflected routine CNA care rather than actual restorative services.
An LPN left the MCU with only one CNA present, despite a staffing guideline requiring two staff members on the unit at all times. While the LPN was off the unit, a resident with dementia became verbally aggressive with two other residents, covered one resident's mouth, threw a walker at the CNA, and then exchanged swatting and punching with another resident before the CNA separated them. The residents involved had dementia-related diagnoses and cognitive impairment, and one resident later had a UTI identified.
Insufficient Nursing Staffing and Weekend Coverage
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs and to maintain the staffing levels identified in its own facility assessment. Review of PBJ staffing data showed the facility repeatedly triggered for excessively low weekend staffing during three reporting quarters in 2025. The facility assessment stated the building was licensed for 106 residents, had an average daily census of 70 to 80 residents, and included 65 residents who required at least two-person assistance. The staffing plan called for a full-time DON, full-time ADON, full-time MDS RN, full-time wound care RN, five RN/LPNs on the 6:00 AM to 6:00 PM shift, two RN/LPNs on the 6:00 PM to 6:00 AM shift, six CNAs on days, and four CNAs on nights. Review of assignment sheets, Daily Staffing Postings, and punch-in records for selected dates from January through September 2025 showed that scheduled staffing often appeared adequate on paper, but actual staffing was affected by frequent call-offs and staff leaving before completing 12-hour shifts. Across multiple three-day periods, the census ranged from 68 to 84 residents, while the punch-in records reflected varying RN/LPN and CNA hours that did not consistently match the staffing structure in the facility assessment. The records showed repeated shortages involving RNs, LPNs, CNAs, LNAs, and CMAs, with some staff clocking out early and some shifts left uncovered when call-offs occurred. Interviews confirmed the staffing problems. An LNA stated there were CNA/LNA shortages on every shift, especially weekends, and that some days tasks could not be completed on time because of staffing shortages. The staffing schedule coordinator stated call-offs occurred mostly on weekends, staff had two hours to report call-offs, and if coverage could not be found he had to cover the shift himself. A resident council meeting reflected resident concern that there were not enough nursing staff, particularly on PM and nocturnal shifts, and that only two CNAs were available to assist residents eating in the dining hall even though several residents needed help. An RN also stated there were days when CNA shortages occurred on the floor and that numerous CNA call-offs had been observed in the preceding weeks. The DON stated staffing depended on census and acuity and acknowledged higher turnover during 2025 and 2026. The facility policy required sufficient staff with the skills and competencies necessary to provide care and services to all residents in accordance with care plans and the facility assessment.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and to have a licensed nurse in charge on each shift. Survey findings cited failures related to resident rights, quality of care, and pressure injuries for 13 residents reviewed for staffing concerns. Interviews with residents, staff, and resident council members described frequent short staffing, delayed call light response times, rushed care, missed showers, and staff working extended shifts, while the nursing scheduler stated staffing was based on census rather than resident acuity and that many residents required two staff members for care. During meal service observations, Resident 54 was seen trying to eat while seated too far from the table and spilling food on themselves and the floor until a NA assisted 25 minutes later. Resident 35 had a breakfast tray placed out of reach and remained unable to access the meal until a NA repositioned them 15 minutes later. Resident 4, who had a paralyzed left arm, was observed attempting to eat with the tray positioned on the left side, causing food to fall on their clothing and the floor. A NA stated they were the only one working in the assisted dining room and were also passing meal trays on the south hallway. The report also described inadequate wound and skin care. Resident 3 had a surgical wound on the right hip that was not adequately assessed, monitored, or treated according to professional standards. Resident 79 developed a pressure injury on the right hip in the facility. Residents and a resident representative reported call lights taking up to an hour or longer to be answered, staff appearing rushed, and concerns about cleanliness and missed care. Staff interviews confirmed frequent shortages, pulled bath aides, missed breaks, and the DON stating the facility often had to work the floor due to a lack of licensed nurses.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff each day to meet resident needs and to maintain a licensed nurse in charge on each shift. Review of the Payroll Based Journal showed the facility had a one-star staffing rating and low weekend staffing for the second fiscal year quarter from 01/01/26 through 03/31/26. Interviews with residents and staff described delayed responses to call lights, delayed incontinence care, and difficulty completing showers, two-hour checks, and mechanical lift transfers because there were not enough aides scheduled or available to cover call-offs. Residents reported long waits for assistance. One resident stated call lights were not always answered timely. Another said there was not enough staff for mechanical lift transfers and that she frequently had to wait to get up. A third resident reported that on first shift and weekends there were not enough staff and care was not always timely. Another resident stated the facility was short-staffed on all shifts and call lights sometimes took at least an hour and a half to be answered. A resident’s daughter also reported concerns that care was not being provided timely. One resident said staff told him they would come back but did not return for several hours, and he stated night shift was really bad. Direct observations showed residents waiting for incontinence care while soiled. One resident was observed lying in bed pointing to her brief and stated she was wet and had last been changed the night before; an LPN checked the brief, confirmed it was wet, then left the room without changing her. Another resident was observed waiting for incontinence care and stated he had been waiting a long time to be changed before eating; his brief was saturated with urine, and staff confirmed he had waited about two to three hours. A third resident’s call light was observed blinking, and after an ADON briefly entered and left without doing anything, a CNA later provided care; that resident stated he had waited an hour to an hour and a half to be changed. Staff interviews also confirmed staffing shortages, including assignments where only two aides were on a unit, changes in assignments were not always communicated, call-offs were not always covered, and staff were not always able to complete showers, checks, changes, or two-person transfers in a timely manner.
Insufficient Nursing Staffing Caused Delays in Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs and did not have an established planned staffing level for determining the number and type of nursing staff needed. The census was 208 residents, and the DON stated the facility had many open RN, LPN, CNA, and ADON positions and could not state the number of vacant nursing positions. The DON also stated the facility did not have a specific number of nursing staff established for each shift. Staff interviews described ongoing short staffing, especially on the 7:00 PM to 7:00 AM shift, with residents reporting long waits for care and treatment, limited staff availability in the dining room, and difficulty reaching staff by telephone. Resident interviews described delays in ADL care and response to needs. One resident stated that on an evening shift he lay in his own feces for over two hours waiting for care, that staff cut off the call light and said they would return, and that his buttocks became irritated while he waited. Another resident stated that at night residents would spend hours itching and waiting to be changed and reported a recent urinary tract infection. A CNA stated there was insufficient staff to provide care for residents who required two or more staff for ADLs and transfers, and that the facility often relied on overtime because staff called out during the evening shift. Medication administration records showed repeated delays across multiple residents and shifts. For one resident with paraplegia, multiple scheduled morning medications were given several hours late on multiple days, evening medications were often administered after midnight, and one antibiotic dose scheduled for 6:00 AM was not given until more than 27 hours later. For another resident with multiple chronic conditions and dependence for ADLs, numerous scheduled medications were administered several hours late, including one dose of adalimumab given more than eight hours late and one antibiotic dose not administered until the following day. For a third resident, multiple evening medications were administered many hours late, including doses given the next morning after being scheduled for the prior evening. The DON stated the acceptable medication administration window was one hour before to one hour after the scheduled time, but said she did not know about the repeated delays and that nurses either forgot to document or were running late. The report also documented missed ordered enteral nutrition. A resident with a PEG tube and an order for Jevity 1.5 at 60 mL per hour for 22 hours daily was observed disconnected from the feeding at a time when the feeding should have been infusing, and later remained disconnected even after a new feeding cycle should have started. An LPN assigned to the resident confirmed she had not connected the feeding and said she forgot because there were a lot of things going on. The DON stated the LPN’s assignment was typically about 30 residents and acknowledged the facility had received complaints and grievances regarding insufficient staffing and delays in resident care.
Insufficient Nursing Staff for Restorative Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to carry out restorative nursing interventions as ordered for residents on the restorative roster. Surveyors found that the facility did not employ dedicated Restorative Nursing Aides and instead placed restorative tasks on the daily Point of Care task lists of general floor CNAs. The Restorative/MDS Coordinator stated that she did not schedule, supervise, or audit restorative care delivery and had never observed structured 15-minute restorative sessions being provided. Interviews with floor CNAs showed that restorative care was not being delivered as separate, scheduled programming. Multiple CNAs stated they did not perform restorative therapy, did not have time to spend 15 minutes with residents, and could not provide restorative services because of workload demands. One CNA stated restorative care was documented as completed because it was considered part of routine CNA duties, while others stated no residents received restorative care or that staff were too busy to provide it. For four cognitively intact residents, surveyors found that restorative services were not being carried out as planned. One resident with Type 2 DM and CHF said staff did not have enough time to complete care-planned exercises or grooming programs. Another resident with ESRD and Type 2 DM reported going two consecutive days without her lower extremity prosthesis being applied and said upper extremity exercise routines were not done. A third resident with Type 2 DM and ESRD said staff did not provide dedicated time for three restorative programs, and a fourth resident with hemiplegia and gait abnormality said ordered active ROM and dressing routines using exercise equipment were not performed after therapy discharge. Although Point of Care documentation showed restorative tasks marked complete, staff and resident interviews confirmed these entries reflected routine basic care rather than actual 15-minute restorative sessions.
Insufficient MCU Staffing During Resident Altercation
Penalty
Summary
The facility failed to provide enough nursing staff on the Memory Care Unit and failed to maintain a licensed nurse in charge on the unit when an LPN left the MCU and CNA A was left as the only staff member. During that time, Resident #1, who had dementia, major depressive disorder, and a history of urinary tract infections, was sitting in the dining room with Residents #2 and #3, both of whom also had dementia-related diagnoses and cognitive impairment. The facility staffing guideline stated that two staff members were required on the MCU from 6:00 A.M. to 10:00 P.M. at all times. While the LPN was off the unit, Resident #1 and Resident #2 began verbally arguing, and Resident #1 covered Resident #2's mouth with a hand. CNA A separated the residents, after which Resident #1 threw a walker at CNA A and a pair of pants fell from the walker. Resident #3 reached down to pick up the pants, and Resident #1 became irritated and swung at Resident #3. Resident #3 swung back, and both residents began swatting at each other until CNA A separated them again. The LPN returned and was notified while walking up the hallway. The facility investigation documented that the residents were assessed and had no injuries, and Resident #1 later had a urine sample showing a UTI. Interviews showed the LPN had asked CNA A to watch the residents while he/she briefly left the MCU to deliver paperwork, leaving only one staff member on the unit. The Administrator stated the LPN was expected to call, text, or use a walkie talkie to get another staff member to the MCU before leaving.
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