Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Schofield Residence during CMS and state inspections, most recent first.
A Life Safety Code survey revealed that portable resident lifts in the facility were not inspected and tested per manufacturer's recommendations. The facility's policy required regular inspections, but maintenance staff had not performed preventative maintenance checks recently. An undated document indicated that eight lifts were inspected, but the Executive Director of Environmental Services and the Administrator acknowledged that the facility should follow the manufacturer's maintenance guidelines, which include monthly inspections.
A Life Safety Code survey found that electrical panels on both floors of the facility were obstructed by soiled linen and mobile hampers, violating the required three feet of clearance. Despite signs and red tape indicating the restricted area, staff continued to place items within this zone. Interviews revealed that the accumulation was due to staffing shortages and a lack of understanding of the red tape's purpose, compounded by the room's layout and vacant maintenance positions.
The facility's fire alarm system was not properly maintained, with issues including the failure to functionally test duct detectors annually and inadequate documentation of semi-annual load testing for sealed lead acid batteries. The Executive Director of Environmental Services was unaware of these issues, contributing to the deficiency.
A Life Safety Code survey revealed that the facility did not conduct fire drills at least once per shift per quarter, as required by their policy. The review showed missing drills for certain shifts across the first three quarters of 2024. The Administrator noted that the Maintenance Director was responsible for scheduling these drills, but the facility had been without one recently, and no missed drills were reported in quality assurance meetings.
A resident with severe cognitive impairment was observed with unclean fingernails while eating, indicating a failure in providing adequate nail care and hygiene. Despite facility policies requiring daily nail care, staff did not offer or document such care, leading to a deficiency in maintaining the resident's personal hygiene.
A resident's care plan requiring two staff members for bed mobility was not followed, as a CNA provided care independently. The resident, who was cognitively intact, required maximal assist for bed mobility, but the CNA did not review the care plan before providing care. Staff interviews confirmed the expectation to review care plans to ensure safety, highlighting a break in protocol.
A resident in an LTC facility developed a wound on their left knee after a tray table incident, but the wound was not assessed or treated according to facility protocols. The dressing was applied without a physician's order, and there was a lack of communication and documentation among staff. The DON expected immediate reporting and treatment, but these procedures were not followed, leading to a delay in care.
A resident was found self-administering medications without an assessment or physician's order, contrary to facility policy. The resident, who was cognitively intact, had various medications at their bedside, which they purchased online. Nursing staff were unaware of the resident's actions, and there was no documentation of an evaluation for self-administration. The facility failed to ensure proper assessment and documentation, leading to the deficiency.
A smoke barrier door on the second floor of the facility did not fully close due to being hung up on its frame. Maintenance staff could not confirm recent checks, and the Executive Director of Environmental Services identified loose screws needing adjustment. The door was believed to be part of a smoke barrier wall, but architectural drawings were unavailable to confirm this.
Two residents with dementia and wandering behavior eloped from the facility due to inadequate assessment and care planning for wandering/elopement risks. The facility's policies on elopement risk assessment and wander guard evaluation were not consistently followed, leading to incomplete care plans and lack of safety interventions. Staff interviews revealed inconsistencies in performing assessments and a lack of a scoring system to determine risk levels.
Deficiency in Maintenance of Resident Lifts
Penalty
Summary
During a Life Safety Code survey, it was found that patient care related electrical equipment, specifically portable resident lifts, were not inspected and tested according to the manufacturer's recommendations. The facility's policy, titled Maintaining Resident Medical Equipment, required that all medical equipment be inspected to ensure proper operation, referencing and maintaining equipment manufacturer manuals for specific preventative maintenance. However, an observation on the first floor revealed a Hoyer-type resident lift with a sticker indicating it was inspected by an outside contractor and was due for the next inspection in the same month. The manufacturer's user manual included a Maintenance Safety Inspection Checklist, which required monthly inspections of various components of the lift. A document titled Lift Inspections indicated that eight resident lifts were inspected, but the document was undated. Interviews conducted during the survey revealed that the facility's maintenance staff had not performed preventative maintenance checks on the lifts recently. The Executive Director of Environmental Services found an undated Lift Inspections document in the former Maintenance Director's office, and the position was currently vacant. The Administrator acknowledged that the facility should follow the owner's manual for equipment maintenance and stated that an outside contractor inspected the lifts twice a year, but the maintenance staff should also perform preventative maintenance as indicated in the manual. The Executive Director of Environmental Services confirmed that most of the facility's Hoyer-type resident lifts were manufactured by Company A and that manufacturer's recommendations should be followed, expecting monthly lift inspections to be completed and documented.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Corrective Action: An audit was conducted by maintenance staff for all lifts in the house. All lifts were inspected at that time with no negative findings. At the time of the audit, maintenance ensured that all lifts were accounted for and we were following the manufacturer manuals for all lifts in use. Identify Other Residents: All residents have the potential to be affected by this deficient practice. No other residents were identified as being affected by this deficient practice. Systemic Changes: The Director of Facilities or Designee to in-service all maintenance staff on preventative maintenance of equipment based on the manufacturer’s manual, as well as on the updated lift inspection form. Monitor Corrective Actions: The Director of Facilities or Designee will review the monthly lift inspection and report all findings to the Administrator and the QAPI Committee at the monthly meeting. The QAPI Committee is responsible for ongoing monitoring and compliance. Person Responsible for Implementation: The Director of Facilities will be responsible for monitoring the plan.
Inadequate Clearance in Front of Electrical Panels Due to Soiled Linen Accumulation
Penalty
Summary
During a Life Safety Code survey, it was observed that electrical systems were not properly maintained due to inadequate clearance in front of electrical panels on both the first and second floors of the facility. Specifically, bags of soiled linen and mobile hampers were repeatedly found obstructing the required three feet of clearance in front of electrical panels in various Soiled Linen Rooms. Despite signs and red tape marking the area to be kept clear, staff continued to place items within the restricted zone. Interviews with staff revealed that the accumulation of bags was a recurring issue, particularly after morning care or total bed changes, and that maintenance staff were responsible for regular pickups. The deficiency was further compounded by staffing challenges, as the facility's Maintenance Director and second shift Housekeeper positions were vacant, leading to inconsistent removal of soiled linen and garbage bags. Staff interviews indicated a lack of understanding regarding the purpose of the red tape, and despite knowing the importance of keeping the area clear, the odd shape of the rooms and the location of the electrical panels made compliance difficult. The Administrator acknowledged the issue and the challenges posed by the room layout, but the absence of key staff members exacerbated the problem, resulting in the observed deficiencies.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Corrective Action: All soiled linen, garbage bags, and mobile hampers found obstructing the 36-inch clearance in front of electrical panels were immediately removed from the South, East, and North Hall Soiled Linen Rooms on both the first and second floors. Identify Other Residents: All residents have the potential to be affected by this deficient practice. No other residents were identified as being affected by this deficient practice. Systemic Changes: A facility wide audit will be conducted to check for clearance around all electrical panels. The red tape and signage have been enhanced with floor decals labeled “DO NOT BLOCK – ELECTRICAL PANEL CLEARANCE ZONE” to provide clearer visual warnings. All Nursing, Environmental, and Maintenance Staff received in-service training on electrical panel clearance requirements. An audit tool will be created to check the electrical panel, and the maintenance department will be educated on the audit tool. The soiled utility rooms will be audited by the maintenance department daily for four (4) weeks, then three (3) times per week for eight (8) weeks, then weekly for three (3) months. Monitor Corrective Actions: The Director of Facilities or designee will report the audit results monthly to the QAPI Committee. The QAPI Committee is responsible for the ongoing monitoring and compliance. Person Responsible for Implementation: The Director of Facilities.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility's fire alarm system was found to be inadequately maintained during a Life Safety Code survey. Specifically, the survey revealed that the fire alarm system's initiating devices, such as duct detectors, were not functionally tested on an annual basis as required by the 2010 edition of the National Fire Protection Association 72: National Fire Alarm and Signaling Code. The inspection and testing report from an outside contractor dated December 5, 2024, listed several deficiencies, including the inability to locate three duct detectors and the visual inspection only of another duct detector. These devices were last inspected and functionally tested in 2023, indicating a lapse in the required annual testing. Additionally, the facility failed to maintain proper documentation for the semi-annual load testing of the fire alarm system's sealed lead acid batteries. The batteries were observed to be dated from 2023, and the inspection reports indicated that they were load tested only annually, not semi-annually as required. During an interview, the Executive Director of Environmental Services was unaware of the issues with the duct detectors and stated that the batteries were load tested annually, contrary to the requirements. This lack of awareness and documentation contributed to the deficiency in maintaining the fire alarm system.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Corrective Action: Outside Contractor returned to facility on 04/04/2025 and tested the three previously missed duct detectors M1-165 Administration Board Room, M1-169 Activities, and M2-82 second floor bathing. As well as they tested duct detector M1-176 that was noted on the report as “visual inspection only.” The contractor was notified to schedule load testing every six months/semiannually on the batteries in the fire alarm system. Identify Other Residents: Director of Facilities to review all fire alarm system inspection reports since the last survey for any other missed devices/missed inspections/additional batteries. All residents have the potential to be affected by this deficient practice. No other residents were identified as being affected by this deficient practice. Systemic Changes: Facility to revise its fire alarm service agreement to require full compliance with NFPA 72 testing standards, including mandatory documentation of device locations and test outcomes, as well as twice a year load testing of the batteries within the fire alarm system. The Director of Facilities to be educated by the Administrator on thoroughly reviewing the inspection reports after each inspection to identify any discrepancies and addressing timely. The Director of Facilities or Designee to be onsite to ensure proper completion of the annual and semiannual inspection. All maintenance staff to be educated. Monitor Corrective Actions: Director of Facilities to report the results of our recent fire alarm system inspection at our monthly MAY QAPI meeting, then moving forward the Director of Facilities will report the results of the semiannual and annual inspection to the QAPI Committee. The QAPI Committee is responsible for the ongoing monitoring and compliance. Person Responsible for Implementation: Director of Facilities
Failure to Conduct Required Fire Drills Per Shift Per Quarter
Penalty
Summary
During a Life Safety Code survey, it was found that the facility failed to conduct fire drills at least once per shift per quarter, as required by their policy. The policy, titled Fire Safety Training Program, mandates twelve fire drills annually, with each shift conducting a drill every quarter. However, a review of the fire drill report binder revealed that in the first quarter of 2024, only two drills were conducted, one on the third shift and one on the first shift. In the second quarter, three drills were conducted, but two were on the third shift and one on the first shift, with no drills on the second shift. In the third quarter, three drills were conducted, two on the second shift and one on the first shift, again missing the third shift. The Administrator, during an interview, stated that the Maintenance Director was responsible for scheduling and performing fire drills. However, the facility had been without a Maintenance Director since the previous week, and the former Maintenance Director had reported completed fire drills at the facility's monthly quality assurance meetings without indicating any missed drills. The Administrator expected all fire drills to be documented, and the Trainer mentioned in the policy referred to the Maintenance Director. This deficiency affected both resident use floors of the facility.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Corrective Action: No residents were identified as being affected by this deficiency. Identify Other Residents: All residents have the potential to be affected by this deficient practice. No other residents were identified as being affected by this deficient practice. Systemic Changes: Director of Facilities or Designee to in-service all maintenance staff on the minimum requirement to conduct one fire drill, per shift, per quarter. Director of Maintenance to review the policy and procedure titled Fire Safety Training Program. Maintenance to conduct 2 fire drills monthly for the first 4 months on alternating shifts to ensure that the minimum requirement of one fire drill on every shift per quarter takes place. All drills will be planned 4 months in advance by the Director of Maintenance to ensure drills will be done on the appropriate shift. Monitor Corrective Actions: The Director of Facilities or Designee will review all completed fire drills monthly and report all findings to the Administrator and the QAPI Committee monthly. The QAPI Committee is responsible for the ongoing monitoring and compliance. Person Responsible for Implementation: The Director of Facilities will be responsible for monitoring the plan.
Failure to Provide Adequate Nail Care and Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received adequate grooming and personal hygiene services. Specifically, the resident was observed on multiple occasions with dark brown debris under their fingernails while eating with their hands. The facility's policy required that residents receive sponge baths twice daily, including nail care, but this was not adhered to for the resident in question. The resident, who was severely cognitively impaired, had a care plan that specified they required moderate assistance for personal hygiene and eating. Despite this, the resident's treatment records for nail care were incomplete, and there was no documentation of any refusals of care. Observations over several days confirmed that the resident's nails were not cleaned, and staff failed to provide or offer nail care during routine care activities. Interviews with staff, including CNAs, LPNs, and the Director of Nursing, revealed that nail care was expected to be provided whenever needed for infection control and general hygiene. However, the staff did not follow through with these expectations, and there was a lack of documentation regarding any refusals of care. The facility's failure to provide necessary nail care was acknowledged by multiple staff members, including the Administrator, who emphasized the importance of maintaining resident hygiene for dignity and infection control.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 Corrective Action for Resident Identified: Upon identification, staff immediately assisted the resident with hand hygiene and nail care. The resident’s care plan was reviewed and updated to ensure nail care is provided and documented as part of daily grooming tasks. The CNA assigned to the resident received immediate re-education regarding proper hygiene assistance and documentation practices. The facility will conduct an audit of all residents requiring assistance with ADLs, focusing specifically on grooming and nail care. Additionally, the Occupational Therapy department will identify residents who eat with their hands and their need for appropriate assistive devices. Dietitians will also be consulted to assess whether alternative food options are more suitable for the identified residents. The audit will include visual inspections, interviews, and documentation review. Systemic Changes to Prevent Recurrence: The facility’s Resident Hygiene Policy was reviewed and clearly defines staff responsibilities regarding nail care and hygiene for residents requiring ADL assistance. All direct care staff will receive in-service education covering: - Importance of maintaining personal hygiene for residents - Proper nail care techniques - Infection control concerns related to unclean hands and fingernails - Preserving resident dignity during meal times and hand hygiene before and after meals. Monitoring and Quality Assurance: The Director of Nursing (DON) or designee will perform random weekly audits of 5 residents requiring ADL assistance for 8 weeks to ensure nail care and hygiene are being performed and documented. Resident mealtimes will be observed daily by nurses to ensure residents are assisted with hand hygiene prior to eating. Results will be reviewed monthly by the Quality Assurance meetings, and corrective action will be taken immediately for any noncompliance. If compliance is maintained at 100% for 8 weeks, audits will transition to monthly for 3 additional months. Responsible Person: Director of Nursing or Designee
Failure to Follow Care Plan for Resident Assistance
Penalty
Summary
The facility failed to implement the comprehensive person-centered care plan for a resident, leading to a deficiency. Specifically, the care plan for the resident required a maximal assist of two staff members for bed mobility, including rolling in bed. However, a Certified Nurse Aide (CNA) provided care independently, rolling the resident and placing them on a bedpan without assistance. This action was contrary to the care plan, which was designed to meet the resident's medical, physical, and psychosocial needs. The resident involved was cognitively intact and able to communicate effectively. The care plan, dated over two years prior, specified the need for two staff members to assist with bed mobility. Despite this, the CNA did not review the care plan before providing care, relying instead on their familiarity with the resident. The CNA admitted to not consistently reviewing care plans unless there was a reported change in the resident's condition, which contributed to the oversight. Interviews with various staff members, including Registered Nurses, Licensed Practical Nurses, and the Director of Nursing, revealed an expectation that care plans should be reviewed prior to providing care to ensure resident safety. The failure to adhere to the care plan was acknowledged as a break in protocol, emphasizing the importance of following care plans to prevent such deficiencies. The incident was reported, and an investigation was initiated, confirming the CNA's deviation from the care plan.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 Corrective Action Taken for the Resident Identified The resident was assessed immediately by nursing staff, and no injury was sustained. The incident was self-reported to the Department of Health. The CNA involved in this incident is no longer employed at this facility. The resident’s care plan was reviewed with no changes at this time. Identification of Other Residents Who Could Be Affected A facility-wide review will be conducted for all residents requiring 2-person assist for bed mobility, transfers, or ADLs. The review will include audits of care plans and direct observation of CNA compliance. Systemic Changes Made to Prevent Recurrence Mandatory in-service training will be completed for all CNAs and nursing staff covering: - Reading and interpreting care plans - The importance of following assistance level requirements - Reporting discrepancies or uncertainties immediately Monitoring and Quality Assurance - The Unit Managers or designee will conduct weekly audits of 5 resident care plans per unit and corresponding staff performance for 8 weeks to ensure care is delivered per plan. - Results will be reviewed monthly by the Quality Assurance meetings, and corrective action will be taken immediately for any noncompliance. - If 100% compliance is observed for 8 weeks, audits will reduce to monthly for 3 additional months. Person Responsible: Director of Nursing or Designee
Failure to Follow Wound Care Protocols
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive centered care plan. Specifically, a wound treatment was initiated without a physician's order, and there was a delay in the assessment of the wound. The facility's policy on skin care required staff to remain alert to skin changes and report areas of concern immediately to ensure prompt intervention. However, this protocol was not followed for a resident who had a wound on their left knee. The resident, who was cognitively intact and had no prior open wounds, was observed with a large adhesive dressing on their left knee, which was lifting at the corners and was undated and unlabeled. The resident reported that the dressing was applied after a tray table hit their knee, but could not recall who applied it or when. Despite the presence of the wound, there was no documented evidence of an assessment or physician's order for treatment until several days later. Staff interviews revealed a lack of awareness and communication regarding the wound, with some staff members assuming others were informed or had taken action. The Director of Nursing and other supervisory staff stated that they expected staff to report new skin findings immediately and obtain a physician's order for treatment. However, the wound was not properly assessed or documented in a timely manner, and the necessary communication and documentation protocols were not followed. This resulted in a delay in appropriate care and treatment for the resident's wound.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for the Resident Identified Upon discovery, the resident was assessed immediately by the nurse, and an incident report was completed. A provider was notified, and an order for [REDACTED]. Identification of Other Residents Who Could Be Affected No other instances of undocumented or unauthorized wound care were found. Systemic Changes to Prevent Recurrence - The Skin Care Policy was reviewed to ensure that it clearly requires: - Full documentation of any skin issues or injuries, - Immediate provider notification for new wounds, - Physician order [REDACTED]. - All licensed nursing staff will receive re-education on: - Skin assessment documentation, - Wound identification and reporting procedures, - The importance of adhering to physician orders [REDACTED]. - Weekly Shower/Skin notification sheet for all residents will be documented and submitted to the Director of Nursing (DON) or Designee for review to ensure: - All skin concerns are promptly identified, - Treatment orders are in place, - Documentation is complete and accurate. Monitoring and Quality Assurance - The Director of Nursing or designee will audit 10% of resident Shower/Skin Notification Sheets weekly for 8 weeks to ensure compliance with documentation, physician orders, and care plan accuracy. - Results will be reviewed monthly by the Quality Assurance meetings, and corrective action will be taken immediately for any noncompliance. - After 8 weeks of 100% compliance, monitoring will transition to monthly audits for 3 additional months. Responsible Person: Director of Nursing or Designee
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that a resident was properly assessed by the interdisciplinary team to determine their ability to safely self-administer medications. Resident #66 was observed with various medications in their room, including [MEDICATION NAME], Vitamin C, Men's Multivitamin, and Pepto-Bismol, which they self-administered without an evaluation or physician's order permitting them to do so. The facility's policy required an assessment and a physician's order for residents to self-administer medications, but this was not followed for Resident #66. Resident #66, who was cognitively intact and capable of making their own healthcare decisions, had a history of [DIAGNOSES REDACTED]. Despite this, there was no documented evidence in the care plan or medical records that Resident #66 had been evaluated for self-administration of medications. The resident had been purchasing medications online and self-administering them without the knowledge or approval of the nursing staff, who were unaware of the resident's actions until the survey. Interviews with the nursing staff revealed a lack of communication and oversight regarding Resident #66's medication management. Licensed Practical Nurses and the Registered Nurse Supervisor acknowledged that Resident #66 should not have had medications at their bedside without an order, and the Director of Nursing and Administrator expected that an order and care plan update should have been in place. The failure to assess and document Resident #66's ability to self-administer medications led to the deficiency identified during the survey.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action Taken for the Resident(s) Identified The medications were removed from resident #66, as resident already had physician orders [REDACTED]. Identification of Other Residents Who Could Be Affected A facility-wide audit to be conducted to identify other residents who would like to self-administer their medications. If residents are identified wanting to self-administer, they will be assessed by the interdisciplinary team for appropriateness. Systemic Changes to Prevent Recurrence - The Resident Self-Medication/Self-Treatment Instructions Policy was reviewed to ensure there are clear procedures for resident requests, assessments, care planning, documentation, and ongoing monitoring. - A new Self Administration Evaluation Tool for self-administration capability will be implemented and must be completed by the interdisciplinary team within 72 hours of a resident’s request. - All licensed staff to be re-educated on resident rights to self-administer medications, including the requirement for assessment and care plan updates. Monitoring and Quality Assurance - The Quality Assurance Director or designee will audit 10% of all resident records weekly for 8 weeks to ensure: - Proper assessments are completed - Care plans reflect the self-administration status - Medications are stored and administered in accordance with facility policy Results will be reviewed monthly by the Quality Assurance meetings, and corrective action will be taken immediately for any noncompliance. After 8 weeks, if 100% compliance is sustained, monitoring will continue monthly for an additional 3 months. Responsible Person: The Quality Assurance Director or Designee
Smoke Barrier Door Fails to Close Properly
Penalty
Summary
During a Life Safety Code survey, it was observed that a smoke barrier door on the second floor of the facility did not fully close. The door, located across from a resident room, was found to be hung up on its door frame. Maintenance Staff #2 mentioned that the door had been checked in the past but could not confirm if it was checked recently. The Executive Director of Environmental Services noted that the screws were loose and the door required adjustment to close properly. They also believed the door was part of a smoke barrier wall, but were unable to confirm this due to the absence of architectural drawings. A review of the facility's undated floor plan indicated that the door was indeed located along a smoke barrier wall.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action: Following the observation of the lavatory across from resident room [ROOM NUMBER] not fully closing, due to the door being hung up on its door frame. Maintenance immediately fixed the lavatory door to ensure proper closure. Identify Other Residents: All residents have the potential to be affected by this deficient practice. No other residents were identified as being affected by this deficient practice. All doors identified within the smoke barriers walls were inspected, with no negative findings. Systemic Changes: All maintenance staff to be re-educated by the Facilities Director or designee re-educated on the proper closing and latching of smoke barrier doors. The Director of Maintenance or Designee will create a new audit tool that will be utilized to perform bi-monthly audits of smoke barrier doors for 6 months. Monitor Corrective Actions: Director of Facilities to report the results of the bi-monthly audits at the monthly QAPI Committee. The QAPI Committee is responsible for the ongoing monitoring and compliance. Person Responsible for Implementation: The Director of Facilities.
Inadequate Supervision and Assessment for Wandering Residents
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents with dementia and wandering behavior. Both residents were not accurately assessed and care planned for wandering or elopement, leading to their elopement through the front door of the facility. The facility's Elopement Risk Assessment policy required completion of an assessment within 24 hours of admission or when new wandering behavior was identified, but this was not consistently performed. Additionally, the facility's Wanderguard Departure Alert System policy required evaluation of residents with independent mobility and restless behavior for wander guard candidacy, but this was not adequately documented or implemented. Resident #1, who had Alzheimer's and was severely cognitively impaired, exhibited wandering behavior on multiple occasions, yet there was no specific care plan for wandering or elopement risk. The resident was able to self-propel in a wheelchair and frequently ambulated, but this was not reflected in the care plan or Kardex. Despite documented wandering behavior, the resident's care plan lacked interventions for wandering or elopement risk. The resident eloped when the receptionist allowed them to sign out, assuming they were with visitors, highlighting a failure in monitoring and assessment. Resident #4, also severely cognitively impaired, frequently walked and wandered aimlessly, yet their care plan did not address potential wandering or elopement risks. The resident was able to walk with supervision and use a wheelchair, but specific interventions for wandering or elopement were not initiated. The resident eloped by pushing on the front entrance door, activating the alarm, and was later found outside. The facility's investigation did not identify the incomplete care plan or lack of safety interventions, and staff interviews revealed inconsistencies in performing wandering/elopement assessments and a lack of a scoring system to determine risk levels.
Plan Of Correction
Plan of Correction: Approved January 24, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action: Following the elopement of Resident #1, the resident was issued a wander guard, with no further attempts to elope. Resident #1 wander guard was removed on 6/17/2024 after a nursing elopement eval was conducted and it was determined the resident no longer was a wander risk due to a change in condition. The resident discharged on [DATE]. Following the elopement involving Resident #4, the resident was issued a wander guard. A comprehensive review of the Nursing Elopement Evaluations was conducted during a full house audit on 4/24/24. The audit revealed that the evaluations were not providing a risk factor score, which led to an immediate correction that same day. Consequently, all residents underwent new evaluations to assess and mitigate potential risk factors. Review of the affected resident was completed on 4/24/24. An individualized care plan that specifically addresses their wandering tendencies, including strategies for preventing elopement, safety supervision protocols, and personalized interventions that consider their medical and psychosocial needs were completed. A mandatory in-service for all staff members will be completed by 2/25/25 by the In-service Coordinator discussing the precautions and interventions to follow to prevent a resident from eloping. In addition, it also discusses the process for how to respond if a resident elopes. The Director of Maintenance will conduct a thorough review of the facility’s physical environment to identify and secure potential exit points, such as doors and windows by 1/24/25. A communication protocol will be established to ensure that any changes to residents' behavior, care plans, or assessments are communicated to all relevant staff members. Identify Other Residents: A facility-wide review to identify any other residents who may exhibit wandering behavior or are at risk for elopement will be completed within one month and will involve evaluating each resident's history, cognitive status, and any behavioral indicators. Existing care plans for all residents at high risk for wandering or elopement will be reviewed to ensure they include suitable strategies to manage their behaviors safely. Systemic Changes: Following the elopement on 4/21/2024 the facility updated the nursing elopement evaluation to include a risk factor score. The Missing Residents/Door Alarms/WanderGuard System policy and procedures were revised to include procedures to follow. These policies include clear guidelines for assessment, care planning, monitoring, and intervention. Monitor Corrective Actions: A random sample of 10 residents, with 5 from each floor, along with all new admissions, will be audited on a weekly basis for a duration of 4 weeks using the Resident Review Audit Tool (see attached). Following this, a random sample of 5 residents, plus all new admissions, will be audited weekly for another 4 weeks. The audit will review the elopement evaluations done at admission or quarterly, including the scores, identified risks, and the suitability of the care plans and interventions. The Administrator/QA Director is responsible for compliance. The results will be reviewed in the Quality Assurance meeting monthly. The QA committee will identify trends or patterns and make recommendations to revise the plan of correction as indicated.
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Illustrative
What surveyors actually found near you
We read the 164 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kenmore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mcauley Residence | 0.8 mi | ★★★★★ | 0 | 0 |
| Safire Rehabilitation Of Northtowns, L L C | 2.5 mi | ★★★★★ | 2 | 0 |
| Degraff Memorial Hospital-skilled Nursing Facility | 2.7 mi | ★★★★★ | 1 | 0 |
| Elderwood At Amherst | 3.4 mi | ★★★★★ | 1 | 0 |
| St Catherine Laboure Health Care Center | 4.3 mi | ★★★★★ | 5 | 0 |
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