Citations in Florida
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Florida.
Statistics for Florida (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Florida
A resident with TBI, psychiatric diagnoses, unsteady gait, confusion, and a high fall-risk score had an active MD order for 1:1 supervision and fall precautions. Despite this, the assigned CNA left the bedside and walked down the hall to discuss break coverage instead of using the call light, leaving the resident unsupervised. During this time, the resident exited through a nearby emergency exit door, descended a flight of stairs, and was found at the bottom with multiple abrasions. Facility policy and staff interviews confirmed that 1:1 supervision required the sitter to remain within arm’s length of the resident and to request breaks via call light, and the facility’s neglect policy defined inadequate supervision as neglect.
A resident with a PICC line in the upper arm was observed with a transparent dressing that had not been changed according to the expected weekly schedule. An LPN stated that PICC dressings are supposed to be changed weekly, while another LPN indicated that the RN supervisor usually performs all PICC dressing changes but was not present. The DON confirmed that weekly PICC dressing changes are required and are the responsibility of the nurse on the cart, and acknowledged that this resident’s dressing should have been changed. There was no physician order for PICC dressing changes, despite a facility policy stating that wound care is to follow current standards of practice with physician orders documented on the Treatment Administration Record.
A resident had a physician order for daily abdominal staple wound care with normal saline and a dry dressing on the day shift, but the Treatment Administration Record lacked documentation that the ordered wound care was completed on several days. One LPN reported that dressings were changed when the resident was cared for but admitted forgetting to document on specific days, and another LPN could not recall whether the dressing was changed on one of the missing dates. This resulted in an incomplete medical record that did not accurately reflect the resident’s wound care as required by facility policy.
A resident receiving IV antibiotic therapy for a wound infection did not receive care under required enhanced barrier precautions. During a PICC line dressing change, an LPN did not wear a gown, despite the resident’s care plan directing use of enhanced barrier precautions per facility policy. The DON stated the resident should have been on enhanced barrier precautions due to the IV and wound, and that a gown should have been worn. Facility policy requires gown and glove use for high-contact care activities, including central line and wound care.
The facility failed to complete individualized baseline care plans within 48 hours of admission for three newly admitted residents. One resident admitted for rehab after a fall had a baseline care plan that was essentially blank, lacking goals, instructions, and any interventions, including those related to a known fall history. Another resident admitted from the hospital with chest pain had an incomplete baseline care plan in which a falls/safety goal was marked but no interventions were documented. A third resident admitted with acute respiratory failure with hypoxia had a baseline care plan with multiple goals (falls/safety, oral/dental, pain, anticoagulant use) circled but no interventions identified. The unit manager and DON confirmed that these baseline care plans were not completed as required by facility policy.
A resident admitted after a fall at home with a closed head injury and transferred for rehabilitation had physician orders for OT, PT, and speech therapy evaluations and treatment that were not completed as directed. Although a wheelchair evaluation and provision occurred shortly after admission, the therapy department did not perform the ordered OT, PT, and speech evaluations within its usual 48-hour timeframe and instead scheduled them for a later date. The evaluations were never carried out because the resident was sent to the hospital for a change in mental status, and both the therapy director and DON confirmed that the physician-ordered therapy evaluations were not completed.
A resident with an indwelling urinary catheter and severe cognitive impairment was repeatedly observed in bed with the urinary drainage bag resting on the floor, despite physician orders for proper catheter management and a care plan identifying risk for UTI and requiring appropriate positioning of the bag and tubing. The CNA providing care acknowledged that catheter bags should not touch the floor but confirmed that the bag was on the floor during observation, attributing this to the bed being in a low position. The facility’s catheter care policy, which specifies that the drainage spigot must not touch the floor and that the catheter be maintained at an appropriate level, was not followed.
Two residents were not treated with dignity during care activities. A post-surgical resident who was cognitively intact and required substantial/max assistance with ADLs reported that urine splashed on the floor and on her body while using a bedside commode at the bedside, which appeared to lack the correct collection container; multiple commodes in storage areas were later observed without buckets or drainage collection. Another resident with mild cognitive impairment and dependent in ADLs was observed near the nurses’ station, slouched in a wheelchair and calling for help to be repositioned, and was then handled roughly by two staff members while being repositioned in front of others.
Surveyors identified multiple failures including nonfunctioning call lights in five rooms without a written protocol for timely response, missed wound and catheter care for a cognitively impaired resident with a right hip wound and indwelling catheter, and numerous omissions in medication and treatment administration for two other residents. One resident with complex conditions and heart failure did not consistently receive ordered daily weights, diuretics, IV antifungal therapy, diabetes injectables, vital sign monitoring, PICC/MID line measurements, or Hepatitis A and B vaccines as documented on the MAR. Another post‑surgical resident with a pain management care plan received PRN Naproxen for moderate to severe pain, but there was no documentation explaining why ordered PRN Oxycodone was not offered or given, nor whether the pain medication administered was effective.
A resident who was cognitively intact but required substantial to maximum assistance with ADLs following knee replacement surgery was discharged home with orders for OT, PT, home health, and DME including a standard walker. Although the SSD faxed home health orders to an agency, there was no confirmation that services were accepted or scheduled, and no documentation in the record regarding the status of home health arrangements at discharge. The resident later reported still waiting for home health treatment, indicating the resident was discharged without verified home health services in place.
Failure to Maintain Required 1:1 Supervision Resulting in Resident Fall Down Stairwell
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a newly admitted, cognitively impaired resident who had an active order for 1:1 supervision and fall precautions. The resident had diagnoses including traumatic brain injury, impulse disorder, generalized anxiety disorder, polyneuropathy, and a healing clavicle fracture, and had a fall risk assessment score of 10 indicating risk for falls. Nursing documentation noted the resident had multiple trips to the bathroom with watery stools, an unsteady gait, confusion, restlessness, and agitation, and was on hourly rounds while staff awaited implementation of 1:1 supervision. Despite an existing physician order for 1:1 supervision to ensure safety and support cognitive recovery, the assigned CNA left the resident’s bedside to walk two doors down the hall to ask another staff member about break coverage after providing the resident with water and covering him in bed. The facility’s policy and staff interviews indicated that 1:1 supervision required the sitter to remain at the bedside at all times, within one arm’s length of the resident, and to use the call light to request breaks rather than leaving the room. During the period the resident was left unsupervised, the resident exited the unit through a nearby emergency exit door located approximately 30 feet from the resident’s room. The resident descended a flight of eight stairs and was found by staff sitting at the bottom of the steps after the exit door alarm sounded. On assessment, the resident had abrasions to the right side of the forehead, the bridge of the nose, the right hand palm, and the right hand fourth digit. The incident occurred in the context of the facility’s own policy defining neglect to include inadequate supervision when a victim is left alone despite a caregiver being present but not providing necessary supervision. Interviews with the risk manager, RN leader, administrator, and DON confirmed that the sitter should not have left the resident alone and that the resident’s restlessness, impulsiveness, and psychiatric/TBI history made continuous supervision necessary under the ordered 1:1 precautions.
Failure to Perform Timely PICC Line Dressing Changes per Standards of Practice
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate administration of IV therapy by not performing Peripherally Inserted Central Catheter (PICC) dressing changes according to professional standards for one resident. During observation, the resident was noted to have a PICC line in the right upper arm with a transparent dressing dated 2/11, indicating it had not been changed weekly as required. An LPN stated that PICC dressings are supposed to be changed weekly, believed to be on Saturdays, and another LPN reported that the RN supervisor typically changes all PICC dressings but was not present that day. The Director of Nursing confirmed that PICC dressings should be changed every week and that it is the responsibility of the nurse on the cart, acknowledging that this resident’s dressing should have been changed and that there was no physician order for PICC dressing changes. Review of the facility’s skin and wound management policy showed that wound care is to be managed based on current standards of practice, with a physician order documented on the Treatment Administration Record when skin impairment is identified, but no such order existed for this resident’s PICC dressing care. These findings demonstrate that the facility did not follow its own policy and professional standards regarding PICC line dressing changes and lacked appropriate physician orders for this aspect of the resident’s IV therapy care.
Failure to Accurately Document Ordered Wound Care Treatments
Penalty
Summary
The facility failed to ensure complete and accurate documentation of wound care treatments in the medical record for one resident. Resident #1 had a physician’s order dated 01/17/2026 for daily abdominal staple wound care with normal saline, pat dry, and application of a dry dressing on the day shift through 01/26/2026. Review of the Treatment Administration Record showed no documentation that the ordered abdominal wound care was completed on 01/18/2026, 01/19/2026, or 01/23/2026. In interview, one LPN stated she changed the resident’s abdominal dressing whenever she cared for the resident but acknowledged she must have forgotten to document the dressing changes on 01/18 and 01/23, while another LPN could not recall whether the dressing was changed on 01/19. The facility’s documentation policy requires clinical staff to document care and services in a manner that accurately reflects the clinical care provided and provides a complete account of the resident’s care, treatment, and response.
Failure to Use Enhanced Barrier Precautions During PICC Line Dressing Change
Penalty
Summary
The facility failed to implement its infection prevention and control program by not using enhanced barrier precautions during intravenous therapy care for Resident #2. On 02/27/2026 at 10:32 AM, an LPN was observed changing Resident #2’s PICC line dressing without wearing a gown. Resident #2 had an IV for antibiotic medications related to a wound infection, and the resident’s care plan dated 02/02/2026 specified that enhanced barrier precautions were to be provided per facility policy. The Director of Nursing stated that Resident #2 should be on enhanced barrier precautions due to the IV and wound, and that the LPN should have worn a gown, while also noting that there was no order for enhanced barrier precautions. The LPN reported not thinking a gown was needed to change a PICC line dressing. Review of the facility’s Enhanced Barrier Precautions policy showed that gown and glove use is required for high-contact resident care activities, including device care such as central lines and wound care for any skin opening requiring a dressing.
Failure to Complete Individualized Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement individualized, person-centered baseline care plans within 48 hours of admission for three residents, as required by its Plan of Care Policy and Procedures. The policy, revised on 9/25/17, required that an individualized baseline plan of care be created within 48 hours of admission, including initial goals and interventions based on admission orders, physician orders, dietary orders, therapy services, social services if applicable, and other areas needed to provide effective care until the comprehensive care plan was completed. Record review for one resident admitted for rehabilitation after a fall at home showed that the baseline care plan was essentially blank, containing only the spouse’s signature on one page and lacking any initial goals, instructions, or interventions, including failure to address the resident’s history of falls or to identify goals and interventions to prevent further falls. Record review for a second resident admitted from the hospital with chest pain for rehabilitation services showed that the baseline plan of care had an incomplete first page, and while a goal for falls/safety was circled, no interventions were identified for that goal. For a third resident admitted from the hospital with acute respiratory failure with hypoxia for rehabilitation services, the baseline plan of care also had an incomplete first page, and the goals for falls/safety, oral/dental, pain, and anticoagulant use were circled without any corresponding interventions documented. In interviews, the unit manager stated that the admitting nurse was required to complete a comprehensive assessment and personalized baseline care plan at admission and that she reviewed new admissions the next day to ensure orders, assessments, and baseline care plans with goals and personalized interventions were completed. Both the unit manager and the DON confirmed, upon review, that the baseline care plans for these three residents were incomplete and did not include the required goals and interventions needed to meet residents’ needs until the comprehensive plans of care were completed.
Failure to Provide Ordered Rehabilitation Therapy Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered specialized rehabilitative services, specifically occupational, physical, and speech therapy evaluations and treatment, for one resident admitted for rehabilitation following a closed head injury. The resident was discharged from the hospital to the facility on 1/15/26 with a primary diagnosis of closed head injury and with physician orders dated 1/16/26 for OT, PT, and speech therapy evaluations and to treat as indicated. The Medical Certification for Medicaid Long-Term Care and Services and Patient Transfer Form dated 1/14/26 documented that the resident was being discharged to a skilled facility for rehabilitation. The resident’s daughter reported that her father had been hospitalized after a fall at home and that she was informed by the resident and his wife that rehabilitation therapy would not begin until 2/02/26. The Director of Therapy confirmed that although the resident was admitted with therapy orders on 1/16/26, only a wheelchair evaluation was completed on 1/16/26 and a wheelchair was provided that day. She stated that the standard practice was to complete therapy evaluations within 48 hours of admission, but in this case, the PT, OT, and speech evaluations were not performed as ordered and were instead scheduled for 2/02/26. These evaluations were not completed on 2/02/26 because the resident was sent to the hospital that day for a change in mental status. The DON confirmed that the resident had orders dated 1/16/26 for OT, PT, and speech therapy evaluations, which were acknowledged by the primary care physician on 1/21/26, and that these ordered evaluations were not completed as directed by the physician.
Failure to Maintain Urinary Catheter Bag Off the Floor
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not ensuring that a resident’s indwelling urinary catheter drainage bag was kept off the floor, as required by facility policy and the resident’s care plan. On multiple observations over several days, the resident was seen lying in bed with the urinary catheter bag positioned on the door side of the bed and resting on the floor, with photographic evidence obtained on several of these occasions. The resident had diagnoses including an encounter for fitting and adjusting a urinary device, an active physician order for an indwelling urinary catheter with instructions to use a catheter tube securing device and adjust its position as needed, and a care plan identifying the resident as at risk for urinary tract infection related to incontinence and the presence of an indwelling catheter, with an intervention to position the catheter bag and tubing to promote dignity and drainage. During an interview, the CNA responsible for the resident’s care stated that catheter care involved ensuring there were no kinks in the tubing, emptying the bag, and reporting output to the nurse, and acknowledged that the urinary drainage bag should not touch the floor. When asked to observe the resident’s catheter bag while it was resting on the floor, the CNA confirmed that it was on the floor and explained that sometimes when beds are in a low position, the bags will touch the floor. The resident’s quarterly MDS showed a BIMS score of 6 out of 15, indicating severe cognitive impairment. The facility’s catheter care policy required that the drainage spigot not touch the floor, that tubing be free of kinks, and that the catheter be kept at an appropriate level to promote urine flow and maintain dignity, which was not followed in this case.
Failure to Maintain Resident Dignity During Toileting and Repositioning
Penalty
Summary
The deficiency involves failures to treat residents with dignity and respect for their rights. For one resident admitted post–knee replacement surgery, a comprehensive assessment documented that the resident was cognitively intact and required substantial to maximum assistance with ADLs. During a phone interview, the resident reported that while using a bedside commode placed next to her bed, urine splashed onto the floor and her body, which she described as humiliating. She stated it appeared the bedside commode did not have the correct bottom or collection container attached. Subsequent observation of the facility’s supply closet and shower room revealed multiple bedside commodes stored without attached buckets or drainage collection containers, and the Nursing Home Administrator (NHA) acknowledged these findings. A second resident with mild cognitive impairment and dependence for ADLs was observed sitting in a wheelchair next to the nursing station, slouched over to the right side, and yelling for help to be repositioned. The resident was then observed being handled roughly by two staff members as they attempted to reposition and adjust the resident in the wheelchair in front of others who were watching. This interaction occurred in a public area near the nursing station, and the NHA was made aware of the observation.
Nonfunctioning Call System, Missed Wound/Catheter Care, and Medication Administration Failures
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, resident preferences, and goals, including failure to ensure timely staff response to call lights due to a nonfunctioning call system in multiple rooms. The facility’s policy on inoperable call bell systems required immediate notification of Maintenance and the Executive Director of Clinical Services, placement of hand or tap bells within reach of affected residents, education on their use, and 15‑minute checks with documentation when a large number of residents were affected. During a tour of the South unit, surveyors observed that call lights were not functioning in five specific rooms at various times, and the Director of Maintenance later stated he had only been made aware of the nonfunctioning call lights the previous day. The DON also stated there was no written policy or protocol for answering call lights timely, despite having referenced a call light policy in a grievance response. The facility also failed to provide ordered wound care and catheter care for a resident with significant medical conditions. This resident had diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, and cognitive communication deficit, with a BIMS score indicating severe cognitive impairment. Physician orders included catheter care every shift and right hip wound care with betadine and a bordered dressing three times weekly and as needed. Record review showed no documentation of right hip wound care from 02/19/26 to 02/24/26, and the DON acknowledged that wound care orders were not entered until 02/24/26 and that there was no documentation of wound care on 02/23/26. On observation, the resident was disheveled, partially uncovered, with a visible darkened area on the right hip under a brief, and the indwelling urinary catheter tubing was not secured, with the call light on the floor and out of reach. The ADON acknowledged the need to cover the resident, the presence of the right hip wound without a dressing, and the unsecured catheter tubing, and the wound care nurse acknowledged that wound care was not completed on one of the ordered days. The facility further failed to administer medications and treatments as ordered for two other residents. For one resident with discitis, type 2 diabetes mellitus, and heart failure, physician orders included daily weights for congestive heart failure, Bumex, Micafungin IV, Ozempic weekly, Victoza daily, vital signs every shift, PICC/MID line measurements, and Hepatitis A and B vaccines. The MAR showed multiple omissions, including missing daily weights on two days, missed doses of Bumex, Micafungin, Ozempic, and Victoza, lack of documented vital signs and PICC/MID line measurements on a specified date, and non‑administration of ordered Hepatitis A and B vaccines on several dates. The DON acknowledged that this resident had several medications that were not given in the month and also acknowledged that all medications had to be locked at all times. For another resident admitted post‑knee replacement surgery, with a care plan for pain medication therapy, orders included PRN Naproxen every six hours for pain and PRN Oxycodone every four hours for moderate to severe pain levels 5–10. The MAR documented administration of Naproxen on several occasions for pain levels of 5–6, but the record did not show why the ordered Oxycodone was not administered or offered for moderate to severe pain, nor did it document whether the administered medication was effective. The DON acknowledged these findings.
Failure to Arrange Ordered Home Health Services at Discharge
Penalty
Summary
The facility failed to ensure ordered home health services were arranged for a resident at discharge, resulting in the resident returning home without confirmed home health care. The resident had been admitted after knee replacement surgery, was cognitively intact, and required substantial to maximum assistance with activities of daily living. A comprehensive assessment documented these needs, and a physician’s order dated 01/30/26 directed discharge home with OT, PT, home health services, and DME including a standard walker. The Social Services Director reported that the resident’s discharge was initially delayed because the ordered walker had not been delivered, and stated she faxed the home health orders to an agency on 01/29/26 but did not obtain or document confirmation that services were accepted or scheduled. The resident reported in a phone interview nearly a month after discharge that she was still waiting to receive home health treatment, and record review showed no documentation regarding the status of home health arrangements or follow-up on the referral at the time of discharge. Record review and interviews confirmed that the resident was discharged home without verified home health services in place, and the facility’s documentation lacked any evidence of confirmation or tracking of the home health referral, despite the resident’s identified need for substantial assistance and ordered post-acute services.
Some of the Latest Corrective Actions taken by Facilities in Florida
- Modified the receptionist/front-desk resident exit process by using a LOA binder with blue (supervision required) vs. white (safe for unsupervised LOA) sheets, requiring residents to sign in/out for each LOA, requiring clinical approval prior to exit, and limiting front-door opening to staff remote/keypad access (J - F0835 - FL) (J - F0689 - FL)
- Removed the automatic-open function on the front double doors so doors remained locked and required staff remote/keypad entry/exit (J - F0835 - FL) (J - F0689 - FL)
- Extended receptionist hours and established coverage processes for breaks/step-away coverage and after-hours LOA/visitor entry/exit (J - F0835 - FL) (J - F0689 - FL)
- Changed the facility elopement policy to reflect CMS’s definition of elopement (J - F0835 - FL)
- Completed facility-wide elopement risk assessments in the EMR for all current residents (J - F0835 - FL) (J - F0689 - FL) (J - F0689 - FL) (J - F0600 - FL)
- Implemented daily exit-door checks as an ongoing monitoring process (J - F0689 - FL) (J - F0600 - FL)
- Performed routine exit-door alarm/function checks at all exit doors and tested exit alarms via an independent contractor (J - F0600 - FL)
- Converted locked exit doors to keypad/key fob exit function (removing delayed egress) and educated staff/contract therapy staff on the change (J - F0689 - FL) (J - F0600 - FL)
- Trained staff on Missing Resident Drill/Elopement response steps including responding to door alarms, using the elopement binder/books, performing resident headcounts, and notifying the Administrator/DON (J - F0835 - FL) (J - F0689 - FL) (J - F0689 - FL) (J - F0600 - FL) (J - F0600 - FL)
- Conducted missing-resident/elopement drills at varying times with staff participating collectively from each department (J - F0835 - FL)
- Implemented random weekly elopement drills performed by DON/ADON/designee (J - F0600 - FL)
- Implemented random-shift elopement education audits performed by DON/ADON/designee (J - F0600 - FL)
- Implemented ongoing competency testing on elopement awareness and prevention (including signs/symptoms of exit-seeking behavior, interventions, and notification) for staff and contract therapy staff (J - F0689 - FL) (J - F0600 - FL)
- Educated licensed nurses to communicate physician determinations/changes in resident capacity and to notify the DON/Administrator timely to trigger prompt re-evaluation of elopement risk (J - F0835 - FL) (J - F0689 - FL)
- Implemented QAPI/QA committee review of the revised exit/LOA process and elopement concerns (including ad hoc meetings with Medical Director participation) to provide oversight of corrective interventions (J - F0835 - FL) (J - F0689 - FL) (J - F0689 - FL) (J - F0600 - FL) (J - F0600 - FL)
Failure of Administrative Oversight Leads to Undetected Elopement of Cognitively Impaired Resident
Penalty
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.
Failure to Supervise Cognitively Impaired Resident Resulting in Unnoticed Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment to prevent unsafe wandering and elopement for a cognitively impaired resident. The resident was admitted with diagnoses including esophageal cancer, severe protein‑calorie malnutrition, adult failure to thrive, and a history of immunosuppression therapy. Therapy and clinical evaluations shortly after admission documented moderate cognitive impairment, decreased insight, poor judgment, and decreased safety awareness. A Speech Language Pathology evaluation showed moderate cognitive‑communication deficits with impaired short‑term memory, problem solving, and executive functioning, and a SLUMS score indicating moderate cognitive impairment. The admission MDS BIMS score also indicated moderate cognitive impairment, and the care plan identified cognitive loss/dementia and fall risk. Multiple nursing and provider notes over the following weeks documented intermittent and worsening confusion, treatment‑interfering behaviors such as repeatedly pulling out IV/PICC lines, disorientation, and statements reflecting confusion. Despite this documentation, the facility’s Elopement Risk Evaluation completed on 11/6/25 concluded the resident was not at risk for elopement. The Unit Manager who completed the tool answered “No” to questions about cognitive impairment, poor decision‑making, exit‑seeking behaviors, wandering oblivious to safety, and history of elopement, while acknowledging the resident was independently mobile and able to exit the facility. On 11/19/25, a psychiatric APRN formally evaluated the resident for capacity at the request of the primary physician and documented that the resident lacked capacity to make decisions related to healthcare or long‑term placement, was significantly disoriented, and could benefit from a guardian or POA. Another APRN note the same day described significant disorientation and fluctuating mental status, with risk of delirium and unsafe behaviors. Nonetheless, the facility did not update the elopement risk assessment or care plan to reflect this change in condition and did not implement elopement‑specific interventions. On the day of the incident, staff notes and the facility’s own timeline show that the resident was last seen at the nursing station around mid‑morning, when he denied needing anything. The front desk receptionist left the front desk unattended to go to the kitchen, and the front door, which could be opened without staff intervention, was left accessible. Around that time, EMS exited the building with another resident, and the facility asserts the doors closed and locked, but the receptionist later stated that a visitor likely opened the front door, allowing the cognitively impaired resident to leave unnoticed. The resident walked out the front door, crossed a two‑lane road, and traveled approximately half a mile over uneven terrain and near multiple water retention ponds to a nearby college dormitory. College staff found him in the dorm, describing him as confused, disoriented, unsteady, shaking, disheveled, and unsure of where he was. EMS documentation noted he did not remember where he was supposed to be and believed he was in a different city. The facility did not become aware that the resident had left until contacted by campus security after EMS had been called, and there was no documentation in the clinical record that the resident had exited the facility without staff knowledge or supervision. Interviews with the Unit Manager indicated she was told not to document the incident and that no elopement re‑evaluation or care plan update was completed afterward. The facility’s failure to recognize and act on the resident’s documented cognitive impairment and lack of capacity, to accurately assess elopement risk, to maintain supervision at the front entrance, and to document the elopement led to the determination of Immediate Jeopardy under F689. The resident’s family member reported being very upset that they were not notified of the incident until 24 hours later and expressed concern about what could have happened while the resident was unsupervised outside the facility. The Administrator and DON acknowledged in interviews that the resident left the facility without staff knowledge and supervision, but the Administrator repeatedly resisted characterizing the event as an elopement, instead describing it as the resident going for a walk and forgetting to sign out. The Administrator also stated that she would allow residents she considered cognitively impaired but without a formal incapacity statement to leave unsupervised and was unaware of the psychiatric APRN’s documented incapacity determination at the time. The DON confirmed that she did not direct staff to make a late entry documenting the incident and did not order a new elopement risk assessment, stating she believed the resident was alert and oriented and that a new evaluation was only done when a resident newly expressed a desire to leave and “did not make sense.” These actions and inactions, in the context of extensive documentation of confusion and impaired safety awareness, contributed directly to the unsafe elopement and the cited deficiency for failure to prevent accidents and provide adequate supervision.
Removal Plan
- Resident #900 no longer resides at the facility and was successfully discharged home as planned.
- Resident #900 was immediately placed on 1:1 staff observation.
- A licensed nurse performed a complete skin inspection for Resident #900 with no new skin concerns identified.
- Resident #900’s cognitive status was re-evaluated using the BIMS assessment.
- The Administrator/Designee re-educated all staff on Missing Resident Drill and Elopement policy, emphasizing responding to door alarms, using the elopement binder, performing a resident headcount, and Administrator/DON notification.
- The Administrator modified the receptionist process for residents exiting the facility and added it to new hire education, including use of a binder with blue (requires supervision) and white (safe for unsupervised LOA) sheets, clinical team determination of supervision, and resident sign-in/sign-out for each LOA; front door opened by remote or keypad.
- The 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 to 7:00 a.m.–9:00 p.m., 7 days/week.
- The front desk coverage process was updated to establish coverage when the receptionist is on break/steps away and to define the process for 9:00 p.m.–7:00 a.m. for assisting residents with LOA and/or visitors entering/exiting.
- 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 by the DON/Designee.
- The Administrator confirmed the LOA process is included in the new admission packet.
- The DON/Designee completed a new elopement risk assessment on all current residents in the electronic medical record system.
- The receptionist on duty for the event was re-educated on ensuring residents exiting the facility were approved by clinical staff prior to exit and on the binder/blue-white sheet LOA process and door access process.
- The DON/Designee re-educated all employees on F689 (including CMS definition of elopement), the updated facility elopement policy, documentation of resident incidents in the clinical record, and the new receptionist process for resident exiting (binder/blue-white sheets, clinical team determination, sign-in/sign-out, remote/keypad door access).
- All licensed nurses were educated on communicating physician changes to a resident’s capacity and notifying the DON and/or Administrator at the time of determination to ensure timely re-evaluation of elopement risk.
- An ad hoc QA meeting was held with the facility Medical Director in attendance via phone.
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision and Door Controls
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a cognitively impaired resident who had been repeatedly identified as an elopement risk. The resident was admitted with diagnoses including unspecified dementia of unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, as well as cognitive communication deficit and a history of cerebral infarction, alcohol abuse with alcohol-induced anxiety disorder, and syncope and collapse. A quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and documented that the resident could ambulate 150 feet with supervision or touching assistance. The resident’s care plan included a focus area for risk of elopement, citing exit‑seeking behavior and ambulating without assistance in hallways, with interventions such as diversional activities, frequent visual checks, and use of an audible monitoring system via an electronic monitoring device, which had been initiated and then resolved prior to the incident. Elopement risk evaluations on multiple dates identified the resident as an elopement risk, and a prior physician order for a wander management bracelet had been in place but was discontinued before the elopement. In the months leading up to the incident, facility records documented ongoing concerns about the resident’s wandering and exit‑seeking behaviors. A palliative care note recorded that the resident’s representative was concerned about the resident’s wandering and overall safety. Nursing and psychology notes described escalating behavioral concerns, agitation, combativeness secondary to confusion, not following safety instructions, and repeated attempts to leave the unit through an exit door. Staff documented periods of agitation and exit‑seeking in November and December, with multiple redirection attempts required to return the resident to his room. Despite these documented behaviors and repeated elopement risk evaluations, the resident did not have an electronic monitoring device in place at the time of the elopement, and the resident’s primary care physician stated he had not been informed of exit‑seeking behaviors or of the decision to remove the electronic monitoring device. On the day of the elopement, staff last observed the resident around the nurses’ station and his room shortly before the incident. A CNA reported leaving the resident at the nurses’ station before going on break and, upon returning, was unable to locate him in his room or the building. A missing resident code was initiated, and staff began searching. The resident had exited from the second‑floor hallway near the maintenance office into a stairwell by holding the door handle for approximately 30 seconds, then proceeded down the stairs to a first‑floor door that opened to the outside without an alarm. From there, the resident walked through the parking lot and onto nearby roads, ultimately traveling approximately 0.6 miles away from the facility toward streets with posted speed limits of 30 mph and 55 mph. Multiple staff members reported not hearing any door alarms, and interviews revealed inconsistent staff understanding of how to identify elopement‑risk residents and who should be wearing electronic monitoring devices. The resident was missing for about 10 minutes without staff knowledge before being located off‑site by a CNA and returned to the facility, where he stated he had been going for a walk and that no one saw him leave. This failure to supervise and to ensure effective elopement prevention measures resulted in a determination of Immediate Jeopardy. Additional interviews and record reviews highlighted gaps in staff awareness and communication related to elopement risk and monitoring systems. One CNA stated she was unsure how to identify residents at risk for elopement or who should be wearing an electronic monitoring device and did not know if any residents in the facility were at risk. The maintenance and housekeeping director stated that only the main lobby door was protected by the electronic monitoring device system and that other doors did not use these devices, while the regional nurse confirmed that the electronic monitoring device system only worked on the front door and would not have alerted at other exits. The nursing home administrator acknowledged that the resident had an elopement assessment upon admission and had previously worn an electronic monitoring device, but did not have one at the time of the incident, and that the door used to exit to the outside did not have an alarm. Staff accounts of the incident varied regarding the duration the resident was missing, but consistently indicated that no door alarms were heard and that the resident was found off facility grounds, damp from the rain, after the missing resident code was called. These documented actions and inactions formed the basis for the cited deficiency under the requirement to keep the environment free from accident hazards and to provide adequate supervision to prevent accidents.
Removal Plan
- Implemented 1:1 enhanced monitoring for Resident #1 upon return to the facility until discharge.
- Updated Resident #1's care plan.
- Completed a PTSD evaluation for Resident #1 with no concerns.
- Reviewed Resident #1's elopement risk and completed an updated elopement evaluation with plan of care updates as indicated.
- Interviewed Resident #1 upon return to the facility and evaluated the identified exit door used for proper function/alarm with no issues identified.
- Evaluated all facility internal exit doors for proper function with no issues identified.
- Completed education on doors and alarms for 100% of staff.
- Placed temporary auditory sensor alarms at identified secondary doors that exit the facility.
- Held an Ad Hoc QAPI committee meeting to review the concern, approve corrective interventions, and approve a PIP.
- Initiated mock elopement drills.
- Initiated education on the Missing Resident/Elopement Policy/Procedure (including elopement books) and Abuse/Neglect/Exploitation and completed education for all facility staff and contract therapy staff.
- Reviewed the prior 90 days of daily exit door checks to validate completion and continued daily door checks per QAPI direction.
- Reviewed elopement books to ensure proper information is in place and books are easily accessible.
- Verified functioning of the electronic monitoring device check machine.
- Evaluated current residents for elopement risk and completed new elopement evaluations with plan of care reviews/updates as indicated.
- Reviewed current residents with electronic monitoring devices to verify evaluation accuracy/appropriateness and proper orders/documentation and updated evaluation, order, and plan of care as indicated.
- Checked the electronic monitoring device system at the front door and confirmed it was functioning.
- Held a follow-up Ad Hoc committee meeting to review actions/interventions/outcomes and approve PIP items; Medical Director participated.
- Educated direct care licensed nursing staff on completion of elopement evaluations.
- Verified proper functioning of exit doors and alarms by the regional maintenance consultant.
- Converted locked exit doors to remove delayed egress, implemented keypad/key fob exit function, and educated staff and contract therapy staff.
- Educated direct care licensed nursing staff on interventions and notification for residents who refuse/remove wander guard device.
- Verified resident photos and resident room name door tags for identification/verification and updated as indicated.
- Held an Ad Hoc committee meeting to review steps taken and approve PIP item completion.
- Held an Ad Hoc committee meeting.
- Reviewed and updated the elopement drill tracking form/process to improve organization of the search and updated the location form to ensure all facility areas are assigned.
- Initiated ongoing competency testing related to resident elopement awareness and prevention (signs/symptoms of exit-seeking behavior, interventions, and notification) and completed testing for staff and contract therapy staff.
- Provided education to licensed staff on identifying elopement risk and locating electronic monitoring device status.
Failure to Prevent Elopement of High-Risk Resident and Respond to Exit Door Alarms
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to an exit door alarm and not providing adequate supervision to prevent an elopement. On the day of the incident, a CNA left the resident at the nurse’s station around 1:45 p.m. to go on lunch break. The resident, who had a history of exit-seeking and wandering behaviors, was later discovered missing from his room at approximately 2:15 p.m. A facility-wide missing resident code was initiated, and staff began searching the building and surrounding area. Multiple staff members reported they did not hear any door alarms at the time of the elopement. The resident had been admitted with diagnoses including unspecified sequelae of cerebral infarction, alcohol abuse with alcohol-induced anxiety disorder, unspecified dementia with moderate cognitive impairment, cognitive communication deficit, and syncope and collapse. His most recent MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and he was able to ambulate 150 feet with supervision or touching assistance. The care plan identified him as at risk for elopement due to exit-seeking behavior and ambulating without assistance in hallways, with interventions such as diversional activities, frequent visual checks, and use of an audible monitoring system. Elopement risk evaluations on multiple dates had identified him as an elopement risk, and prior progress notes documented escalating behavioral concerns, repeated attempts to leave through exit doors, agitation, combativeness, and exit-seeking behaviors. Despite this history, the resident did not have an electronic monitoring device in place at the time of the incident, and the prior intervention to use an audible monitoring system had been resolved. The resident exited from a second-floor hallway door near the maintenance office into a stairwell, holding the door handle for approximately 30 seconds to open the delayed egress door, then proceeded down the stairs to a first-floor exit door that had no alarm and could be opened freely from the inside. He then exited through another alarmed door near the business office to the parking lot, but staff reported not hearing any alarms. The resident walked through the parking lot and onto nearby roads, ultimately being found approximately 0.6 miles from the facility by a CNA who left in her car to search for him. Interviews revealed inconsistent staff understanding of which residents were at elopement risk and who should be wearing electronic monitoring devices, with at least one CNA stating she was unsure how to identify elopement-risk residents or whether any such residents were currently in the facility. The facility’s failure to supervise the resident adequately and to ensure effective functioning and response to exit door alarms resulted in an elopement that surveyors determined created a likelihood for serious injury and/or death and was cited at Immediate Jeopardy. Additional interviews highlighted gaps in communication and assessment related to the resident’s elopement risk. The Nursing Home Administrator stated that the resident did not exhibit wandering and exiting behaviors prior to the incident, despite documentation of prior exit-seeking and agitation. The resident’s primary care physician described him as having cognitive decline with variable mentation and stated that if the facility decided to remove the electronic monitoring device, this should have been communicated to him; he also reported he had not been informed of any exit-seeking behaviors. Some staff, including an LPN and CNAs, acknowledged that the resident had shown exit-seeking behaviors in November and December, and one CNA stated that if staff had known more, they might have been more aware of the need to continue monitoring for elopement risk. The combination of the resident’s known elopement risk, removal of monitoring interventions, lack of staff awareness, and failure to respond to or detect door alarms led directly to the resident’s unsupervised departure from the facility.
Removal Plan
- Implemented 1:1 enhanced monitoring for Resident #1 upon return to the facility until discharge
- Updated Resident #1’s care plan
- Completed a PTSD evaluation for Resident #1 with no concerns identified
- Reviewed Resident #1’s elopement risk status; completed an updated elopement evaluation and updated the plan of care as indicated
- Interviewed Resident #1 upon return to the facility; resident described the path taken and what occurred to the NHA/DON
- Evaluated the identified exit door used to leave the unit for proper function and alarm; no issues identified
- Evaluated all facility internal exit doors for proper function; no issues identified
- Completed education on doors and alarms for 100% of staff
- Placed temporary auditory sensor alarms at identified secondary doors that exit the facility
- Held an Ad Hoc QAPI committee meeting to review the concern, approve corrective interventions, and approve a PIP
- Initiated mock elopement drills (every shift for one week, then daily for one week, then every other day ongoing per QAPI recommendations)
- Initiated education on the Missing Resident/Elopement policy/procedure (including elopement books) and Abuse/Neglect/Exploitation; educated all facility staff and contract therapy staff
- Reviewed records of previous daily exit door checks for the past 90 days to validate completion; continued daily door checks per QAPI direction
- Reviewed elopement books to ensure proper information is in place and books are easily accessible
- Verified functioning of the electronic monitoring device check machine
- Evaluated current residents for elopement risk; completed new elopement evaluations and reviewed/updated care plans as indicated
- Reviewed current residents with electronic monitoring devices to verify evaluation accuracy/appropriateness, proper orders, and documentation for placement; updated evaluation/order/care plan as indicated
- Checked the electronic monitoring device system at the front door and confirmed it was functioning
- Held a follow-up Ad Hoc committee meeting to review actions/interventions/outcomes and approve PIP items; Medical Director participated
- Educated direct care licensed nursing staff on completion of elopement evaluations
- Verified proper functioning of exit doors and alarms by the regional maintenance consultant
- Converted locked exit doors to remove delayed egress; exit doors now require key fob/keypad for exiting; educated all facility staff and contract therapy staff
- Educated direct care licensed nursing staff on interventions and notification for residents who refuse/remove wander guard device
- Verified resident photos and resident room name door tags for identification/verification and updated as indicated
- Held an Ad Hoc committee meeting to review steps taken and approve PIP item completion
- Held an Ad Hoc committee meeting; reviewed and updated the elopement drill tracking form/process and updated the location form to ensure all facility areas are assigned
- Initiated ongoing competency testing on resident elopement awareness and prevention (signs/symptoms of exit-seeking behavior, interventions, and notification); completed for facility staff and contract therapy staff
- Provided education to licensed staff regarding identifying elopement risk and locating electronic monitoring device status
Failure to Follow Two-Person ADL Assistance Care Plan Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff followed a resident’s care plan requiring two-person assistance for Activities of Daily Living (ADL) care, resulting in a fall and right hip fracture. The resident had multiple significant diagnoses, including cerebrovascular disease, a stage IV sacral pressure ulcer, malignant neoplasm of the breast, chronic pain syndrome, atrial fibrillation, and was receiving palliative care. The active care plan, revised in October 2025, documented that the resident had an ADL self-care performance deficit related to multiple conditions and required substantial/maximal assistance of two staff for bed mobility and dependent/total assistance with transfers using a mechanical lift with two staff and a medium pad. The care plan also identified the resident as being at risk for falls or fall-related injury due to impaired mobility and decreased safety awareness, and included interventions such as a bariatric mattress, bed in lowest position, bolsters, a left side mobility bar, and cues for safety awareness. On the date of the incident, the resident’s ADL care was provided by one CNA instead of two, contrary to the care plan. A review of the CNA task list from early December through early January showed that the resident had been documented as receiving one-person ADL assistance on 21 of 31 days reviewed, despite the care plan specifying two-person assistance for bed mobility and transfers. On the morning of the fall, a newly hired CNA (CNA B) reported that it was her first day of work and that she was being coached by another CNA (CNA A). When they entered the room, CNA A directed CNA B to care for the other resident in the room while CNA A cared for the resident with the two-person assistance requirement. CNA B pulled the privacy curtain and began providing care to the other resident. While doing so, she heard a thud and then heard CNA A exclaim that the resident was on the floor. When CNA B looked out from behind the curtain, she saw CNA A running toward the resident’s bed from the doorway, and observed the resident on her back toward her right side with her head toward the top of the bed; the bed was in a high position, and the resident was complaining of right hip pain. Further interviews and documentation clarified the circumstances of the fall. CNA B stated that she and CNA A had not reviewed the Kardex prior to entering the room and that, as a new employee, she did not know how to access the Kardex at that time; she later learned that the resident was obese and required two people for transfers and bed mobility. An LPN familiar with the resident reported that the resident was totally dependent for care by two staff members and confirmed that she was assigned to the resident on the day of the fall. The LPN stated that CNA A had asked her to obtain a wound dressing because the resident’s dressing was soiled, and while the LPN was getting the dressing, she heard CNA A yell that the resident was on the floor. The LPN found the bed raised and the resident lying on the floor between the beds, initially on her right side and then rolled to her back, with her head close to the wall and her hands on her head; the resident complained of head pain and stated she had hit her head. The resident was assisted back to bed with a mechanical lift and multiple staff, and shortly thereafter complained of severe right hip pain. Subsequent SBAR documentation, radiology reports, and hospital emergency department notes confirmed that the resident had sustained a mildly displaced right femoral neck fracture with femoral shaft impaction and an acute sub-capital fracture of the right femoral neck after being dropped by staff during a transfer, while taking Eliquis for atrial fibrillation and reporting right hip pain.
Removal Plan
- Suspended the CNA involved with the incident and terminated the CNA.
- Reported the CNA to the board of nursing.
- Held an ad hoc QAPI committee meeting with the Administrator, DON, and Medical Director to review the incident and plan to be implemented.
- Initiated and completed neglect education for licensed nurses and CNAs regarding proper positioning of residents in bed during routine care, wound care, and repositioning, with emphasis on abuse and neglect, and obtained staff signatures prior to the staff's first shift.
- Completed assessments to determine which residents required assistance with ADL care while in bed, proper positioning during care, and the number of people required to assist during care while in bed.
- Completed a comparison to ensure all residents' care plans and Kardexes accurately reflected residents' bed mobility needs and the number of staff required to assist.
- Initiated competencies for licensed nurses and CNAs in providing ADL care and repositioning residents during ADL care while in bed.
- Conducted an ad hoc QAPI meeting with root cause analysis and discussion.
- Completed the root cause analysis identifying the root cause as the CNA's failure to follow the resident's plan of care.
- Conducted an ad hoc QAPI meeting to ensure all QAA/QAPI components of the incident were addressed and in substantial compliance.
- Initiated ongoing monitoring of CNA documentation to ensure it matched the Kardex, visual confirmation that the appropriate number of staff provided care, and resident interviews when possible to confirm appropriate staffing was used for care.
- Provided education for all newly hired licensed staff and CNAs on reviewing the Kardex prior to providing care and using the appropriate number of staff for bed mobility.
Neglect Due to Failure to Follow Two-Person ADL Assistance Care Plan Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not implementing care plan interventions requiring two-person assistance with activities of daily living (ADLs). The resident had an active care plan, revised on 10/16/25, that identified an ADL self-care performance deficit related to atrial fibrillation, hypertension, overactive bladder, history of breast cancer, dementia, anemia, and an end-stage disease process. The care plan specified that the resident required substantial/maximal assistance of two staff for bed mobility and was dependent/total with transfers, requiring a mechanical lift, two-person assistance, and a medium pad. The care plan also documented that the resident was at risk for falls or fall-related injury due to impaired mobility and decreased safety awareness, with interventions including a bariatric mattress, bed in lowest position, bolsters to bed, a left-side mobility bar, and cues for safety awareness. Despite these documented needs, the resident’s CNA task list from 12/10/25 through 01/10/26 showed that the resident received one-person ADL assistance on 21 of 31 reviewed days. On 01/10/26, the resident’s ADL care was again provided by only one CNA instead of two, contrary to the care plan. CNA B reported that this was her first day of work and that she was being coached by CNA A. When they entered the room around 5:15 AM, CNA A directed CNA B to care for the other resident in the room while CNA A cared for this resident. CNA B pulled the privacy curtain and began care on the other resident. She then heard a thud and CNA A exclaiming that the resident was on the floor. When CNA B looked, she saw the resident on her back, toward her right side, with her head toward the top of the bed, which was in a high position, and the resident was complaining of right hip pain. The DON later learned that the resident had fallen from the bed while CNA A was providing care alone. CNA A admitted she had not reviewed the care plan or Kardex before providing care and confirmed she provided care by herself. During a reenactment, CNA A demonstrated that the resident had been positioned on her right side, holding the mobility bar, with the bed at about waist height. CNA A walked to the doorway to ask the nurse to perform a dressing change because the resident’s dressing was soiled, leaving the resident in that side-lying position with the bed elevated. As CNA A was returning from the doorway, the resident’s left leg bent and its weight pulled the resident over the side of the bed to the floor, where she landed on her back and rolled to her left side. The resident complained of hitting her head, and CNA A called for help. Subsequent clinical documentation, including an SBAR note and radiology and emergency department reports, confirmed that the resident sustained a mildly displaced right femoral neck fracture with femoral shaft impaction, described as an acute sub-capital fracture of the right femoral neck, after being dropped or falling during transfer/bed mobility care provided by one CNA instead of the two-person assistance required by the care plan.
Removal Plan
- Suspended the CNA involved with the incident and terminated the CNA.
- Reported the CNA to the board of nursing.
- Held an ad hoc QAPI committee meeting with the Administrator, DON, and Medical Director to review the incident and implement a plan.
- Completed neglect education for licensed nurses and CNAs on proper positioning during routine care, wound care, and repositioning in bed, with emphasis on abuse and neglect, and obtained staff signatures prior to the staff's first shift.
- Completed assessments of residents to determine ADL assistance needs while in bed, proper positioning during care, and the number of persons required to assist during in-bed care.
- Completed competencies for licensed nurses and CNAs in providing ADL care and repositioning during in-bed ADL care.
- Conducted an ad hoc QAPI meeting to complete root cause analysis and discussion.
- Completed the root cause analysis identifying the root cause as the CNA's failure to follow the resident's plan of care.
- Conducted an ad hoc QAPI meeting to ensure all QAA/QAPI components were addressed and the facility was in substantial compliance.
- Initiated ongoing monitoring by the Administrator, NHA, DON, Unit Managers, IPCO, SDC, shift supervisor, and weekend supervisor to ensure CNA documentation matched the Kardex, the appropriate number of staff were observed providing care, and resident interviews were conducted when possible to confirm appropriate staffing was used.
- Provided education for all newly hired licensed staff and CNAs on reviewing the Kardex prior to providing care and using the appropriate number of staff for bed mobility.
Failure to Respond to Exit Alarm and Supervise High-Risk Resident Resulting in Elopement and Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from neglect by not responding appropriately to an exit door alarm and not providing adequate supervision to prevent elopement. The resident had diagnoses including dementia, psychotic disorder with hallucinations, depression, delusional disorder, falls, muscle weakness, and lack of coordination. A recent MDS showed a BIMS score of 6, indicating severe cognitive impairment, and progress notes documented wandering, impulsivity, agitation, difficulty with redirection, and concern for safety. The resident had been assessed as at risk for elopement, with an elopement risk score of 19 on admission (≥12 indicating risk) and a subsequent score of 10, and the care plan identified elopement risk related to cognitive impairment with interventions such as notifying other departments of elopement risk and using verbal cues and distraction techniques. On the night of the incident, the resident was last seen by the assigned CNA around 2:30 a.m. in bed asleep. Shortly thereafter, an emergency stairwell exit door alarm by the therapy department sounded. Video footage later reviewed by the Director of Plant Operations showed the resident, without a walker or wheelchair, walking down the therapy hallway holding the railing, leaning on the stairwell door at approximately 2:32 a.m., triggering the alarm and the audible message “Exit now, exit now,” and then opening and closing the door. The resident then descended two flights of stairs and exited the building through another alarmed door to the outside, all unwitnessed by staff. The stairwell and exterior areas had no cameras, and no staff were observed responding to the alarm during at least 20 minutes of reviewed footage. Multiple staff heard or were informed of the alarm but did not initiate the facility’s elopement procedures. The supervising LPN on duty, who was on the second floor when the alarm first sounded, attempted to silence the alarm but could not recall the code and assumed the alarm was malfunctioning. She contacted maintenance for assistance and then returned to other tasks on the first floor without initiating a search, checking outside, or calling a code for a head count. The assigned CNA was on break when the alarm sounded, received a call from the supervisor about the alarm, and believed it was another malfunction similar to a prior event; he did not check on his residents when he returned from break and recalled the alarm still sounding. The LPN assigned to the resident heard an unfamiliar alarm but did not recognize its source, did not immediately verify resident whereabouts, and reported not having been trained on elopement drills or the sound of the door alarms. Other staff on the first floor either did not hear the alarm or were told by the supervisor that it was a malfunction. During this time, the resident left the facility, walked through the parking lot, crossed a four-lane road, and entered a neighborhood where he fell, sustaining a left forehead laceration and left elbow skin tear, and was eventually found outside, wet and shivering in the rain, by local law enforcement and transported to the hospital. The facility did not become aware of the resident’s absence until notified by law enforcement, and the resident had been missing for approximately two hours without staff knowledge, leading surveyors to determine Immediate Jeopardy related to neglect and failure to prevent elopement. Interviews with clinical providers further underscored the resident’s known risks. The nurse practitioner and physician described the resident as having advanced dementia, confusion, cognitive dysfunction, impulsivity, restlessness, difficulty with redirection, shuffling gait, and muscle weakness, with a history of expressing a desire to go home and requiring assistance with ambulation using a walker. Staff nurses and CNAs reported that the resident frequently wandered, was extremely confused, constantly tried to get up, was unsteady on his feet, and required frequent redirection, with some staff stating he should have been on 1:1 supervision or 15-minute checks due to his behaviors and fall risk. Despite these known risks and the existing care plan identifying elopement risk, staff did not implement effective supervision or appropriate responses to the door alarm on the night of the incident, resulting in the resident’s unwitnessed elopement and injury.
Removal Plan
- Implemented 1:1 supervision with staff at all times for Resident #2 due to elopement risk.
- Implemented an order that Resident #2 may only go out on leave of absence (LOA) with a responsible party.
- Updated Resident #2 care plan to include family assisting with placement to a secured unit.
- Updated Resident #2 care plan to include providing the resident with a 1:1 companion as needed to decrease risk of exit seeking.
- Provided education to the assigned nursing supervisor and assigned nurse regarding responding to alarming doors, searching immediate surroundings, completing a head count when doors alarm, and timely DON notification of elopement.
- Suspended the nurse supervisor and assigned CNA pending investigation.
- Held an ad hoc QA meeting regarding elopement with the Administrator, DON, ADON, VP of Clinical Operations, and Medical Director.
- Conducted ongoing QAPI discussions focused on response to alarming doors, elopement drills, head counts, and prevention of neglect related to elopement.
- Provided education to the DON, ADON, and Administrator regarding the elopement, affected policies, alarming doors, head counts, risk management reports, reporting to AHCA, elopement drills/audits, QAPI, hourly head count, investigation guidance, and ongoing education/monitoring.
- In-serviced department heads on responding to alarming doors and checking surrounding areas to visually ensure the area is secure.
- Initiated abuse and neglect policy education with all current staff, emphasizing neglect, maintaining a safe environment, and required actions when a door alarm sounds.
- In-serviced assigned staff on responding to alarming doors, checking surrounding areas, performing a head count, and neglect/elopement prevention and response.
- Conducted elopement drills on every shift, then implemented random weekly drills performed by DON/ADON/designee.
- Started elopement education audits, then transitioned to random-shift audits performed by DON/ADON/designee.
- Completed elopement risk reassessments for all residents by ADON, clinical unit managers, and DON.
- Reviewed care plans for residents at risk for elopement by DON.
- Reviewed the elopement binder for accuracy by DON.
- Audited all current residents' LOA orders in the electronic health system by DON, ADON, and unit managers.
- Performed routine door monitor/alarm function checks at all exit doors by the Director of Maintenance.
- Tested exit alarms by a third-party independent contractor.
- Updated the CE-4 Elopement Prevention Policy; reviewed with the IDT in ad hoc QAPI and re-issued to all departments with education provisions.
- In-serviced current staff on the updated CE-4 Elopement Prevention Policy.
- Implemented emergency in-servicing education that all alarming doors must be treated as potential resident elopement and require a head count, and that only maintenance can identify a malfunctioning door alarm.
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