Citations in North Carolina
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in North Carolina.
Statistics for North Carolina (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in North Carolina
A resident with moderate cognitive impairment and altered mental status was prepared for EMS transfer when EMS personnel observed multiple live cockroaches on the resident’s body and in the bed. The resident, who required supervision for ADLs, was unaware of the insects. EMS reported that staff acknowledged a cockroach infestation. ED documentation confirmed the resident arrived with insects on him and required immediate cleaning. Staff interviews described widespread cockroach presence on med carts, in rooms, and on residents over several months, and maintenance and a pest control specialist confirmed a heavy, ongoing infestation during the period surrounding the incident.
The facility failed to maintain an effective pest control program, leading to a prolonged cockroach infestation on multiple halls and in resident rooms. Pest control invoices showed routine visits but lacked documentation of reasons for treatment or specific applications, while staff across disciplines reported cockroaches on residents, in beds, on med carts, and throughout rooms and hallways. A resident with moderate cognitive impairment who was transferred to the ED for AMS was found by EMS and ED staff to have cockroaches on his body and in his bed. NAs and housekeeping staff described a longstanding, severe roach problem, use of over‑the‑counter sprays, and absence of evening housekeeping coverage. The Maintenance Director and Administrator acknowledged months of cockroach activity, reliance on word‑of‑mouth reporting instead of a formal work‑order or monitoring system, and no adjustments to the pest control program or systematic audits despite knowing that roaches had been found on residents.
Surveyors found multiple failures in food labeling, dating, and storage in the kitchen and nourishment rooms. In the walk-in cooler and freezer, opened bags of hard-boiled eggs, breadsticks, and shredded cheese were either undated or carried old open dates. In nourishment room refrigerators, fruit lacked resident identification and date, and numerous single-serve orange juice containers were past their best-by dates. In the kitchen, several opened loaves of bread in unmarked bags, some without dates, were stored in very close proximity to open containers of sanitizing cleaning solution. The Dietary Manager and Administrator acknowledged that staff were expected to label and date all opened food and to check and discard expired items.
A resident with Alzheimer’s disease, heart failure, and dementia had three documented unwitnessed falls in her room, each assessed by nursing staff as causing no injury. However, the annual MDS was coded to show no falls since the prior assessment. The MDS Coordinator, who reviewed the fall event history and completed the assessment, later acknowledged that the MDS should have been coded to indicate two or more falls without injury. The DON and Administrator both stated that MDS assessments are expected to be accurate and that this resident’s fall history should have been correctly reflected on the annual MDS.
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy by not ensuring staff wore gowns and gloves during high-contact care for multiple residents with invasive devices and chronic wounds. An RN administered medications via a feeding tube to a resident on EBP using only gloves despite posted signage requiring a gown for high-contact device care. Two nurses and a NA transferred a resident with a PICC line using a mechanical lift while wearing only gloves, and no EBP signage had been posted for that resident. Another NA provided care to a resident with open sacral wounds, infections, and a central line while wearing gloves but no gown, despite clear EBP signage and available PPE. Staff interviews showed misunderstanding or reliance on missing signage, and leadership confirmed that gowns and gloves were required for these high-contact activities under the facility’s EBP policy.
Surveyors found expired medications and supplies in two medication rooms and one medication cart, including expired Jardiance tablets, Ocusoft eye cleanser wipes, and Promethegan suppositories. A nurse confirmed she was assigned to the affected cart and stated she checks it before each shift but had missed the expired item. Unit managers and night-shift nurses were reported to be responsible for routine checks of medication rooms, while the DON described a process in which unit managers check rooms and carts weekly and nurses check their carts prior to each shift, yet expired items remained in active storage.
Surveyors observed a nurse leave four insulin pens unattended on top of a medication cart on two occasions while walking away and out of sight, with a resident seated next to the cart waiting for medication. Review of the same cart found several insulin and injectable pens in use without required open and expiration dates, as well as pens that remained on the cart past the discard timeframe specified by the manufacturer. The nurse acknowledged forgetting to date a newly opened insulin pen and not returning the pens to the correct cart, while leadership confirmed staff are expected to keep medications secured, label pens when opened, and remove expired medications.
Two residents experienced inaccurate medical record documentation when one NPO resident’s medications were ordered and recorded as given by mouth instead of via g-tube in the EMR and MAR, despite staff administering them through the g-tube, and another resident’s ordered compression hose were repeatedly charted on the TAR as applied and removed even though staff reported the resident did not wear them and frequently refused the treatment, with refusals not properly documented.
Surveyors found that the facility repeatedly failed to obtain and document informed consent before initiating psychotropic medications for several residents with dementia, mood disorders, psychosis, and anxiety. Multiple residents with severe cognitive impairment were receiving antipsychotics, antidepressants, antianxiety agents, and mood stabilizers such as olanzapine, haloperidol, quetiapine, lorazepam, trazodone, duloxetine, venlafaxine, lamotrigine, mirtazapine, and fluoxetine without any record that they or their representatives had been informed of the risks and benefits or had consented. Interviews with the Administrator, DON, ADON, MDS nurse, and SW showed that responsibility for obtaining psychotropic consents was shared between the MDS nurse and SW, but they were not consistently notified of new or changed orders, were unclear that consents were required for all psychotropics (not just antipsychotics), and acknowledged that frequent staff turnover and process gaps led to consents "slipping through the cracks."
A cognitively intact resident with an existing DNR order informed the facility of this status at admission, and both the physician orders and EMR documented the resident as DNR. However, the DNR form was not present in the advance directives notebook at the nurse’s station, one of the two locations designated by the facility for such documentation. Nursing staff reported they rely on either the advance directives notebook or the EMR to determine code status, and the Interim DON and Administrator acknowledged that the notebook and EMR were expected to match, but in this case they did not.
Resident Dignity Compromised by Cockroach Infestation and Insects on Resident During EMS Transfer
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity when the resident was found with multiple live cockroaches on his body and in his bed during preparation for transfer to the hospital. The resident had moderate cognitive impairment, required a wheelchair for mobility, and needed supervision with bathing and dressing. On the day of the incident, nursing documentation showed the resident became increasingly confused and disoriented to self and place, and EMS was called for evaluation of altered mental status. When EMS personnel arrived and turned the resident, they observed an unspecified number of live insects consistent with cockroaches crawling on the resident and in his bed. EMS staff reported that facility staff acknowledged a cockroach infestation and later filed an Adult Protective Services report. The emergency department provider note documented that the resident arrived at the hospital with an unspecified number of insects on him and was immediately cleaned by nursing staff. Due to altered mental status, the resident was minimally able to participate in the evaluation and could only nod or shake his head inconsistently. Interviews with facility staff revealed that the nurse who arranged the transfer did not observe cockroaches on the resident and stated EMS did not report this to her at the time. The nurse aide assigned to the resident that day reported hearing from another aide that EMS personnel had observed cockroaches on the resident and were stomping them on the floor while preparing him for transport, and she stated it had been several hours since she last provided personal care to the resident before his transfer. Additional staff interviews and external observations confirmed ongoing cockroach activity in the facility around the time of the incident. A nurse aide reported that cockroaches were “terrible” in the fall and winter, and that she had seen cockroaches on medication carts, on residents, in beds, on ceilings, and in resident rooms, including a prior incident where a resident had a cockroach on his clothing without being aware of it. The Maintenance Director acknowledged a cockroach infestation in November and December and stated staff had reported seeing cockroaches as recently as about one month prior, including reports of cockroaches found on residents. A pest control specialist who evaluated the building in late January described the facility as heavily infested with active cockroach activity. The Administrator confirmed frequent cockroach sightings in the facility during the preceding months and acknowledged awareness that EMS had reported seeing cockroaches on a resident being transferred to the hospital.
Failure to Maintain Effective Pest Control Resulting in Cockroach Infestation on Units and Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a pest‑free environment and to operate an effective pest control program, resulting in ongoing cockroach infestation in resident care areas and on residents. Pest control invoices from December documented weekly services and aerosol treatments on the 100 and 200 halls, but did not state the reason for treatment, what pests were being treated, or details of the specific applications. One invoice noted evidence of German cockroaches in a specific room, yet there was no documentation of staff reports of cockroach activity or targeted follow‑up. Staff interviews consistently described a longstanding, significant cockroach problem beginning in the prior summer or fall, with heavy activity in October, November, December, and January, particularly on the 100 and 200 halls. One resident, identified as having moderate cognitive impairment and requiring a wheelchair and supervision with bathing and dressing, experienced a change in condition with altered mental status and was transferred to the ED. EMS documentation for this transfer indicated that, during assessment in the facility, live insects consistent with cockroaches were observed on the resident’s body and in his bed. EMS personnel reported that when they questioned staff about a bug problem, staff confirmed that the facility had a cockroach infestation and stated there was nothing that could be done about it. The ED provider note also documented that the resident arrived with insects on him and was immediately cleaned by nursing staff. Multiple staff members, including NAs and nursing staff, reported observing cockroaches on residents, in resident beds, on medication carts, on walls, ceilings, floors, and other surfaces, and behind refrigerators and in HVAC units. Several NAs stated that cockroaches had been present "everywhere" on the 100 and 200 halls, including on resident clothing and in rooms where residents ate meals and food was often spilled. Staff also reported that housekeeping was only present during daytime hours, that over‑the‑counter household sprays were used between exterminator visits, and that everyone in the facility was aware of the pest problem. Despite this, staff frequently did not submit work orders or formal reports, assuming administration and maintenance already knew. The Maintenance Director initially denied recent pest problems but later acknowledged a cockroach infestation in November and December, primarily on the 200 hall, and admitted he had been told at some point that cockroaches had been found on residents. He stated he did not contact the pest control company, adjust the pest control program, or implement any monitoring after learning this. He also reported that he did not participate in QAPI, had no records of pest‑related work orders, and largely relied on word of mouth rather than a documented system. The Administrator similarly acknowledged frequent cockroach sightings in October and November, recognized that the contracted pest control provider was not effective, and confirmed that there was no work order system for pests, no room audits for pest activity, and reliance on word‑of‑mouth reporting and over‑the‑counter sprays by housekeeping. A pest control specialist from a new company later described the facility as heavily infested with active German cockroach activity at the time of his initial evaluation, confirming the extent of the infestation.
Improper Food Labeling, Dating, and Storage in Kitchen and Nourishment Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper labeling, dating, and storage of food items in the kitchen and nourishment rooms. During an initial kitchen tour with the Dietary Manager, an opened plastic bag of hard-boiled eggs was found in the walk-in cooler without a date, and in the walk-in freezer an opened undated plastic bag of breadsticks and an opened bag of shredded cheese labeled as opened on 1/9/26 were observed. The Dietary Manager stated that all food items were expected to be labeled and dated upon opening and that expired items were to be discarded. Further observations in the nourishment rooms and kitchen revealed additional issues. In the 100-hall nourishment room refrigerator, a plastic grocery bag containing apples and oranges lacked a resident name and date, and seven single-serve orange juice containers had a best-by date of 1/24/26. In the 300-hall nourishment room refrigerator, four orange juice containers with a best-by date of 1/24/26 and six with a best-by date of 1/17/26 were found. The Dietary Manager reported that Dietary Aides were responsible for daily checks of nourishment room refrigerators and stated the refrigerator had been checked that day but did not know how the expired and unlabeled items were missed. In the kitchen, three opened loaves of bread in unmarked clear plastic bags, with incomplete or missing dates, were stored on a shelf in very close proximity to two open half-full containers of sanitizing cleaning solution. The Dietary Manager confirmed that food should not be stored near cleaning solutions and that food items should be labeled and dated, and the Administrator stated he expected staff to check for and discard expired food and to label and date stored food items.
Inaccurate MDS Coding of Resident Fall History
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident by incorrectly coding the fall history section of the resident’s annual Minimum Data Set (MDS) assessment. The resident, admitted with diagnoses including Alzheimer’s disease, heart failure, and dementia, experienced three unwitnessed falls in her room during the assessment look-back period, as documented in nurse’s progress notes and a fall event record. Each time, the resident was found sitting on the floor and assessed by nursing staff, with documentation indicating no injury from any of the falls. Despite this documented fall history, the annual MDS assessment indicated that the resident had no falls since the prior assessment. During interviews, the MDS Coordinator confirmed she was responsible for completing the fall history on the annual MDS and that she reviewed the resident’s fall event history when coding the assessment. She acknowledged that, based on the documented falls occurring after the prior MDS, the annual MDS should have been coded to reflect two or more falls without injury. The DON and the Administrator both stated that MDS assessments are expected to be accurate and correctly coded, and that the annual MDS should have reflected that the resident had fallen since the prior assessment.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents with certain devices or chronic wounds. For a resident with a feeding tube, an RN administered medications via the feeding tube without wearing a gown, despite an EBP sign posted at the doorway and PPE available across the hall. The nurse used hand sanitizer and gloves but omitted the gown, later acknowledging awareness that the resident was on EBP and that the sign referenced gowns and gloves for high-contact care involving a feeding tube. The Infection Preventionist and Director of Nursing both stated that a gown and gloves should have been worn for this care. Another deficiency occurred with a resident who had a PICC line and was receiving IV antibiotics for endocarditis. During a transfer from wheelchair to bed using a mechanical lift, two nurses and a nurse aide entered the room and completed the transfer wearing only gloves and no gowns. They assisted the resident with rolling and removed the lift pad without donning gowns. There was no EBP signage posted inside or outside the resident’s room, even though the resident had a PICC line in place. One nurse reported she normally wore a gown and gloves for PICC-related care but was not prompted to don a gown for the transfer because there was no EBP sign. The Infection Preventionist later stated that the resident should have been placed on EBP due to the PICC line and that she had overlooked obtaining the order and posting the signage. A further deficiency was identified with a resident who had open wounds on the sacrum, infections, and a central line used for IV antibiotics. An NA entered this resident’s room, which had an EBP sign posted and PPE available outside the door, carrying only gloves and not wearing a gown. The NA provided care in the room, moved around the bed, accessed the closet, and exited the room still wearing gloves and carrying a trash bag, all without donning a gown. The NA stated she knew the resident was on EBP due to open wounds and infections but believed a gown was only required for dressing changes. The Infection Preventionist and DON stated that, due to the resident’s open wounds, infections, and central line, the NA should have worn both gown and gloves when providing high-contact care. Across these events, five staff members (three nurses and two nurse aides) did not follow the facility’s EBP policy, which defined high-contact activities as including dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, device care or use (including central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters), and wound care for chronic wounds or those with MDRO. The failures included not donning gowns during high-contact care for residents with a feeding tube, a PICC line, and chronic pressure ulcers with a central line, as well as the failure to identify and place a resident with a PICC line on EBP and post appropriate signage. The Administrator stated that he expected all staff members to use the appropriate PPE according to the enhanced barrier signs posted for each resident and to wear the required PPE when providing care to residents on EBP. However, the observations and interviews documented that staff either misinterpreted the EBP signage, relied solely on signage that was missing, or misunderstood when gowns were required, resulting in noncompliance with the facility’s infection control policy for EBP.
Expired Medications Found in Medication Rooms and Cart
Penalty
Summary
Surveyors identified a deficiency related to medication storage and control when expired medications were found in two of three medication rooms and one of seven medication carts reviewed. In the 300 hall medication room, a bottle of Jardiance 10 mg with an expiration date of 2/17/2026 was present; the nurse accompanying the surveyor confirmed the expiration date and stated that the unit manager was responsible for checking the medication room weekly for expired medications. The 300 hall Unit Manager, who had been employed at the facility for two months, reported she needed to confirm with the DON how often the medication room should be checked for expired medications. On Medication Cart #3, which was assigned to the same nurse, surveyors found a box of Ocusoft eye cleanser wipes with an expiration date of 10/2025; the nurse confirmed the expiration date and stated she checked her cart prior to each shift for expired medications and supplies but must have missed this item. In the 200 hall medication room refrigerator, surveyors found a box of Promethegan 12.5 mg suppositories with an expiration date of 1/2026; the nurse present confirmed the expiration date and stated that unit managers were responsible for weekly checks of medication rooms and that night shift nurses should check the medication room each night. The DON later stated that unit managers check medication expiration dates weekly in medication rooms and carts, nurses check their carts prior to each shift, and night shift nurses check for expired medications in medication rooms, and explained that medication expiration dates were checked because expired medications could lose effectiveness or become more potent over time.
Unsecured and Improperly Labeled Insulin and Injectable Medications on Medication Cart
Penalty
Summary
The deficiency involves failure to secure and properly manage insulin and other injectable medications on a medication cart. During continuous observation of medication administration with one nurse on Medication Cart #1, four insulin injector pens were left unattended on top of the cart while the nurse twice walked away and out of eyesight of the cart. On both occasions, a resident was seated beside the cart waiting for medication while the unsecured insulin pens remained on top. The nurse later stated the pens belonged on another cart, acknowledged she had placed them on Cart #1 earlier when administering insulin because the medication aide could not give insulin, and admitted she did not realize she had left them unsecured when she walked away. Further observation of Medication Cart #1 revealed multiple issues with labeling and expiration of injectable medications. One Novolog pen for a resident had 12 units remaining and a blank label with no open date or expiration date. One Lantus pen for another resident had 80 units remaining and a blank label with no open date or expiration date. A Novolog pen for a third resident had 100 units remaining and a blank label with no open date or expiration date; the nurse later stated she had opened it at noon the same day and forgot to date it. An Aspart pen for another resident was labeled as opened on 01/08/26 with an expiration date of 02/04/26, despite manufacturer directions stating Aspart pens should be discarded 28 days after opening. A Liraglutide injection pen for another resident was labeled as opened on 01/10/26 with an expiration date of 02/06/26, although manufacturer directions indicated it should be discarded 30 days after opening. The DON and Administrator confirmed that staff are expected to keep medications secured, label injector pens with open and expiration dates at the time of opening, and remove expired medications from use.
Inaccurate Medication Routes and Treatment Documentation in Medical Records
Penalty
Summary
The deficiency involves failures to maintain accurate and complete medical records for two residents. For one resident with a history of severe dysphagia from a previous stroke and an NPO (nothing by mouth) diet order, multiple medication orders in the electronic medical record (EMR) were entered with the route as "by mouth" instead of via gastrostomy tube (g-tube). These included lorazepam, sertraline, and geri-tussin DM. The March Medication Administration Record (MAR) showed these medications as administered as ordered by mouth over multiple days, even though the resident was NPO. Nursing staff who regularly cared for this resident reported that all medications were always crushed and administered through the g-tube and that the resident did not receive medications by mouth. One nurse stated she had not noticed that some medications were ordered by mouth on the MAR, while another nurse acknowledged she had noticed the incorrect route but did not correct it due to time constraints. The Nurse Practitioner confirmed that she entered the orders and that the EMR defaulted to the oral route, which she failed to manually change to g-tube, resulting in inaccurate documentation of the administration route in the medical record. For a second resident, there was an order for knee-high compression hose to be applied in the morning and removed in the evening. The March Treatment Administration Record (TAR) showed staff initials indicating that the compression hose were applied and removed daily, with one exception. However, observation revealed the resident was not wearing compression hose, and the nurse aide responsible for treatments stated the resident did not wear them and could not explain why the TAR had been initialed as if they were applied. A nurse, the ADON, and the DON all reported that this resident frequently refused compression hose and that refusals should have been documented as such on the TAR rather than initialing as if the treatment had been completed, indicating inaccurate documentation of treatment administration and refusals in the medical record.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation for multiple residents. For one resident with generalized anxiety disorder and severe cognitive impairment, the record showed an active PRN lorazepam order with no documentation that the responsible party was informed in advance of the risks and benefits or that consent was obtained. Another resident with major depressive disorder, anxiety disorder, borderline personality disorder, hallucinations, and unspecified psychosis, who had intact cognition and no documented behaviors, was receiving risperidone, duloxetine, and lamotrigine without any record that she or her guardian had been informed of the risks and benefits or had consented to these treatments. A third resident with schizophrenia, anxiety disorder, bipolar disorder, and schizoaffective disorder, with moderate cognitive impairment and no behavioral symptoms, was receiving trazodone, venlafaxine, quetiapine, and haloperidol, again with no documentation that the responsible party had been informed in advance or had consented. Another resident with Alzheimer’s disease, major depressive disorder, anxiety disorder, and insomnia, who was severely cognitively impaired and wandering, was receiving mirtazapine, fluoxetine, lamotrigine, and lorazepam on a routine basis. The electronic medical record contained no documentation that the responsible party had been informed in advance of the risks and benefits of these medications or had consented. A resident with dementia, major depressive disorder, and hallucinations was receiving daily olanzapine for hallucinations, with MDS documentation of severe cognitive impairment and daily antipsychotic use, but there was no record that the responsible party had been informed of the risks and benefits or had consented. Another resident with unspecified dementia, generalized anxiety disorder, major depressive disorder, and cognitive communication deficit, who was severely cognitively impaired and receiving antidepressant, antipsychotic, and anticonvulsant medications routinely, was administered olanzapine, lamotrigine, and trazodone without documentation that the representative had been informed in advance of the risks versus benefits or had consented. Interviews with facility staff revealed systemic process issues contributing to the lack of psychotropic consents. The Administrator stated that the Social Worker (SW) and MDS Coordinator were responsible for obtaining psychotropic medication consents but acknowledged that no consent forms could be found for the identified residents and was unsure where the breakdown occurred. The MDS Coordinator and SW both confirmed they shared responsibility for obtaining consents when new psychotropic medications were ordered or existing orders were changed, but reported they were not always informed of new orders or changes, and that providers sometimes added or changed psychiatric medications without notifying them. The Assistant DON/Interim DON and DON stated they believed consents were required for antipsychotics but were not aware of the need for consents for all psychotropic medications, and both cited frequent position changes and acknowledged that obtaining psychotropic consents had “slipped through the cracks.” Psychiatric Nurse Practitioners documented ongoing psychotropic regimens and stability for some residents, including notes that one resident was stable on olanzapine with no indication for gradual dose reduction, and another was stable on olanzapine, lamotrigine, and trazodone with no medication changes needed. However, despite these ongoing psychotropic treatments and routine administration documented on the MARs, the facility’s records lacked corresponding informed consent documentation for each of the psychotropic medications identified in the survey. Staff interviews consistently confirmed the absence of psychotropic consent forms for the affected residents and an inability to explain precisely where in the process the failure to obtain and document consent had occurred.
Failure to Maintain Consistent DNR Documentation in Designated Locations
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s advance directive documentation in both locations designated by facility policy. A cognitively intact resident, admitted with an existing Do Not Resuscitate (DNR) status, reported that he had informed the facility of his DNR upon admission and understood it to mean that staff would not perform CPR if needed. The resident’s physician orders contained an advanced directive order for DNR, and the electronic medical record (EMR) displayed a DNR status in the advance directive banner at the top of the resident’s EMR page. However, when surveyors reviewed the advance directive notebook kept at the nurse’s station, there was no DNR form on file for this resident, despite the EMR and physician orders indicating DNR status. A nurse stated that she would look either in the advance directives notebook or in the EMR to determine a resident’s code status. The Interim DON confirmed she was responsible for ensuring the notebook matched the EMR and for obtaining provider signatures on DNR forms, and acknowledged that the resident’s DNR form was missing from the notebook. The Administrator also stated that code status information in the advance directives binder and EMR should match and that staff were expected to check either source for code status.
Some of the Latest Corrective Actions taken by Facilities in North Carolina
- Checked and tested the wander management system and door alarms, including testing the bracelet through the front door and having maintenance check alarm doors for faults (J - F0689 - NC)
- Reapplied and maintained wander alarm bracelets on the resident’s person and on the rollator walker (J - F0689 - NC)
- Updated the resident’s plan of care for elopement risk after readmission (J - F0689 - NC)
- Ensured the physician order for the wander alarm bracelet was entered into the electronic medical record (J - F0689 - NC)
- Updated the elopement board and binders with the resident’s picture and room number (J - F0689 - NC)
Failure to Prevent Elopement of Cognitively Impaired Resident Resulting in Off-Site Fall
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise a cognitively impaired resident at known risk for elopement, resulting in the resident exiting the building without staff knowledge. The resident had dementia with moderate cognitive impairment (BIMS score 10/15), was resistive to nursing home placement, expressed a desire to leave or go home, and had poor decision-making skills. An elopement risk assessment identified the resident as at risk for elopement, and an elopement alarm bracelet was ordered verbally per the Medical Director and applied on 01/22/26, initially to the resident’s wrist and then additionally to her walker and cane when she repeatedly removed the device from her person. However, there was no corresponding physician order documented for the elopement alarm device in the physician orders at that time, and the alarm bracelet placement on equipment was contrary to manufacturer instructions, which specified that transmitters should be worn on the ankle or wrist and not directly attached to equipment. On the morning of the elopement, multiple staff observed the resident wandering, confused, and exit-seeking over several hours. The Weekend RN Supervisor reported seeing the resident frequently between 7:30 AM and 9:30 AM, during which the resident was asking to leave, wanting to go outside, and attempting to open exit doors that remained locked and would not open for her. The Weekend RN Supervisor redirected the resident multiple times and had her sit in a chair near the 200 Hall medication cart, but after seeing the resident walk toward another hall around 9:30 AM, she did not see her again. A nurse aide assigned to the resident noted that the resident was walking around the hall and refused breakfast between approximately 8:30 AM and 9:00 AM, removed the breakfast tray, and then had no further contact with the resident that morning. Another nurse observed the resident at about 9:40 AM wandering on a different hall looking for turtles, walked her to a courtyard door to show where the turtles were, and then saw her walk back toward the nurses’ station near the front lobby; this was the last confirmed sighting of the resident inside the facility. Despite the resident’s known elopement risk, active exit-seeking behavior that morning, and the presence of an elopement alarm system, no staff reported hearing an elopement alarm sound, and no one observed the resident leaving the building. The DON stated she last saw the resident standing by the nurses’ station approximately 15–20 minutes before being asked about her whereabouts by the Weekend RN Supervisor, and a facility-wide search (Code [NAME]) was not initiated until the resident’s family arrived for a visit and reported they could not find her. During the period when the resident’s whereabouts were unaccounted for, a civilian observed her walking along a public two-lane road without sidewalks in cold weather, and later found her down a steep embankment near a riverbed after seeing her walker abandoned by the roadside. EMS and fire personnel documented that the resident had fallen approximately 17 feet down the embankment, required rescue with a stokes basket and ladder, and was transported to the hospital, where she was found to have a right frontal forehead contusion but no acute intracranial injury. EMS personnel and the civilian both reported that no elopement alarm bracelet was observed on the resident at the scene, while the facility later confirmed that an alarm bracelet remained attached to the resident’s walker and that the device functioned when tested at the front door, indicating that the resident had been able to leave the facility without effective alarm activation or staff intervention.
Removal Plan
- Conduct staff interviews with nursing, dietary and housekeeping staff who were present and working during the time of the elopement.
- Initiate the missing person protocol and conduct a head count of all current residents, documenting that residents are present and accounted for.
- Contact the on-call physician and notify the Medical Director.
- Complete a full skin assessment upon the resident's return from the hospital and document findings.
- Check and test the wander management system and door alarms, including testing the bracelet through the front door, and have maintenance check alarm doors for faults.
- Determine the likely exit route and confirm other doors are locked and require a code.
- Reapply an alarm bracelet to the resident's person and maintain a wander alarm bracelet on the rollator walker.
- Update the resident's plan of care for elopement risk after readmission.
- Ensure the physician order for the wander alarm bracelet is entered into the electronic medical record.
- Update the elopement board and binders with the resident's picture and room number.
- Implement 1-on-1 supervision for the resident using licensed nurses, nursing assistants and dietary staff.
- Transition the resident to 15-minute checks as a trial with continued monitoring for further incidents.
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