Citations in New Jersey
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in New Jersey.
Statistics for New Jersey (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in New Jersey
A resident with acute and chronic respiratory failure, gastrostomy status, and anoxic brain damage, who was rarely/never understood per MDS, had incomplete documentation of enteral nutrition. Staff reported that feeds are to be documented on the MAR, TAR, and an enteral nutrition log, and that all care is to be recorded in PCC within the shift. Review of the resident’s nutrition log showed a missing entry for a scheduled early-morning feeding, despite facility policies requiring timely, accurate, and complete EMR documentation of nursing interventions and enteral feedings.
Surveyors found that the facility did not maintain required environmental standards in multiple resident-accessible areas. Dining/activity rooms on upper floors were documented at temperatures below the acceptable range, and a dining room that leadership described as decommissioned had no signage and remained accessible. In resident rooms, a loose pipe was found on the floor, privacy curtains were not properly hooked, and a ceiling vent had visible grayish buildup. A hallway linen cart was left partially uncovered with dried substances and stains on its cover. On two upper floors, hallways, rugs, walls, handrails, and dining rooms showed large dark stains, peeling wallpaper, and worn surfaces, with nursing and housekeeping leadership acknowledging that these conditions had persisted despite repeated cleaning and prior verbal reports. These findings conflicted with the facility’s own policy requiring a safe, clean, comfortable, and homelike environment in all resident areas.
The facility failed to provide sufficient CNA staffing to ensure timely and appropriate incontinence care for a resident who was cognitively intact, always incontinent of bladder and bowel, and dependent for toileting hygiene and transfers. On one unit, two CNAs were assigned to 28 residents, and a CNA reported having about 14 residents and not being finished with morning care. During an incontinence round, an RN/Unit Manager found the resident wearing double incontinence briefs that were saturated with urine, with wet pads and linens and a urine odor, despite no care plan entry or documentation that the resident had requested double briefs. Review of electronic CNA documentation showed toileting hygiene tasks were routinely signed off as completed, but on the day of observation only a single entry was recorded shortly after midnight, with no further documentation of incontinence care by the day shift, even though the resident was listed as incontinent and only two CNAs were scheduled on that floor.
A severely cognitively impaired resident with dementia refused medication, and an LPN continued attempts to administer it. When the resident threw juice, the LPN pushed the resident’s wheelchair forward toward another chair, then grabbed the resident’s arm and roughly pushed the resident into another wheelchair, as confirmed by video. An activity aide witnessed the event but did not immediately report it to the DON or nursing supervisor, instead leaving a written statement that was not promptly found. A subsequent skin assessment showed no injuries, and the facility’s investigation substantiated the abuse allegation.
The facility failed to timely report two separate allegations of staff-to-resident abuse to the SSA. In one case, a cognitively intact resident with TBI and anxiety later reported to a therapist that a maintenance worker had sexually abused them during a respite stay; the facility learned of this from law enforcement and did not report it to the SSA because the resident had been discharged. In the other case, a severely cognitively impaired resident with dementia was observed on video and by an activity aide being roughly handled by an LPN during a medication refusal, but the aide did not immediately notify nursing leadership, and the facility did not report the allegation to the SSA until the following day, outside the required reporting timeframe.
A resident with multiple chronic conditions, including type II DM, cerebral infarction, COPD, and HTN, developed new excoriation to the bilateral groins and scrotum that was documented by an RN, with the physician notified but no documentation that the resident’s representative was informed. In interviews, the RN acknowledged that the representative should have been notified and that such contact should be charted, while the DON and LNHA confirmed the expectation that representatives be notified of new conditions such as skin excoriation. Review of facility policy showed a requirement to promptly notify a resident’s representative of changes in condition within 24 hours, which was not met in this instance.
A resident with severe cognitive impairment, expressive aphasia, and neurologic deficits became frustrated during a verbal argument with a roommate and pushed a bedside table into the roommate’s abdomen. Facility documentation noted the altercation and added care plan interventions focused on emotional support and allowing time for the resident to express feelings. However, the care plan was not revised to include specific interventions to protect the roommate or other residents from future physical acting out when staff were not present, resulting in a cited deficiency in care planning.
A resident with hemiplegia, aphasia, apraxia, and speech disturbances, who was cognitively intact per MDS and required substantial assistance with toileting and bathing and was at risk for pressure ulcers, had multiple gaps in EMR documentation for bladder continence and toilet use, bowel movements and toilet use, and hygiene over several days and shifts, despite a care plan intervention directing daily skin observation during ADL care. A CNA, the DON, and the LNHA confirmed that CNAs are responsible for providing and documenting ADL care in the EMR and that nurses and unit managers must ensure care is provided and documented, while the facility’s charting policy requires complete and accurate documentation of all services rendered.
A cognitively intact resident with a left shoulder fracture told an RN that they did not want any male caregivers, and the RN assured the resident this preference would be honored. However, the preference was not documented in the medical record, not added to the care plan, and not communicated in shift-to-shift reports. As a result, a male CNA provided care to the resident, and leadership later confirmed they were unaware of the preference and that the failure to follow it occurred at the nursing level, despite facility policy allowing residents to choose healthcare providers consistent with their interests and personal care needs.
A resident with severe cognitive impairment and a history of nontraumatic chronic subdural hematoma was found on the floor after an unwitnessed fall and was later admitted to the hospital with a left hip fracture. An RN reported the resident had leg pain, prompting a physician to order pain medication and an x-ray. Although an internal incident report and QA documentation identified the event as an unwitnessed fall, the facility did not report this injury of unknown origin to the NJDOH. The DON and LNHA stated they did not consider the event abuse or suspicious and therefore did not report it, despite a facility abuse/neglect policy requiring immediate reporting of injuries of unknown source.
Incomplete Documentation of Enteral Feeding in EMR
Penalty
Summary
The deficiency involves the facility’s failure to ensure that clinical records were complete and accurately documented for a resident receiving enteral nutrition. The resident had diagnoses including acute and chronic respiratory failure (unspecified for hypoxia or hypercapnia), gastrostomy status, and anoxic brain damage, and was rarely/never understood per the most recent quarterly MDS, which prevented completion of a BIMS assessment. Facility staff, including an LPN and RN, reported that enteral feeds are to be documented on the MAR, TAR, and an enteral nutrition log, and that documentation for resident care is to be completed in PointClickCare (PCC) within the shift and as soon as possible. The RN stated that documentation is important to track what is happening with residents and that many residents are vulnerable and nonverbal. During review of the resident’s January nutrition log, the surveyor identified missing documentation for a scheduled feeding time on 1/7/26 at 5:00 AM. This omission was shown to the LNHA, ADON, and DSW. The DON later stated that the expectation is that all documentation for residents should be completed. Facility policies titled “EMR Documentation-PCC” and “Nutrition: Enteral (GT, JT, NJT, NGT)” require timely, accurate, and complete clinical documentation in PCC, including recording enteral feedings in the EMR. Despite these policies and stated expectations, the enteral feeding for the identified date and time was not recorded, resulting in an incomplete clinical record for the resident’s nutrition.
Failure to Maintain Safe Temperatures and Clean, Homelike Environment in Resident Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in multiple resident-accessible areas. Surveyors observed that thermostats in the 3rd and 4th floor dining/activity rooms showed temperatures of approximately 67°F and 66.7°F, and a later temperature check in the 3rd floor dining room showed 64°F, below the facility’s own policy definition of comfortable and safe temperature levels and below the CMS temperature range referenced in state guidance. The 3rd floor dining room, which the LNHA stated was decommissioned and not in use, had no signage or notifications indicating it was closed, and the doors could be opened by surveyors, visitors, residents, and staff. Facility environmental temperature and safety rounds documentation did not include temperature measurements for any dining/activity areas on any floor. Additional environmental deficiencies were observed in resident rooms and common areas. In one resident room, a white pipe was found on the floor, which a CNA stated was likely from the metal cover under the sink. On a 6th floor hallway near a resident room, a linen cart was observed not fully covered, with whitish and blackish dried substances and a brownish stain on the cover; the Director of Recreation and a CNA acknowledged the cart should not be left open and that the white stain was from soap that had burst. In two separate resident rooms on the 4th floor, privacy curtains were hanging and not properly hooked on the rods, and in one of those rooms, a ceiling vent was observed with an accumulation of grayish substances upon entry. Surveyors also documented widespread issues with cleanliness and maintenance of floors, walls, and dining areas on the 5th and 6th floors. On the 5th floor, between specific rooms, the hallway rug was stained with a large dark brownish substance, handrails were scuffed and worn, and walls were stained with brown substances; wallpaper was peeling in at least one hallway area, and rugs throughout the 5th floor, including around the nursing station and near several rooms, had dark stains. The 5th floor dining room area had peeling wallpaper. The 5th floor RN/UM reported she had repeatedly raised these concerns with the LNHA, Maintenance Director, and DON for over a year and that shampooing every two weeks did not remove the stains. On the 6th floor, the main dining room had peeling wallpaper on the ceiling near the television and on the walls, and the rug area by the windows was stained with a brownish substance. These conditions were inconsistent with the facility’s Safe and Homelike Environment Policy, which requires a safe, clean, comfortable, and homelike environment in all resident-frequented areas, including hallways and dining/activity rooms.
Insufficient CNA Staffing Leads to Untimely Incontinence Care and Undocumented Double Brief Use
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to ensure timely and appropriate incontinence care, as evidenced by staffing levels and the condition of an incontinent resident. On one morning, the Nursing Home Resident Care Staffing Report showed a census of 118 residents on the 7 AM–3 PM shift with a CNA-to-resident ratio of 1:14.8. On the 5th floor, there were 28 residents and only two CNAs assigned. When interviewed, a CNA on that unit stated she had about 14 residents, described the assignment as hard, and reported she was not finished with morning care. On another day, the posted staffing report showed a census of 117 with 10 CNAs on the 7 AM–3 PM shift, for a ratio of 1 CNA to 11.7 residents. The facility’s own leadership later acknowledged that staffing concerns and at times not meeting New Jersey minimum staffing ratios were known issues. During an incontinence round on the 5th floor, the RN/Unit Manager confirmed that a resident was incontinent of both bladder and bowel and obtained the resident’s permission to check the incontinence brief. The RN/Unit Manager and surveyor observed that the resident was wearing double incontinence briefs that were wet with urine. The RN/Unit Manager also found that the resident’s pads, folded linen, and cloth-type chuck under the resident were wet beyond the pads, and there was a noticeable urine odor. The RN/Unit Manager stated she was unaware that the resident had requested double briefs and indicated that double briefs were not allowed unless specifically requested by the resident and included in the care plan. She further stated she was unsure whether this preference was in the care plan. The surveyor was unable to interview the CNA assigned to the resident at that time. Record review for this resident showed diagnoses including type 2 diabetes mellitus without complications, COPD unspecified, need for assistance with personal care, and difficulty in walking. The care plan identified a focus on potential impairment to skin integrity with an intervention to assist with toileting needs, but there was no care plan entry documenting a preference for double incontinence briefs or any documented evidence that the resident had requested them. The most recent quarterly MDS showed the resident was cognitively intact (BIMS 15/15), always incontinent of bladder and bowel, and dependent for toileting hygiene and toilet transfer, with no documented skin impairment. Review of CNA electronic documentation for toileting hygiene from 1/10/26 to 1/22/26 showed the task was checked off every shift as completed with the resident dependent and requiring assistance of two or more helpers. However, on 1/23/26, only one shift at 12:17 AM documented toileting hygiene, and there was no documentation by the 7 AM–3 PM shift or any evidence of incontinence care after 12:17 AM that day, despite the resident being listed on the facility’s list of incontinent residents and only two CNAs being scheduled on the 5th floor for that shift.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by LPN
Penalty
Summary
The facility failed to protect a severely cognitively impaired resident from physical abuse by a staff member. The resident, who had dementia without behavioral disturbances and a BIMS score of 2/15, was admitted on an unspecified date. According to the facility’s investigation and video surveillance, an LPN continued to attempt to administer medication despite the resident’s refusal. When the resident threw juice at the LPN, the LPN grasped the resident’s wheelchair armrest and pushed the wheelchair forward toward another chair. Video further showed the LPN grabbing the resident’s left arm and roughly pushing the resident into another wheelchair. The LPN later provided a written statement denying any abuse. An activity aide witnessed the incident around 10:10 AM but did not immediately notify the DON or the nursing supervisor. Instead, the aide wrote a statement and left it for the DON, which was not found until a later date. The LPN clocked out at 10:36 AM that day and did not return to the facility. A skin assessment completed afterward documented no injuries. The DON stated that the LPN had no prior history of inappropriate interactions with residents and that a criminal background check at hire showed no concerns. The facility’s investigation ultimately substantiated the allegation of abuse toward the resident.
Failure to Timely Report Allegations of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to timely report allegations of staff-to-resident abuse to the State Survey Agency (SSA) for two residents. In the first case, a resident admitted for a respite stay with traumatic brain injury and anxiety, and assessed as cognitively intact with a BIMS score of 13, later disclosed an allegation of sexual abuse by a maintenance worker to a therapist after discharge. The facility became aware of the allegation when contacted by local law enforcement, and the administrator confirmed that the resident had not voiced any allegations during the stay. Although the facility verified that the accused staff member was removed from the schedule and subsequently resigned, the administrator stated the allegation was not reported to the SSA because the resident no longer resided at the facility. In the second case, a resident with dementia and a BIMS score of 2, indicating severe cognitive impairment, was involved in an incident in which an LPN continued to attempt medication administration despite the resident’s refusal. When the resident threw juice at the LPN, the LPN grasped the resident’s left arm and roughly pushed the resident into another wheelchair, as observed by an activity aide and on video surveillance. The activity aide did not immediately notify the DON or nursing supervisor and instead left a written statement the following day. The DON confirmed that the facility did not become aware of the incident until that statement was found and that the initial notification to the SSA was not made until the day after the incident, contrary to the facility’s abuse prevention policy requiring covered individuals to report suspicions of abuse immediately, but no later than two hours after forming the suspicion.
Failure to Notify Resident Representative of New Skin Excoriation
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a change in the resident’s medical condition. A closed record review for a resident admitted with type II diabetes, cerebral infarction, COPD, and hypertension showed that on 1/11/26 at 11:39 PM, an RN documented newly identified excoriation (scraped skin) to the resident’s bilateral groins and scrotum and that the physician was notified. There was no documented evidence that the resident’s representative was informed of this new skin condition, despite the change being recorded in the progress notes. During an interview, the RN stated that a resident’s representative was to be notified of any change in a resident’s medical condition and that such notification should be documented, and acknowledged that if the family had been notified, it would have been charted. The RN further stated that the representative should have been informed. In a joint interview, the DON and LNHA confirmed that staff were expected to notify the resident’s representative of any new conditions, including skin excoriation, and that the RN should have informed the representative of the change. Review of the facility’s “Change in a Resident’s Condition or Status” policy dated February 2021 showed that the facility would promptly notify a resident’s representative of a change in medical condition within 24 hours, which did not occur in this case.
Failure to Revise Care Plan After Resident-to-Resident Physical Altercation
Penalty
Summary
The deficiency involves the facility’s failure to adequately revise the care plan for a resident after an incident of resident-to-resident physical aggression. Resident #3 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, aphasia, apraxia, and speech disturbances, and had a BIMS score of 7/15, indicating severe cognitive impairment. On 1/10/26, a verbal argument occurred between Resident #3 and their roommate, Resident #1, related to the television remote control. RN #1 entered the room and observed Resident #3 waving the television remote, appearing frustrated, and pushing the bedside table toward Resident #1, bumping Resident #1 in the abdomen. Progress notes by UM #1 documented that Resident #3 had a verbal argument with the roommate and became frustrated, pushing the table at the roommate. Following this incident, the facility updated Resident #3’s care plan with a focus on difficulty expressing themselves due to expressive aphasia and added interventions such as providing emotional support and allowing time to express feelings. However, the care plan did not include any interventions addressing how the facility would protect the roommate or other residents when Resident #3 became frustrated in the absence of staff, nor did it include measures to address Resident #3’s risk of physically acting out toward others. During an interview, the DON and the Licensed Nursing Home Administrator confirmed that the updated interventions would not prevent Resident #3 from another altercation with another resident when staff were not present. This failure to include adequate, person-centered interventions to address the underlying source of the problem and to protect other residents constituted the cited deficiency.
Failure to Maintain Complete and Accurate ADL Documentation in EMR
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident when required ADL documentation was missing from the electronic medical record (EMR) over multiple days and shifts. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, aphasia, apraxia, and speech disturbances. A comprehensive MDS dated 1/12/26 showed a BIMS score of 14/15, indicating the resident was cognitively intact, and documented that the resident required substantial assistance with toileting and bathing and was at risk for pressure ulcers/injuries. The resident’s care plan included a focus on risk for alteration in skin integrity, with an intervention initiated on 1/6/26 directing that the resident’s skin be observed during daily ADL care and abnormalities reported. A review of the resident’s January 2026 task list, which the facility stated should be documented each shift, revealed no evidence of documentation for bladder continence and toilet use, bowel movement and toilet use, and hygiene on multiple specified dates and shifts. Corresponding progress notes for those dates also did not contain documentation related to these tasks. During interviews, a CNA stated that CNAs were primarily responsible for providing ADL care and were required to document all care provided in the EMR, and emphasized that documentation verified monitoring and care. The DON and LNHA confirmed that CNAs were responsible for ADL care and documentation, and that nurses and unit managers were responsible for ensuring both that appropriate care was provided and that CNAs documented the care. The facility’s Charting and Documentation policy dated July 2017 required that all services provided to residents be documented and that documentation be complete and accurate, including treatments or services performed.
Failure to Honor and Communicate Resident Preference for No Male Caregivers
Penalty
Summary
The deficiency involves the facility’s failure to honor and communicate a cognitively intact resident’s expressed preference regarding personal care providers. The resident, admitted with a left shoulder fracture, had an MDS dated 5/7/2025 showing a BIMS score of 13/15, indicating intact cognition. On 5/18/2025, the resident informed an RN that they did not want any male caregivers. The RN told the resident she would ensure that no male caregivers would provide care. This interaction was documented in a Verbal Coaching/Education form dated 5/23/2025, which identified the reason for coaching as the RN being notified of the resident’s preference for no male caregivers. Despite this expressed preference, a review of the resident’s medical record showed no documentation of the preference, no corresponding entry in the care plan, and no evidence that the preference was communicated in shift-to-shift reports. As a result of this lack of documentation and communication, a male CNA provided care to the resident on 5/19/2025, contrary to the resident’s stated wishes. During an interview, the LNHA, with the DON present, stated they were unaware of the preference request until the investigation and confirmed that the nurse did not follow the resident’s preferences when notified. The LNHA acknowledged that this failure occurred at the nursing level and that the facility’s policy allows residents to choose healthcare providers consistent with their interests, values, and personal care needs.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) as required. A resident with diagnoses including nontraumatic chronic subdural hematoma and a BIMS score of 00, indicating severe cognitive impairment, was found on the floor in an unwitnessed incident in the afternoon. Progress notes documented that the resident was found on the floor at approximately 2:30 p.m. and was later sent to the hospital at approximately 9:30 p.m. for further evaluation. A subsequent progress note indicated that the resident was admitted to the hospital with a left hip fracture, and a facility QA report confirmed the fall was unwitnessed. During a telephone interview, an RN stated the resident had been experiencing leg pain, which led the physician to order pain medication and an x-ray. Facility documentation showed that an internal incident report was completed, but there was no evidence that the injury of unknown origin was reported to the NJDOH. In an interview, the DON, in the presence of the LNHA, stated that the incident was considered a fall and not abuse and therefore was not reported to the NJDOH, and the LNHA stated the fall was not suspicious in nature and did not need to be reported. This was inconsistent with the facility’s Abuse and Neglect policy, which requires that all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation, be reported immediately, but not later than two hours after the allegation is made.
Some of the Latest Corrective Actions taken by Facilities in New Jersey
- Re-educated all staff on the facility’s Elopement and Wandering policy and continued ongoing re-education to reinforce elopement-prevention expectations and procedures (J - F0689 - NJ)
- Implemented monitoring of the 6th floor East and [NAME] stairwell doors to ensure residents at risk had necessary supervision and to prevent unsafe access to stairwell doors (J - F0689 - NJ)
- Placed STOP sign barriers on the East and [NAME] stairwell doors as an additional deterrent to resident exit attempts (J - F0689 - NJ)
- Requested installation of an additional magnetic lock via the door security vendor to strengthen stairwell door security (J - F0689 - NJ)
- Applied a wander guard and verified its functionality to improve elopement prevention for the at-risk resident (J - F0689 - NJ)
- Updated the facility’s front door to eliminate delay in opening and closing to improve door security and reduce elopement risk (J - F0689 - NJ)
- Reviewed the facility elopement policy to reinforce facility expectations and procedures (J - F0689 - NJ)
- Re-educated facility-wide staff on elopement prevention and emergency protocols and validated competency to improve staff response and prevention practices (J - F0689 - NJ)
Elopement of Severely Cognitively Impaired Resident Through Alarmed Stairwell Exit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision for a severely cognitively impaired resident who was at high risk for elopement and exhibited exit‑seeking behaviors. The resident had a Brief Interview of Mental Status (BIMS) score of 2, indicating severe cognitive impairment, poor judgment, poor safety awareness, and an inability to recognize environmental hazards. The resident’s care plan identified a potential for wandering related to behavior and history of wandering, a risk for elopement due to exit‑seeking behavior with an intervention for a wander guard on the left ankle, and special needs for a protective head helmet due to a cranioplasty wound following a traumatic subdural hematoma and craniotomy. The resident was able to ambulate independently and had been admitted after a significant fall that resulted in brain surgery. On the day of the incident, the resident was last seen by an RN at approximately 3:15 PM seated in a wheelchair in the back of the nurse’s station on the 6th floor. Around 3:25 PM, an LPN beginning the 3–11 shift observed the resident no longer in the wheelchair but slowly ambulating in the hallway toward the high side of the unit near the alarmed exit door and then sitting on a couch along that hallway. After reviewing the 24‑hour report, at about 3:35 PM the LPN went to look for the resident and found that the resident was no longer on the couch. The LPN began a room‑to‑room search of the 6th floor and informed the DON that the resident could not be found. A CNA arriving for the 3–11 shift at about 3:30 PM also reported looking for the resident and not seeing them. During this same time frame, the social worker, whose office is across from the alarmed exit door on the 6th floor, returned to the floor and heard a door alarm sounding from the high side exit door. The social worker deactivated the alarm, looked down the stairwell, but only went down two to three flights and did not see anyone, then returned to the floor to inform nursing staff. The social worker and the LPN subsequently went down the stairwell to the bottom and noted that the exit door on the ground floor, which leads directly to a local street, was partially open; they checked outside and did not see any facility residents. The facility’s internal investigation and the resident’s later reenactment indicated it was probable that the resident had opened the 6th floor alarmed exit door, descended ten flights of stairs, and exited through the side egress door to the street. The resident was reported missing to police at approximately 4:17 PM and was later found by local police in a neighboring town and transported to a hospital emergency department for evaluation and overnight stay. The facility’s failure to ensure adequate supervision and to prevent this resident’s access to and use of the alarmed stairwell exit resulted in an elopement that constituted an immediate jeopardy situation beginning at the time the resident was last seen near the exit door.
Removal Plan
- Initiated an immediate room-to-room and in-house thorough search and initiated a foot and car search near the building perimeter
- Paged Code Gray to the entire building to alert all staff
- Informed local police about the missing person and provided the resident’s profile and description
- Notified the resident’s family and physician
- Alerted hospitals of the missing person
- Brought the resident to the emergency department for evaluation and the resident stayed overnight
- Completed a full head count of all residents in the building and confirmed all residents were accounted for
- Reassessed all residents at risk of elopement and re-evaluated care plans; determined interventions were appropriate and in place
- Upon the resident’s return, placed the resident on 1:1 supervision
- Upon the resident’s return, reassessed elopement risk and re-evaluated the resident’s care plan; deemed appropriate and in place
- Re-educated all staff on the facility’s Elopement and Wandering policy and continued ongoing re-education
- Implemented monitoring of the 6th floor East and [NAME] stairwell doors to ensure residents at risk have necessary supervision to prevent unsafe access to stairwell doors
- Placed a STOP sign barrier on both the East and [NAME] doors as an additional deterrent
- Requested a work order from the door security vendor for installation of an additional magnetic lock
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision and Door Security
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe environment and adequate supervision to prevent the elopement of a resident with poor decision-making abilities. The resident had multiple diagnoses, including schizoaffective disorder, bipolar disorder with psychotic features, muscle weakness, difficulty walking, and cognitive deficits with confusion. An Elopement Risk Review earlier in the year had assessed the resident as low or no risk for elopement, and no additional elopement risk assessments were documented between that time and the date of the incident. The resident’s care plan identified a self-care deficit related to cognitive deficits and confusion, and a separate focus that the resident was at risk for falls, accidents, and incidents, but there were no documented care plan interventions specifically addressing elopement risk prior to the incident. On the night of the incident, staff accounts and documentation showed that the resident was last observed inside the facility around 1:00 AM by an LPN and again around 1:30–1:45 AM by a CNA, who reported that the resident was walking around the facility, which was described as usual behavior. The resident later reported that they exited the facility by watching staff enter a code into a keypad at an exit door and then waiting for the door’s locking mechanism light to turn green before going through the door. The Nursing Supervisor on duty stated that the front door lock did not lock immediately upon closing and that it was possible for someone to get out when the door was in that condition. The resident stated that they were only allowed to leave with family, yet left the building alone wearing pajamas, rubber clog-style shoes, no coat, and without their cane. External documentation from the police incident report indicated that a caller observed an elderly person in pajama pants and no jacket on the side of the roadway, identified by first name and an identification bracelet. The caller transported the resident to a convenience store, gave them money, and then left. Police then picked up the resident from the store and returned them to the facility around 2:00–2:08 AM. Facility documentation, including the Facility Reportable Event and progress notes, confirmed that staff were unaware the resident had left until police returned the resident and reported finding them at the convenience store. Interviews with the Unit Manager and DON confirmed that such an unsupervised departure met the facility’s definition of elopement and that the resident was not considered safe to go out independently. The surveyors determined that the facility failed to provide adequate supervision, failed to develop appropriate interventions to prevent elopement for this resident, and failed to follow its elopement and wandering policy, resulting in an Immediate Jeopardy situation under F689. The facility’s elopement and wandering policy stated that residents at risk for elopement would receive adequate supervision to prevent accidents and care according to individualized care plans, and that the facility would use a systematic approach to identify and assess elopement risk. However, the record showed only one Elopement Risk Review earlier in the year, with no subsequent reassessments until after the elopement occurred. The DON described that, following an elopement, the expectation was for assessment, completion of a risk management form, collection of staff statements, and notification of family and physician to support a thorough investigation and root cause analysis. At the time of the survey, only limited staff statements were available, and the survey findings concluded that the facility did not adequately implement its own policy or maintain sufficient supervision and environmental controls to prevent the resident’s unauthorized exit.
Removal Plan
- Safely returned Resident #2 to the facility and placed on one-to-one supervision.
- Applied a wander guard for Resident #2 and verified its functionality, placed the resident on enhanced supervision, and moved the resident to a room closer to the nurse's station.
- Updated Resident #2's care plan.
- Reassessed Resident #2 for elopement risk.
- Conducted a facility headcount.
- Inspected facility exit doors, keypads, alarms, and the wander guard system to validate proper functioning.
- Updated the facility's front door to eliminate delay in opening and closing.
- Reviewed the facility elopement policy.
- Re-educated facility-wide staff on elopement prevention and emergency protocols and validated competency.
- Completed reassessments of at-risk residents.
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