§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and
§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
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Observations:
Based on observations, review of clinical records, facility policies, facility investigative documentation, video surveillance, and resident and staff interviews, it was determined that the facility failed to ensure the environment remained as free of accident hazards as possible by failing to provide adequate supervision and implement effective interventions to prevent an avoidable elopement for one of 12 residents reviewed (Resident CR1). This deficient practice placed Resident CR1 and other residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, & 12) identified by the facility as being at risk for elopement in Immediate Jeopardy due to the likelihood of serious injury, serious harm, impairment, or death.
Findings include:
A review of the facility policy titled " Elopement, " last reviewed January 28, 2026, revealed the facility ' s policy is to provide residents with a safe and secure environment and to proactively prevent resident elopement (when a resident leaves the facility or a designated safe area without staff knowledge or authorization). The policy directs staff to evaluate residents for elopement risk upon admission, readmission, quarterly, and following a significant change in condition. The policy required staff to assess residents with a history of substance use disorder, develop individualized care plan interventions to reduce the risk of elopement, redirect residents who attempt to leave the facility without supervision, and maintain a current photograph of each resident identified as being at risk for elopement.
Observation of the facility ' s main entrance revealed two interior doors leading to the exit area. One interior door opened into an enclosed vestibule, and the second door opened directly to the outside. Neither interior door was locked from inside the building. During weekday daytime hours, a clerical employee was stationed in an office adjacent to the entrance with a direct line of sight to the main hallway and entrance doors.
Observation revealed the exterior entrance operated through an alarmed electronic access system. Between 8:00 AM and 4:30 PM, individuals could enter the building from outside without staff assistance. After 4:30 PM, individuals seeking entry were required to press an exterior call button that signaled staff inside the clinical area to remotely unlock the exterior door. Residents could exit the building from the inside unless an electronic elopement prevention device activated the locking system.
The facility utilized an electronic Wander guard system to help prevent elopement. Residents identified as being at risk for elopement wore an electronic device attached to the resident or mobility equipment, such as a wheelchair or walker. When a functioning electronic device approached a monitored exit, the system locked the interior exit door, activated an audible alarm at the doorway, and illuminated a red indicator light above the door.
A review of facility records dated June 19, 2026, revealed the facility had identified 12 residents as being at risk for elopement, including Resident 1 through Resident 12 (Resident 1, 2,3,4, 5, 6, 7, 8, 9, 10, 11, and 12). These residents relied on the facility ' s elopement prevention system and staff supervision to prevent unauthorized exit from the building.
A closed clinical record review revealed that Resident CR 1 was admitted to the facility on November 13, 2025, with diagnoses to include diabetes mellitus (sugar builds up in the bloodstream), anxiety (a mental health condition characterized by excessive worry or fear) and psychoactive substance use, in remission (an individual used to use mind-altering drugs or substances in the past).
A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 21, 2026, revealed Resident CR 1 was moderately cognitively impaired with a BIMS score of 8 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 indicates significant thinking or memory challenges that could impact daily life).
A review of Resident CR 1 ' s care plan initiated on November 18, 2025, identified a history of substance use disorder with risks for mood or behavioral disturbances, recurrence of substance use, and withdrawal symptoms (physical or emotional symptoms that may occur when an individual stops using certain substances). Interventions included relaxation techniques, referral to mental health services, and identifying Resident CR 1 ' s goals for the stay.
A separate care plan initiated on November 28, 2025, and revised on June 11, 2026, documented behaviors including taking items that belonged to other residents and attempting to use wheelchairs assigned to other residents. On June 16, 2026, three days before Resident CR 1 exited the facility, staff added " wanting to go home " as a behavioral trigger. Despite identifying this trigger, the facility did not revise the care plan to include additional individualized interventions to address Resident CR 1 ' s persistent efforts to leave the facility or the resident ' s repeated use of mobility devices belonging to other residents.
A care plan initiated on March 12, 2026, identified Resident CR 1 as being at risk for elopement. Before Resident CR 1 exited the facility on June 19, 2026, the care plan interventions remained limited to reorienting the resident, encouraging participation in group activities, redirecting the resident away from exit doors, using the Wander guard system, and checking the Wander guard device each shift.
Although the clinical record documented repeated statements over several months that Resident CR 1 intended to leave the facility, increasing exit-seeking behaviors, repeated use of wheelchairs that did not belong to the resident, and continued unsuccessful attempts at redirection, the facility did not revise the care plan to implement additional individualized interventions to reduce the resident ' s risk for elopement. The facility did not revise the elopement care plan until June 19, 2026, after Resident CR 1 exited the building without staff knowledge.
A review of the clinical record revealed Resident CR 1 demonstrated a persistent and escalating pattern of exit seeking behaviors beginning in March 2026. Documentation consistently showed Resident CR 1 repeatedly expressed the intent to leave the facility, packed personal belongings in preparation for leaving, requested housing information, remained focused on returning home, and was frequently unable to be redirected by staff despite repeated interventions.
A nursing progress note dated March 3, 2026, documented Resident CR 1 insisted on leaving the facility. Staff explained facility policies and attempted to redirect the resident without success. Social services documented increased confusion, continued statements about leaving the facility, and determined Resident CR 1 lacked the necessary family support and resources for a safe discharge. On the same date, staff completed an Elopement/Wander Risk Evaluation identifying Resident CR 1 as being at risk for elopement due to forgetfulness, a short attention span, fear, anxiety, repeated statements about wanting to go home, packing belongings, and remaining near exit doors. The evaluation documented Resident CR 1 was independently mobile using a cane, walker, or wheelchair and had a history of substance use disorder. Nursing staff applied a Wander guard device to Resident CR 1 ' s wheelchair on March 3, 2026.
A physician ' s order dated March 10, 2026, directed staff to maintain a Wander guard device for Resident CR 1 and verify the device ' s placement and function each shift.
Clinical documentation continued to demonstrate Resident CR 1 ' s persistent intent to leave the facility. During evaluations completed by the Psychiatric Mental Health Nurse Practitioner on March 15, April 27, May 8, and June 1, 2026, Resident CR 1 continued to report wanting to leave the facility. The Psychiatric Mental Health Nurse Practitioner documented ongoing anxiety related to leaving the facility and increased medication on May 8, 2026, because Resident CR 1 persistently packed belongings and expressed the intent to leave.
Psychology and social services documentation demonstrated the resident ' s continued exit seeking behaviors. On March 25 and April 22, 2026, Resident CR 1 reported plans to return home and stated belongings had been packed in preparation for leaving. On May 5, 2026, Resident CR 1 requested information about obtaining an apartment. On June 17, 2026, the psychologist again documented Resident CR 1 remained focused on leaving the facility and returning home.
The clinical record demonstrated concerns regarding Resident CR 1 ' s use of mobility equipment. Progress notes documented that the Wander guard device was missing on May 17, 2026, and staff reapplied a functioning device on May 21, 2026.
On June 10, 2026, the occupational therapist documented Resident CR 1 was using another resident ' s wheelchair and expressed dissatisfaction with the facility issued wheelchair. The occupational therapist educated Resident CR 1 that the assigned wheelchair contained resident specific safety interventions, including the Wander guard device, a wheelchair cushion, and equipment intended to reduce the risk of injury. Resident CR 1 became upset, yelled at staff, and continued to insist the wheelchair was not hers. Nursing administration assisted Resident CR 1 back into the assigned wheelchair.
On June 11, 2026, the Social Services Director met with Resident CR 1 regarding the wheelchair incident. Despite staff intervention, Resident CR 1 continued to state an intention to leave the facility and maintained the belief that the assigned wheelchair did not belong to her. Documentation entered by the Director of Nursing on June 17, 2026, revealed Resident CR 1 experienced a fall on June 11, 2026, while using a personal wheelchair brought into the facility that did not contain the resident ' s prescribed safety interventions, including the Wander guard device. Staff subsequently removed the personal wheelchair and reissued the facility wheelchair.
A review of the June 2026 electronic treatment administration record (eTAR), an electronic record used to document treatments provided to residents, indicated staff documented verification of the Wander guard device placement and function each shift before the elopement on June 19, 2026.
A review of facility investigative documentation completed by the Director of Nursing (DON) on June 19, 2026, revealed Resident CR 1 exited the facility without staff knowledge or supervision. According to the investigative documentation, video surveillance showed Resident CR 1 holding the exterior entrance door open for an ambulance attendant at 6:35 PM. At 6:37 PM, Resident CR 1 independently propelled the wheelchair through the exit, traveled along the sidewalk, and entered the facility parking lot.
The investigative documentation revealed that at 6:38 PM, Employee 1, Nurse Aide (NA), observed Resident CR 1 in the parking lot while leaving the building for a scheduled break and immediately summoned assistance. At 6:40 PM, Employee 8, Registered Nurse Supervisor (RNS), responded to the parking lot, assisted Resident CR 1 back into the facility, notified the Director of Nursing, and initiated continuous one to one observation.
On June 30, 2026, at 11:15 AM, the surveyor reviewed the video surveillance in the presence of the Director of Nursing. The video confirmed the facility ' s investigative findings, and Resident CR 1 had a cigarette in her mouth throughout the recording. During an interview conducted on June 30, 2026, at 12:00 PM, the Nursing Home Administrator (NHA), Director of Nursing, and regional consultant were unable to explain how Resident CR 1 obtained the cigarette or other smoking materials despite the facility operating as a smoke free facility.
During a telephone interview conducted by the surveyor on June 30, 2026, at 11:53 AM, Employee 1, Nurse Aide, stated that on June 19, 2026, while leaving the building for a scheduled break, Employee 1 observed Resident CR 1 propelling the wheelchair into the center of the parking lot with a cigarette in the resident ' s mouth. Employee 1 reported Resident CR 1 appeared to be looking for a way to light the cigarette and stated she was looking for her husband. Employee 1 immediately requested assistance from an ambulance attendant returning another resident to the facility, who contacted staff inside the building. Employee 1 stated Resident CR 1 frequently expressed the desire to leave the facility, return home, and smoke cigarettes.
A written witness statement completed by Employee 1 and included in the facility ' s investigative documentation confirmed Resident CR 1 was using the assigned facility wheelchair at the time of the elopement. The statement documented that the prescribed Wander guard device was not attached to the wheelchair. Employee 1 documented staff searched Resident CR 1 ' s room but were unable to locate the missing Wander guard device. Employee 1 also reported asking Resident CR 1 where the cigarette had been obtained; however, Resident CR 1 did not provide an answer.
Although the June 2026 eTAR documented staff verified the Wander Guard device every shift. The facility was unable to determine when the device was removed or how Resident CR 1 exited the building without the prescribed electronic device attached to the assigned wheelchair or her person.
During a telephone interview conducted on June 30, 2026, at 1:45 PM, Employee 2, the ambulance attendant, stated that on June 19, 2026, the exterior entrance door was unlocked remotely after Employee 2 pressed the entrance call button. As Employee 2 opened the exterior door to assist another resident into the building, Resident CR 1 independently exited the facility. Employee 2 stated Resident CR 1 had a cigarette in her mouth and initially believed Resident CR 1 intended to smoke outside because other residents were observed smoking in designated outdoor areas. Video surveillance confirmed Resident CR 1 independently opened the first interior door before exiting through the exterior entrance as Employee 2 entered the building.
Additional facility investigative documentation showed Employee 3, Licensed Practical Nurse (LPN), observed the Wander guard device attached to Resident CR 1 ' s wheelchair and functioning properly at 3:00 PM on June 19, 2026. Employee 6, Nurse Aide, documented Resident CR 1 received the evening meal at 4:40 PM without unusual behaviors. Employee 5, Licensed Practical Nurse, observed Resident CR 1 independently propelling the wheelchair to the resident ' s room at 5:20 PM. Employee 4, Nurse Aide, documented Resident CR 1 remained in the room speaking with the roommate at 6:00 PM, and Employee 7, Nurse Aide, documented Resident CR 1 continued speaking with the roommate at 6:20 PM.
Employee 8 Registered Nurse Supervisor (RNS) provided a statement describing being called to the parking lot at 6:40 PM on June 19, 2026, via a phone call from the ambulance attendant, assisted Resident CR 1 back into the facility, contacted the DON and initiated continuous individual observation for Resident CR 1.
Documentation completed by the Director of Nursing on June 20, 2026, summarized the elopement event, documented placement of a new Wander guard device on Resident CR 1 ' s left ankle, and noted plans to transfer Resident CR 1 to a secured unit.
Facility investigative documentation also included documentation identifying residents who required Wander guard devices on June 19, 2026. The record identified 12 residents as requiring electronic elopement prevention devices.
During an interview conducted on June 30, 2026, at 12:30 PM, the Nursing Home Administrator and Director of Nursing confirmed Resident CR 1 had a well documented history of wandering into resident rooms, lounges, and vacant rooms, taking items belonging to other residents, and using mobility devices that did not belong to the resident.
Based on the clinical record, facility investigative documentation, video surveillance, staff interviews, and administrative interviews, the facility knew Resident CR 1 had demonstrated persistent exit seeking behaviors, repeatedly expressed the intent to leave the facility, required an ordered Wander guard device, and had a history of using mobility devices that did not belong to the resident. Despite this knowledge, the facility failed to implement additional individualized interventions as Resident CR 1 ' s behaviors escalated, failed to ensure the prescribed Wander guard device remained in place, and failed to prevent Resident CR 1 from exiting the facility without staff knowledge or supervision.
As a result of the facility ' s noncompliance, Resident CR 1 exited the facility without staff knowledge or supervision and entered the facility parking lot. Despite months of documented exit seeking behaviors, repeated unsuccessful attempts at redirection, repeated use of mobility devices that did not belong to Resident CR 1, a previous incident in which the Wanderguard device was missing, and a physician ' s order requiring continued use of the Wanderguard device, the facility continued to rely primarily on the electronic Wanderguard system and routine redirection.
The facility did not implement additional individualized interventions as Resident CR 1 ' s behaviors escalated and did not ensure the prescribed Wanderguard device remained in place before Resident CR 1 exited the building without staff knowledge or supervision. Because the facility used the same electronic elopement prevention system and staff supervision to protect all residents it had identified as being at risk for elopement, the deficient practice placed Resident CR 1 and other similarly situated residents in Immediate Jeopardy because it created a likelihood of serious injury, serious harm, impairment, or death.
The survey team notified the facility of the Immediate Jeopardy on June 30, 2026, at 1:25 PM and provided the Immediate Jeopardy template at that time.
In response, the facility submitted a written Immediate removal plan on June 30, 2026, at 3:43 PM, and revised plans at 4:37 PM and 5:47 PM. The corrective action plan submitted by the facility included the following measures:
1. Resident CR 1 was placed on continuous one-to-one observation until discharge, applying a new Wanderguard device. Elopement evaluations were completed on all residents identified as being at risk for elopement
2. Current residents at risk for elopement were reviewed to ensure electronic devices were in place and care plans had appropriate interventions.
3. Residents who have Wanderguards will be checked every hour for placement of the device after 4:30 PM until bedtime. Residents who refuse the Wanderguard device will have documentation of refusal and interdisciplinary team meeting will discuss alternative interventions.
4. Education will be provided to all staff on the elopement policy.
5. Audits of corrective actions will be completed daily for seven days, weekly for three weeks, and monthly for two months and reported to the Quality Assurance Performance Improvement department.
6. The individual responsible for overall monitoring of the individualized plan of correction is the NHA or designee.
On June 30, 2026, at 10:30 AM, in the presence of the Assistant Director of Nursing (ADON), the surveyor verified the placement and function of the Wanderguard devices for the 12 residents the facility had identified as being at risk for elopement. The Assistant Director of Nursing demonstrated the testing process using the facility ' s electronic testing device, which displayed a green indicator confirming proper device function.
At 5:15 PM on June 30, 2026, the facility identified five additional (Resident 13, 14, 15, 16, & 17) residents as being at risk for elopement. Surveyors again observed the Assistant Director of Nursing evaluated the placement and function of the Wanderguard devices. During this verification, the electronic testing device displayed a red indicator showing the Wanderguard devices assigned to Resident 16 and Resident 17 were not functioning properly. The malfunctioning devices were immediately replaced by facility staff.
After verification of the facility ' s corrective actions, including observation of the placement and function of Wanderguard devices for all residents identified as being at risk for elopement, review of resident photographs maintained for elopement identification, staff interviews, verification of staff education, and observation of the facility ' s elopement prevention processes, the Immediate Jeopardy was determined to have been removed on July 1, 2026, at 12:15 PM.
28 Pa. Code 201.18 (e)(1) Management.
28 Pa Code 211.10 (a)(c) Resident care policies.
28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 07/15/2026
1. Resident CR1 no longer resides at facility.
2. Care plans of current residents with moderate to high-risk elopement score will be reviewed and revised by IDT for individualized interventions to reduce the resident risk for elopement.
3. All staff to be reeducated on monitoring documenting and reporting any new behaviors to ensure appropriate intervention are implemented as needed. Documentation will be reviewed by IDT at daily standup to ensure proper individualized interventions are implemented.
4. Results of documentation review will be taken to QAPI meeting monthly x 3 for review and recommendations.
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