§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 review of facility policy, review of clinical records, review of facility documentation, and staff interview it was determined that the facility failed to provide adequate supervision for one of five residents reviewed (Resident R1).
Findings Include:
Review of facility policy titled, "Elopement, Unescorted Exit" last revised July 2023 states, "Policy- To strive to report an unauthorized, unescorted, and/or unsafe exit of a cognitively impaired resident from the community and to locate and report any resident suspected of being missing."
Review of Resident R1's clinical record revealed the resident was admitted to the facility on June 26, 2026 with a diagnosis of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), disorientation (state of mental confusion where a person loses their sense of direction, position, or awareness of time, place, and identity), Anxiety (intense, excessive, persistent worry or fear), Hypertension (high blood pressure), Insomnia (you have trouble falling asleep, staying asleep, or waking up too early), and Epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures).
Further review of Resident R1's clinical record revealed a Brief Interview for Mental Status (BIMS) assessment dated July 2, 2026, with a documented score of 9, indicating moderate cognitive impairment.
Review of facility documentation submitted to the State Survey Agency revealed on July 7, 2026, at approximately 7:49 p.m., the facility received a call from a resident of the independent living unit of the community to report that Resident R1 was on her patio. Resident R1 previously resided in the independent living unit of the community and was good friends/neighbors with this other resident. Resident R1 reported to the supervisor that it was a nice day, and he/she wanted to get some fresh air and to take a walk. Resident R1 did not sign him/herself out from the skilled unit prior to leaving and reported being unaware he/she was unable to leave on his/her own.
Continued review of facility documentation submitted to the State Survey Agency revealed per a review of surveillance footage showed Resident R1 exiting through an interior door at 6:56 p.m. and entered the independent living section as an independent living resident entered through the same doorway. At 7:04 p.m. surveillance showed an environmental services employee silencing the wander guard door alarm and exiting through the doorway. The employee reported hearing the alarm, seeing no one nearby, and silencing it. Further review of facility documentation revealed staff on duty did not recall receiving pager alerts. Reviews of pagers found no elopement notifications, and several displayed garbled messages.
Interview on July 23, 2026, at 10:00 a.m. with Nursing Home Administrator, Employee E1, revealed when Resident R1 was initially admitted to the unit, his/her family continued to take the resident back to his/her apartment in the independent living unit of the community. NHA, Employee E1, stated all new admissions have a wander guard applied for the first 72-hours after admission and that Resident R1's was continued due to concerns with cognition.
Continued interview on July 23, 2026, at 10:00 a.m. with Nursing Home Administrator, Employee E1, revealed nursing staff carry pagers that will send an alert when the wander guard alarm is triggered. Nursing Home Administrator, Employee E1, confirmed the pagers for nursing staff did not receive an elopement notification and further confirmed the wander guard alarm (that was triggered by Resident R1) was turned off by environmental services employee, Employee E3.
Review of the facility camera footage showed as independent living unit resident, Resident R2, entered through the doors into the skilled unit, Resident R1 exited the unit into the independent living unit. At 7:04 p.m. environmental services, Employee E3, is observed to disarm the alarm and continued to exit the unit.
Interview on July 23, 2026, at 1:00 p.m. with the environmental services laundry aide, Employee E3, revealed he/she heard the alarm sounding at the door as he/she was leaving and subsequently turned it off. Laundry aide, Employee E3, stated he/she looked around and did not see anyone, so he/she then proceeded to leave.
The Nursing Home Administrator, Employee E1, on July 23, 2026, at 1:44 p.m. confirmed Resident R1 was able to leave the unit, and wander to the adjacent independent living unit space.
28 Pa Code 201.18 (b)(1) Management
28 Pa Code 211.10 (d) Resident care policies.
28 Pa Code 211.12 (d)(5) Nursing services.
| | Plan of Correction - To be completed: 07/31/2026
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and state law.
1. Resident JF returned safely to WBC on 7/7/26 and was placed on every 30 minute checks for safety. Wanderguard remained on and functioning. Nursing supervisor responsible.
1. On 7/8/26, Wanderguard system checked by Corporate Director of Safety and the community's Director of Safety to ensure functionality of the system. Director of Security/NHA responsible.
2. Vendor on site within 48 hours and determined there was a failure within the wanderguard system, requiring repair. Director of Maintenance/NHA responsible.
3. Twenty-four hour monitoring placed for exit door to prevent any further episodes of elopement while wanderguard system was being repaired. DON/NHA responsible.
4. Elopement training completed across departments. NHA/DON/Department Managers responsible.
5. Education provided to independent living residents and WBC family members on procedure for exiting WBC. NHA/Executive Director responsible.
6. Will continue to conduct wander risk assessments as per policy. DON and or designee responsible.
7. Residents at risk for elopement had their care plans reviewed. DON and or designee responsible.
8. Signage placed on the doors of WBC alerting visitors to be mindful of residents that may be in the vicinity of the exit. NHA responsible.
9. Weekly pager compliance audits implemented and being completed and will be reported at QAPI x 6 months. DON and/or designee responsible.
10. Elopement drills to be conducted monthly x 6 months. NHA responsible.
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