Failure to Accurately Assess Dementia-Related Elopement Risk Leading to Resident Elopement
Summary
The deficiency involves the facility’s failure to ensure a resident with a diagnosis of dementia received necessary care and services related to dementia, specifically in the assessment and management of elopement risk. The resident’s admission record documented dementia, bipolar disorder, and insomnia, and the history and physical indicated the resident lacked capacity to understand or make decisions. The MDS assessment showed impaired cognition for daily decision-making and a need for supervision with ADLs. The resident’s care plan identified cognitive status that could increase the risk of wandering or exit seeking and called for assessment of elopement/wandering risk on admission, quarterly, and as needed. Despite these documented conditions and risk factors, the Wander/Elopement Risk Evaluation completed for the resident on 4/6/2026 did not indicate a diagnosis of dementia or any other diagnosis impacting decision-making and concluded the resident was not an elopement or wander risk. During interviews, LVN3 confirmed that the evaluation omitted dementia and other cognition-impacting diagnoses and still indicated no elopement risk, and also stated not knowing whether the resident had a dementia diagnosis. The DON later verified that the evaluation showed no dementia or decision-making diagnosis and that, based on the resident’s assessments and risk factors, the resident had multiple risks for elopement that should have triggered an elopement risk designation under the facility’s own evaluation instructions. On 4/11/2026, nursing progress notes documented that during morning rounds the resident was found missing from the room after having been awake all night and seen self-propelling in a wheelchair in the hallway. A facility search and Code Green were initiated, and local police were notified when the resident could not be located. Review of surveillance video from the front lobby showed the resident in a wheelchair near the front door while a housekeeper worked nearby. After the housekeeper briefly left the camera’s view, the resident rapidly self-propelled around a retractable barrier and exited through an unlocked front door. The housekeeper re-entered the lobby seconds later and continued working while the resident was no longer present. This sequence of events demonstrated that the inaccurate elopement risk assessment contributed to the resident eloping from the facility.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, psychosis, and a history of aggressive behaviors had a care plan calling for calm approaches, redirection, re-approach after de-escalation, non-judgmental support, and other non-pharmacological interventions. During a behavioral episode in which the resident entered another resident’s room and both began hitting each other, staff separated them and physically controlled the resident by "arm to arming" him to a chair near the nurses’ station, repeating this when he tried to get up and became argumentative. Documentation did not describe specific de-escalation or non-pharmacological measures used, and staff reported limited, mostly computer-based training on managing aggressive behaviors. The physician later indicated the resident’s behaviors were instigated by staff and that forceful handling could provoke retaliatory responses, while the facility’s behavior management policy required individualized, non-pharmacological strategies before or alongside psychotropic medication use. This resulted in a deficiency for not providing appropriate behavioral interventions consistent with the resident’s care plan.
A resident with Alzheimer's Dementia, chronic pain, and diabetes was rarely or never understood, had short-term memory problems, made poor decisions, and needed extensive ADL assistance. The EHR showed no care plan for the dementia diagnosis and no behavior monitoring on the MAR, and an RCM/LPN stated they could not locate a dementia care plan for the resident.
The facility failed to provide individualized dementia-focused treatment, activities, and supervision for several cognitively impaired residents on a memory unit. Care plans did not identify residents’ activity preferences or specify meaningful, personalized activities despite documented dementia, behaviors, and need for assistance. Observations showed residents sitting idle, wandering aimlessly, entering cupboards and rooms, yelling out, and one resident repeatedly exposing herself, while an activity aide only played music or passed donuts and drinks without engaging residents in structured activities. Nursing notes documented frequent falls related to self-transfers, physical altercations, feces smearing, and ongoing intimate contact between two residents despite a family member’s explicit request that they be kept apart. Staff interviews revealed that there had been no consistent activities on the unit, residents were largely unsupervised while staff performed care and med passes, and staffing levels were below required ratios, leaving only two aides for about 30 residents. The deficiency was cited under state regulations for resident care planning and nursing services.
Failure to provide person-centered dementia care and services: A resident with severe dementia, anxiety, and diabetes was repeatedly observed calling out for help while lying or sitting in a hospital gown with poor grooming and minimal stimulation in her room. Staff described her as easily overstimulated, needing one-on-one attention, and having worsening confusion and refusals of care, yet her activity plans were conflicting and did not include her known preferences such as classical music, the Beatles, quiet settings, or individualized sensory interventions. Records also showed no recent activity participation, and staff stated no dementia-specific interventions were in place beyond routine activities.
A resident with dementia and a history of intrusive wandering and agitation was found lying in another resident’s bed despite care plans directing staff to redirect her to her own room or a quiet area. A laundry aide identified the room but did not redirect the resident or notify nursing staff, and an MCSS initially looked into the room and left before being informed the resident was still there. The other resident became visibly upset and stated the resident did not belong in the room.
A resident with severe dementia and significant behavioral symptoms, including wandering, aggression, public disrobing, inappropriate urination/defecation, and sexually inappropriate behavior toward female residents, was admitted and later readmitted to a secured unit. Despite known history from a prior facility and ongoing documentation of escalating behaviors, the care plans remained generic and were not revised to address specific risks such as entering female residents’ rooms naked, insisting they were his wife, attempting to get into bed with them, or the need for one-to-one supervision. Staff reported that female residents were afraid and barricading their doors, while leadership minimized or did not recognize the behaviors as sexually inappropriate and did not act on staff concerns. An incident occurred in which the resident, naked from the waist down, refused redirection, physically assaulted an LPN, then entered a female resident’s room and attempted to get into her bed, causing her to fall while trying to escape. Surveyors found that these actions and inactions constituted a failure to provide necessary dementia care and treatment to maintain the safety and well-being of residents on the secured unit.
Failure to Implement Care-Planned Behavioral Interventions for Dementia-Related Episode
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate, necessary, and effective interventions for a resident with dementia and behavioral symptoms, as outlined in his care plan. The resident was admitted with vascular dementia, unspecified psychosis, depression, seizure disorder, cognitive communication deficit, unsteadiness on feet, and muscle weakness, and had a care plan addressing behaviors such as restlessness, anxiety, physical aggression, hallucinations, delusions, exit seeking, verbal aggression, and wandering. The care plan interventions included approaching the resident calmly, re-approaching later if he became agitated, attempting redirection, communicating care before tasks, providing non-judgmental support, keeping him safe during behavioral episodes, documenting behaviors, notifying the physician when behaviors persisted, and using non-pharmacological interventions and activities of interest to keep him engaged. On the evening of the incident, during a medication pass, an RN heard yelling and arguing from another resident’s room and found the cognitively impaired resident standing by a female resident’s bed while both residents were hitting and smacking each other. The resident was yelling at the female resident to get out of his bed. The RN attempted to separate the residents and diffuse the situation, and an unidentified CNA took the resident to the nurses’ station, where he continued to be physically abusive and verbally aggressive toward staff. The physician was notified and new orders were obtained for Haldol and Depakote, and the resident’s son consented to the new medications. The resident was later taken to bed and fell asleep, and the as-needed Haldol was not administered, but Depakote was started as a daily medication. The nursing progress note did not document specific details on how staff attempted to diffuse the situation or what non-pharmacological interventions were used in response to this behavioral episode. Subsequent documentation indicated that the resident had been reported to the physician as having increased agitation and aggressive behaviors with psychotic issues, and that Depakote had been started in response to the incident. The physician later documented that the resident was being treated inappropriately and that his behaviors were instigated by staff, describing the resident as being in a protective mode and stating that he had been told a CNA grabbed the resident. The physician stated that staff should have tried redirection without force, removal from the provoking area, and other calming strategies, and that holding down a cognitively impaired resident could elicit a retaliatory response. CNAs interviewed about the incident reported that they “arm to armed” the resident by wrapping their arms around his arms to move him from the other resident’s room to a chair near the nurses’ station, and that when he stood up and became argumentative or went toward a CNA, they again “arm to armed” him back into the chair. One CNA reported that additional staff from another floor came up and that this likely worsened the resident’s agitation and was overwhelming for him. Multiple CNAs stated they did not feel properly trained to deal with aggressive behaviors, reporting only limited or computer-based training and describing that management’s guidance was mainly to offer food or snacks during behaviors, which contrasted with the more comprehensive behavioral management approach described in the facility’s behavior management policy and the resident’s care plan. The facility’s behavior management policy required that residents exhibiting behaviors negatively affecting themselves or others be reviewed by a behavior management team, that root causes and target behaviors be identified, and that individualized plans of care and non-pharmacological interventions be used to minimize the need for medications or allow for the lowest possible dose. In this case, the record and interviews did not show that the non-pharmacological, de-escalation, and redirection strategies specified in the resident’s care plan and the facility’s policy were effectively implemented or documented during and after the behavioral episode. Instead, staff used physical control techniques (“arm to armed”) and obtained new psychotropic medication orders without clear evidence of prior, thorough use of individualized, non-pharmacological interventions as outlined in the care plan and policy. This failure to follow the resident’s behavior care plan and the facility’s behavior management program requirements led to the cited deficiency for not ensuring the resident received appropriate treatment and services for dementia-related behaviors.
Missing Dementia Care Plan and Behavior Monitoring
Penalty
Summary
Failure to provide appropriate treatment and services for a resident with dementia was identified for Resident 9, who was admitted with diagnoses of Alzheimer's Dementia, chronic pain, and diabetes. The resident was rarely or never understood, had short-term memory problems, made poor decisions, and required extensive assistance with activities of daily living. Review of the electronic health record showed there was no care plan specifically addressing Alzheimer's Dementia, and the April 2026 MAR showed no behavior monitoring in place related to the dementia diagnosis. During interview, the RCM/LPN stated they were unable to locate a care plan for Resident 9 related to dementia care and stated the expectation was that residents have an individualized care plan addressing all areas of care.
Failure to Provide Individualized Dementia Care, Activities, and Supervision on Memory Unit
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide appropriate treatment and services for multiple residents with dementia residing on the Memory Impaired Unit (MIU). The facility’s own assessment dated April 6, 2026 stated that the MIU offers specialized cognitive activities provided by staff trained in dementia care and that Life Enrichment staffing should include one full-time director and three full-time aides. However, review of care plans and observations showed that residents with dementia did not have individualized activity preferences identified or implemented. For example, quarterly MDS assessments for four cognitively impaired residents with dementia (Residents 9, 10, 11, and 12) showed needs for staff assistance and, in some cases, independent ambulation and behaviors, yet their care plans either failed to identify activity preferences or contained only vague, non-individualized directions such as providing activities resembling a prior lifestyle without specifying what those activities were. Observations on the MIU over two days showed that residents were not being engaged in meaningful or structured activities despite the unit’s stated purpose. On one day, 14 residents were observed sitting around tables in the common room while an activity aide played music but did not engage them in any activity. One resident repeatedly pulled her shirt over her head, exposing her breasts, and staff were not consistently present in the common room to address this behavior. No further activities were observed that day. On the following day, an activity aide brought a coffee cart with donuts and drinks, but service to residents was delayed, two residents were not offered any items, and no group activity or engagement occurred. During these observations, residents were seen wandering aimlessly, getting into cupboards and drawers, yelling out, or sitting and sleeping in the common area without stimulation. Clinical record review and nursing notes documented frequent falls and behavioral incidents among the cognitively impaired residents. One resident (Resident 9) was involved in a physical altercation in which he punched his roommate in the face. Another resident (Resident 10) experienced numerous falls over a span of weeks and months, often while attempting to self-transfer from bed, chairs, or to the bathroom, and was also noted to remove her ostomy bag and smear feces in various places. Residents 11 and 12, both with dementia and independent ambulation, were repeatedly documented as engaging in close physical contact, including holding hands, attempting to leave the unit together, and being found in bed together with exposure noted, despite a family member’s clear request that they be separated and that contact not be permitted or encouraged. Staff interviews revealed that there had not been activities in the MIU for some time, that residents wandered the locked unit without redirection while staff were occupied with care and medication administration, and that staffing levels were below the facility’s own requirements, leaving only two nurse aides for 30 residents at times. The Nursing Home Administrator acknowledged that staffing was out of compliance and that the facility was unable to meet necessary nurse aide ratios or daily PPD, contributing to the failure to provide appropriate dementia-specific treatment and services. The deficiency was cited under 28 Pa. Code 211.11(d) Resident care plan and 28 Pa. Code 211.12(d)(5) Nursing services, based on the lack of individualized activity care planning for residents with dementia, the absence of consistent, specialized cognitive activities and engagement on the MIU, the unmanaged wandering and behavioral issues, and the inadequate staffing that left residents largely unsupervised and without appropriate redirection or structured activities.
Failure to Provide Person-Centered Dementia Care and Services
Penalty
Summary
The facility failed to provide person-centered dementia-specific care and services for a resident with diagnoses including type II diabetes mellitus with diabetic neuropathy, unspecified dementia with agitation, and anxiety disorder. The resident was repeatedly observed lying in bed or sitting in a wheelchair in a hospital gown, with unkempt grooming at times, including tangled or greasy hair, a soiled bandage on the upper right forehead with dried dark substance around it, and long fingernails with dark debris under them. Her room often contained only a television on a news station, with no other sensory stimulation observed, while she was heard repeatedly calling out, "help, help, help me please." Facility staff described the resident as having severe dementia that had worsened after returning from the hospital. The wound NP stated she was confused, often refused turning/repositioning and insulin, and no longer could have mildly coherent conversation, instead repeatedly saying "help help, please help me" even when her needs had been met. An LPN stated the resident used to answer some yes/no questions but now mostly said "help help help," and staff did not know what activities would help beyond visiting with her. Another LPN stated the resident was easily overstimulated, preferred one-on-one time, and most enjoyed someone sitting with her or holding her hand at all times. The resident’s record showed prior documentation that her guardian and the facility agreed she would be better suited for an all-female dementia care unit, and later notes stated she would benefit from a dementia unit and might transition there once Medicaid was approved. Her activity care plans were conflicting, with one indicating she was self-directed and another indicating she was dependent on staff for activities, cognitive stimulation, or social interaction. Neither plan included her documented preferences such as the Beatles, classical music, one-on-one discussion approaches, or other sensory interventions. Activity records showed no coded activities for the prior 30 days, and she was not observed in activities on multiple days. The social service director stated no dementia-specific interventions were in place besides routine activities, and the guardian stated staff needed to be more proactive and dementia-aware, noting the resident did better in small quiet environments and liked music and books.
Failure to Redirect Resident with Dementia from Another Resident’s Bed
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with dementia who displayed intrusive wandering and agitation. Resident 4’s clinical record showed diagnoses including dementia and multiple behavior care plans directing staff to redirect her to her own room or a quiet area, offer calm reassurance, and have her lay down when she became verbally or physically aggressive or wandered into other residents’ rooms. Despite these care plan interventions, Resident 4 was observed lying in another resident’s bed in a shared room on the memory care unit, with her eyes closed, while the door remained open and the other resident entered and then shut the door with Resident 4 still in the bed. During the observation, a laundry aide who was in the adjacent room came to the doorway, identified whose room it was, and left without redirecting Resident 4 or notifying nursing staff that she was in another resident’s bed. The Memory Care Support Specialist later came to the room, looked inside, and left before being informed that Resident 4 was still there; after being told, the MCSS entered to address the situation while the other resident repeatedly stated, in a raised and irritated voice, that Resident 4 did not belong in the room. The Memory Care Unit Manager stated that when Resident 4 was found in another resident’s bed, staff would normally redirect her to her own room and indicated the laundry aide should have redirected her or informed nursing staff.
Failure to Provide Adequate Dementia Care and Behavior Management on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary dementia care and treatment to maintain the safety and well-being of residents on the secured dementia unit, particularly one resident with severe vascular dementia and significant behavioral symptoms. The resident was admitted with diagnoses including severe vascular dementia without behavioral disturbance, major depressive disorder, alcohol dependence with alcohol-induced persisting dementia, anxiety disorders, restlessness, and agitation. Physician orders over time included multiple psychotropic and mood-stabilizing medications (Depakote, Zyprexa, Ativan, Rexulti) and an order for placement on the secured unit. A quarterly MDS assessment documented that the resident was severely cognitively impaired, exhibited hallucinations, delusions, physical behaviors toward others, other behavioral symptoms, rejection of care, and wandering, and required maximum assistance for all personal care except eating. From admission through discharge, nursing progress notes documented escalating and persistent behaviors, including wandering into other residents’ rooms, placing clothes and items in toilets, exit-seeking, and increasing agitation and aggression. Early in the stay, staff documented incidents such as the resident exposing himself and urinating on the floor and wall, with staff providing redirection and cleaning. Over time, the resident was repeatedly found in female residents’ rooms, sometimes naked, engaging in inappropriate sexual behavior on their beds, defecating in hallways, and attempting to rub feces on other residents. The resident was transferred for psychiatric evaluation when the psychiatric practitioner indicated the facility was unable to manage his behaviors, and upon readmission he was placed on one-to-one supervision and moved between unsecured and secured units due to a COVID-19 outbreak. Despite these measures, his behaviors of wandering into female residents’ rooms, insisting they were his wife, inappropriate elimination, and physical aggression toward staff and residents continued. Care plan review showed that a behavior care plan and a mood/behavior care plan were initiated early in the stay, with generic interventions such as encouraging social activities, explaining things in a way the resident could understand, administering medications as ordered, monitoring labs, charting behaviors, observing for early warning signs, and consulting psychiatric services. The behavior care plan was last revised on a date that did not reflect the later, more severe behaviors, and the mood/behavior care plan was never revised during the resident’s stay. The care plans did not address specific risks or interventions related to the resident entering female residents’ rooms naked, insisting they were his wife, attempting to get into bed with them, or the use of one-to-one supervision upon readmission. Referral information from the prior facility indicated that the same types of behaviors had been present before admission. Staff and administrator interviews revealed that female residents were afraid of the resident, some were barricading their doors, and that the administrator did not initially consider the resident’s naked entry into female residents’ rooms and attempts to get into bed with them as sexually inappropriate behavior. A documented incident described the resident in the hallway with genitals exposed, refusing redirection, becoming physically aggressive with an LPN, and then entering a female resident’s room naked, claiming she was his wife, and forcefully attempting to get into her bed, leading to the female resident falling out of bed while trying to get away. These events occurred despite the facility’s written dementia care policy, which described person-centered, individualized approaches and staff training for managing dementia-related behaviors, and led surveyors to determine that the facility failed to provide necessary dementia care and treatment for this resident, with the potential to affect all residents on the secured unit. Interviews with staff and leadership further detailed the actions and inactions contributing to the deficiency. An anonymous employee reported that staff concerns about the resident’s behaviors, including entering rooms naked and frightening female residents, were repeatedly brushed off by the administrator until after a female resident fell and subsequently did not walk as before. The administrator acknowledged being aware that the resident had a history of behaviors at the prior facility, including inappropriate urination, wandering, and minimal sleep, and that he believed female residents were his wife. The administrator also stated she did not conduct an on-site review before admission based on advice from the former admissions/marketer director and was initially hesitant to accept the resident. Despite a prior transfer for psychiatric evaluation due to the facility’s inability to manage his behaviors, the administrator decided to readmit him, believing the secured unit could handle his needs. The administrator reported receiving emails from families requesting the resident’s discharge and was unaware that female residents were barricading their doors because staff did not inform her. The combination of inadequate behavior-specific care planning, failure to adjust interventions in response to ongoing and escalating behaviors, and leadership’s handling of staff and resident concerns led to the determination that the facility did not provide appropriate dementia care and services to ensure the safety and well-being of residents on the secured unit.
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