Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with moderate cognitive impairment was able to leave the facility unsupervised during nighttime hours. The resident was observed to be capable of moving herself in a wheelchair, though not quickly. On the evening of the incident, the resident exited the facility while wearing a nightgown and carrying a bag of belongings. The facility's front door alarm was triggered, but there was no receptionist present at the time to respond. Staff were not alerted by the alarm; instead, a visitor noticed the resident outside and rang the doorbell to alert staff. According to written statements and the facility's elopement investigation timeline, the resident exited the building at 9:23 PM and was not brought back inside until approximately 9:34 PM. The staff only became aware of the situation after being notified by a visitor, not through their own monitoring or the alarm system. This sequence of events demonstrates a failure to provide adequate supervision and to ensure the area was free from accident hazards, as required for residents with cognitive impairments.