F603

Based on observation, interview and record review, the facility failed to ensure one of 21 residents (R10) was free from involuntary seclusion, failed to ensure criteria was met for admission to the Secured Dementia Unit and failed to follow physician's guidance for resident's wellbeing to prevent a change in condition reviewed in a sample of 41.These failures resulted in R10, a cognitively intact resident with admitting diagnoses of Post-Traumatic Stress Disorder and Generalized Anxiety, to be admitted to the Secured Dementia Unit on 1/30/26 and remained in the unit until 2/26/26.These failures resulted in Immediate Jeopardy.The Immediate Jeopardy was noted to begin on 1/30/26, when the facility failed to ensure a resident was free from Involuntary Seclusion when a cognitively intact… …

Arcadia Care Toulon · Illinois

Based on medical record review, review of email communication, fall investigation review, resident and staff interview, and facility policy review, the facility failed to ensure Resident #334 was free from an incident of involuntary seclusion. This affected one resident (#334) of two residents reviewed for quality of care and services. The facility census was 119.Actual physical and psychosocial harm occurred on 06/20/26 when Resident #334, who had quadriplegia (partial or total loss of function in all four limbs) and was dependent on staff for toileting, was left alone without supervision on a toilet in a locked common bathroom requiring a code to open without evidence of a functional call signal system. …

Suburban Healthcare and Rehabilitation · Ohio

Based on interview, observation, and record review, the facility failed to keep residents free from involuntary seclusion (separation of a resident from other residents) for 2 (R #1, and R #2) of 3 (R #1, R #2, R #3) residents sampled for involuntary seclusion, when staff failed to implement and document the following: 1. The clinical criteria (rules or standards on which a decision or judgment is made to determine medical necessity) met for placement of R #1 and R #2 in the secured/locked area by R #1 and R #2's physician along with information provided by members of the interdisciplinary team (IDT team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities). 2. …

New Mexico State Veterans Home · New Mexico

Based on review of the clinical record, facility documentation and interviews for 9 of 54 residents (Resident #1, 6, 22, 57, 71, 72, 79, 100 and 126) who reside on a secure (locked) unit, the facility failed to identify the clinical criteria for, and/or document the resident/representative inclusion in, the decision for placement on the unit, and/or failed to document that information for independent egress had been provided. The findings include: 1. Resident #1's [DIAGNOSES REDACTED]. The elopement risk evaluation dated 6/29/18 identified Resident #1 was not identified at risk to wander. 2. Resident #6's [DIAGNOSES REDACTED].#6 was not identified at risk to wander. 3. Resident #22's [DIAGNOSES REDACTED].#22 was not identified at risk to wander. 4. Resident #57's [DIAGNOSES REDACTED]. …

Water's Edge Center for Health & Rehabilitation · Connecticut