Patterson Healthcare Center

In the surveyor’s words

From the most serious findings on record at Patterson Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 4, 2023

  Based on observations, interviews and record reviews, the facility failed to have a system in place to ensure staff increased supervision to prevent elopement for severely cognitively impaired residents who displayed exit seeking behaviors for 2 (#1 and #3) of 7 (#1-#7) sampled residents to prevent elopement. The Immediate Jeopardy situation began on 08/01/2023 at approximately 1:00 a.m. when Resident #1, a severely cognitively impaired resident, eloped from the facility without the facility staff's knowledge. On 08/01/2023 at approximately 1:00 a.m., Resident #1 climbed through his bedroom window and exited the facility grounds through the unlocked fence located at the end of Hall W. […]

• Immediate jeopardy, isolatedF835Aug 4, 2023

  The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to provide supervision to keep a resident free from elopement for 2 (#1 and #3) of 7 (#1 - #7) sampled residents. The facility failed to: 1. Ensure Resident #1, a severely cognitively impaired resident, who was care planned for wandering, was accurately assessed and/or adequately supervised when exit seeking behaviors were displayed; and 2. Ensure Resident #3, a severely cognitively impaired resident, was accurately assessed and adequately supervised when exit seeking behaviors were displayed. The Immediate Jeopardy situation began on 08/01/2023 at approximately 1:00 a.m. […]

• No harm, potential for more than minimal, patternF689Dec 10, 2025

  Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision to a resident to prevent accidents for 1 (Resident #66) of 4 sampled resident investigated for accidents/hazards. Findings:Review of Resident #66's electronic medical record (EMR) revealed, in part, Resident #66 had diagnoses, which included, Alzheimer's disease, dementia, and an altered mental status. Review of Resident #66's Care Plan Conference summary dated 10/01/2025 revealed, in part, Resident #66 had Alzheimer's disease and was consuming non-food items which could cause harm to Resident #66. […]

• No harm, potential for more than minimal, patternF755Dec 10, 2025

  Based on interviews and record reviews, the facility failed to ensure the verification of controlled substances count sheet was completed every shift. This deficient practice was identified for 2 (Medication Cart a, Medication Cart b) of 2 medication carts reviewed for controlled substance reconciliation. Findings:Review of facility's Controlled Substances policy, with a revision date of November 2022, revealed, in part, the nurse coming on duty and the nurse going off duty would count the controlled substances together and document the controlled substances count. […]

• No harm, potential for more than minimal, patternF689Dec 11, 2024

  Based on observations, interviews, record reviews, and facility document review, it was determined the facility failed to ensure a resident that was cognitively impaired and had a high risk of falls had appropriate interventions to prevent future falls for 1 (Resident #12) of 2 residents reviewed for accidents. Findings included: The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/30/2024 revealed, in part, Resident #12 was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #12 had moderate cognitive impairment, and was dependent on staff for toileting transfers. […]