PR SNF Operations LLC

In the surveyor’s words

From the most serious findings on record at PR SNF Operations LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 17, 2023

  Based on record review and staff interview the facility failed to protect the residents' right to be free from neglect. The facility failed to revise the care plan and closely supervise 2 (Resident #1, and #2) of 6 sampled cognitively impaired residents with known exit seeking behavior and/or identified to be at risk for unsafe wandering and elopement. On 1/23/23 at approximately 6:25 p.m., Resident #1 who was cognitively impaired with previous elopement attempt walked out of the facility without staff knowledge. A visitor alerted the staff Resident #1 was walking away in the parking lot. On 2/8/23 at approximately 3:00 a.m., Resident #2 who was cognitively impaired with wandering behavior walked out of the facility without staff knowledge. […]

• Immediate jeopardy, isolatedF689Feb 17, 2023

  Based on observation, record review, and staff interviews, the facility failed to implement processes to ensure adequate supervision of 2 (Resident #1 and #2) of 6 sampled cognitively impaired resident at risk for elopement to prevent unsafe wandering and elopement. On 1/23/23 at approximately 6:25 p.m., Resident #1 who was a vulnerable cognitively impaired with previous elopement attempt walked out of the facility without staff knowledge. A visitor alerted the staff Resident #1 was walking away in the parking lot. On 2/8/23 at approximately 3:00 a.m., Resident #2 who was cognitively impaired with wandering behavior walked out of the facility without staff knowledge. […]

• Immediate jeopardy, isolatedF835Feb 17, 2023

  Based on observation, record review and staff interview the facility's Administration failed to utilize its resources effectively to prevent neglect and ensure cognitively impaired residents at risk for elopement were free from unsafe wandering and elopement. On 1/23/23 at approximately 6:25 p.m., Resident #1 who was cognitively impaired with previous elopement attempt walked out of the facility without staff knowledge. A visitor alerted the staff Resident #1 was walking away in the parking lot. On 2/8/23 at approximately 3:00 a.m., Resident #2 who was cognitively impaired with wandering behavior walked out of the facility without staff knowledge. […]

• Immediate jeopardy, isolatedF867Feb 17, 2023

  Based on record review, review of the facility's policies and procedures, resident, and staff interviews the facility failed to develop and implement appropriate corrective actions related to adequate supervision of cognitively impaired residents at risk for elopement and exit seeking behaviors. Resident #1 was a vulnerable [AGE] year-old male who was in the facility for short term rehabilitation needing increase supervision. On 1/23/23 at approximately 6:25 p.m., Resident #1 who was cognitively impaired with previous elopement attempt walked out of the facility without staff knowledge. A visitor alerted the staff Resident #1 was walking away in the parking lot. […]

• Actual harm, isolatedF600Mar 19, 2025

  Based on observation, staff interview and record review, the facility failed to prevent neglect through lack of adequate assessments and supervision for a confused resident to prevent elopement from the facility for 2 (Resident #5 and #6) of 3 residents reviewed. The lack of supervision contributed to the elopement of Resident #5 and the incorrect assessment of Resident #6 who was confused and mobile via wheelchair. The findings included: Facility policy provided by the DON (Director of Nursing) for Elopement Risk with effective date of 03/2008 and last revision date of 10/2022 was defined as a situation in which a resident leaves the premises or a safe area without the community's knowledge and supervision which may represent a risk to the resident's health and safety. […]