The facility received an immediate jeopardy citation — the most serious level of violation — after inspectors found that administrators knew the resident hadn't returned but treated his disappearance as routine. The resident, identified only as CR#1, was eventually discharged as "against medical advice" without ever coming back to the facility.
Staff told inspectors the resident "was going out every day and never had any problems with health" and that management "estimated that CR#1 was able to take care of himself." The Director of Nursing was notified around 9:00 pm on January 16 through text message and called the resident at home, but he didn't answer. She called again early the next morning with the same result.
The Administrator said CR#1 "was not considered missing due to him frequently leaving the facility on-pass" and that "based off the conditions of CR#1 at the time and his habits, the facility felt he left the facility of his own choosing and was not in immediate danger."
But the facility's own revised policy, updated the day before inspectors arrived, requires staff to search the premises if a resident doesn't return and cannot be reached, then notify law enforcement and Adult Protective Services if the resident isn't found.
The facility had no policy addressing what to do when residents failed to return from outings until February 21, 2025 — more than a month after CR#1 disappeared. The previous sign-out policy was last revised in August 2006.
During the inspection, administrators scrambled to implement new procedures. The Director of Nursing conducted an audit of all residents who had gone out on pass in the past 30 days, identifying 15 who routinely left the facility. Staff received emergency training on February 21 about what to do when residents don't return from outings.
"The DON said if residents are not located, they could be on the street in hot or cold weather," according to the inspection report.
The facility's response revealed systemic confusion about resident rights versus safety protocols. Multiple staff members received training distinguishing between residents leaving "against medical advice" versus those who simply go out on pass and fail to return.
One in-service record noted that "out on pass isn't considered AMA if they don't return. A search must be performed as they are a missing resident."
The Regional VP of Operations and Clinical Services Director had to educate the Administrator and Director of Nursing about "ensuring adequate supervision and follow up for residents who leave out on pass and do not return."
Staff interviews during the inspection revealed the breakdown in communication. An RN said she would check residents' conditions before they left, verify contact information, and call if they didn't return according to timeline, but "no residents had left the building on-pass on 2/21/2025 that she was aware of."
A CNA working the 6 am to 2 pm shift said she was taught that "if staff have not seen residents return for eight hours, to let a nurse know and they will call the resident to find out how they are."
The night shift LVN said nurses should "initiate a search by calling the resident's RP. If staff are unable to get hold of the person, to notify the DON and Administrator."
But none of these protocols existed when CR#1 disappeared in January.
The facility now requires nursing staff to review the resident sign-out book during shift changes and contact residents or responsible parties if they've been out longer than eight hours. If they can't reach anyone, staff must notify the Director of Nursing, Administrator, and law enforcement.
The Director of Nursing will review sign-out logs daily as part of morning meetings. The facility also updated contact information for all residents and responsible parties.
Meanwhile, inspectors found multiple other safety violations during their February visit. A nursing assistant placed a foley catheter bag directly on a resident's bed during care, potentially causing urine to flow backward and trigger infection. The same assistant failed to properly clean the resident during incontinence care, leaving fecal matter that required additional cleaning.
"When CNA C separated Resident #31's buttocks, she cleaned in between the buttocks and the anal three times, and there was bowel movement on the wipes," inspectors noted.
Another nursing assistant provided care to a resident with a feeding tube while the bed was flat and tube feeding continued to infuse, creating aspiration risk. The resident's care plan specifically required keeping the head of bed elevated 45 degrees during and after tube feeding.
"If Resident #76 starts to aspirate and the resident was not found on time, that could be fatal," an LVN told inspectors.
Staff also failed to follow proper infection control procedures. One nursing assistant changed dirty gloves three times without washing hands, placing contaminated items on clean supplies. Another provided care to a resident in enhanced barrier precaution isolation without wearing a protective gown.
Medication storage violations included eyedrops, ointments, and nasal sprays that were opened but not dated, making it impossible to determine if they remained effective. Some medications had been open for unknown periods.
The oxygen concentration for one resident was set at 3.5 liters instead of the ordered 3 liters. The LVN responsible said he "did not get a report from the outgoing nurse and did not know why the concentrator was set at 3.5 L."
The Director of Nursing said giving residents more oxygen than ordered could increase CO2 levels and make them "more confused than usual."
The facility disputed the immediate jeopardy citation but implemented extensive corrective measures. All nursing staff must now complete training before providing direct care. The facility revised its sign-out policy and created new monitoring systems.
CR#1 had already been discharged by the time inspectors arrived, making individual corrective action impossible. The facility's plan noted simply: "CR#1 is no longer a resident at the time of this plan of removal. No corrective action possible to be taken for CR#1."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Manor of Westchase from 2025-02-22 including all violations, facility responses, and corrective action plans.