Elwood Health And Living
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to provide supervision for a cognitively impaired resident residing on the secured unit resulting in the resident (Resident B) leaving the secured unit twice without supervision.Findings include:Resident B's clinical record was reviewed on 10/27/25 at 10:59 a.m.
Diagnoses included anxiety, depression, vascular dementia with behaviors, and stage 3 chronic kidney disease. The resident was admitted to the facility on [DATE REDACTED].A current quarterly MDS (Minimum Data Set) assessment, dated 8/30/25, indicated the resident had no current behaviors and was able to ambulate independently and was severely cognitively impaired.A care plan related to elopement risk, dated 3/22/21, indicated the resident demonstrated exit seeking behaviors. Interventions included escorting the resident outside and use of distractions. A care plan related to exit seeking behaviors, dated 6/8/21, indicated the resident may shake and push/fidget with doors in an attempt to leave the facility.An elopement risk assessment dated [DATE REDACTED], indicated the resident was at risk for elopement.A facility reported incident, dated 7/22/25, indicated the resident was found wandering unsupervised outside of the secured courtyard fence. During an interview on 10/27/25 at 11:43 a.m., the Memory Care Coordinator indicated residents were observed and the doors on the unit were secure. The Memory care Coordinator indicated she reminded staff to make sure doors were closed tight. She reminded visitors and staff to make sure no one followed them off the unit. On 7/22/25, the residents were having an activity in the courtyard. They were located near the entrance door. Resident B was ambulating around the secured area, then went back inside
the facility. The Memory Care Coordinator was not sure how the resident was able to leave the secured courtyard without being noticed. The resident was found on the side of the building right before the driveway (parking lot), unsupervised. A CNA was on break and saw her. It was not known how long she was out there unsupervised. During an interview on 10/27/25 at 1:10 p.m., the Administrator indicated she watched security video for 7/22/25 and saw Resident B exit the building and less than 3 minutes later, she was seen being brought back into the facility by CNA 3. During an interview on 10/27/25 at 1:22 p.m., CNA 3 indicated, on 7/22/25, she saw the resident around lunch time. CNA 3 was not sure of the time but remembered it was in the afternoon. CNA 3 had exited the facility through a side door and observed the resident in the parking lot. She asked the resident what they were doing and the resident said, I got out.
CNA 3 was able to redirect the resident back into the facility without difficulty. CNA 3 indicated the resident did not have a lot of exit seeking behaviors but when she did, she is bad. The residents would go to every single door and try to open them. No further information was provided prior to exit from the facility. This citation is related to intake 2646064.3.1-45 (a)(2)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
ELWOOD HEALTH AND LIVING in ELWOOD, IN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ELWOOD, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ELWOOD HEALTH AND LIVING or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.