Willow Woods Rehabilitation And Nursing

the DON and ADON #314 reviewed and updated, if needed, elopement care plans for 71 of 71 residents.

On 09/27/25 the staffing coordinator #362 completed door checks of all facility exit doors.On 09/27/25 the DON reviewed and updated elopement binders. Resident #1, #2, #5, #13, #17, #20, #22, #27, #28, #38, #72, #43, #49, #58, #62, #70 were identified as elopement risk and verified information was in the Elopement binder. On 09/27/25 the Administrator updated door codes on all facility exit doors.On 09/27/25 the Staffing Coordinator #362, Dietary Manager #327, Transportation Director #370, and the Administrator initiated staff education on elopement and wandering resident policy and best practice, leave of absence policy, abuse policy, supervision of residents policy, and change in condition policy. 71/71 staff educated.

The Agency Nurse Company was provided with an education on elopement and leave of absence policy and procedure and a quiz for all incoming agency aids to the facility.On 09/27/2 the Administrator conducted elopement drills on afternoon shift and day shift. ADON #314 completed/will complete one elopement drill on each shift weekly for four weeks then one elopement drill on rotating shifts monthly for three months and randomly thereafter beginning 09/27/25 and ending 02/27/26.

The DON would complete audits of documentation for change in condition five times a week and randomly thereafter beginning 09/29/25 and ending 10/24/25.

The Administrator completed/will complete audits of bed boards for change in leave of absence five times a week for four weeks and randomly thereafter beginning 09/29/25 and ending 10/24/25.At the time of the survey completed on 10/07/25, there were no further incidents of non-compliance identified related to hazards/accident risk.

This deficiency represents non-compliance investigated under Complaint Number 2633309.

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