Gracy Woods Nursing Center

jeopardy to resident health or safety

policy and did not make any revisions to the policy.

During an interview with the MD on 09/13/2025 at 2:19pm revealed that the administrator did discuss the finding and ensured continuation and participation of all practitioners with resident elopement risk.

Record Review revealed that the RDO re-educated the ADM with CN present on 09/12/2025.

The CN educated the DON on 09/12/2025.

Record review of Wandering and Elopements, policy Interpretation and Implementation In-service and Elopement Drill revealed that the DON educated staff and conducted an elopement drill with 39 of 90 staff.

Record review revealed that wander guard monitoring checklist has been completed for all shifts starting Sept. 1, 2025.

Record review of Elopement Evaluation Observation In-service Training dated 09/12/2025 revealed 16 of 34 Licensed Nurses were in-serviced on completing the elopement assessments.

Record review of elopement risk assessments revealed 93 0f 93 residents had elopement risks assessments completed.

Six residents identified as elopement risk. 6 of 6 residents' elopement risk assessment, care plan and MDS match.

Record review revealed some PRN staff have been educated.

Record review of AMA dated 09/12/2025 revealed the resident refused to sign.

Record review revealed that the medical director was called by the ADM on 09/12/2025 at 1:14pm

Record review revealed that a QAPI meeting was held on 9/11/2025. On 09/12/2025 at 5:05 p.m., an Immediate Jeopardy (IJ) was identified.

While the IJ was removed on 09/13/2025 at 3:00 p.m., the facility remained out of compliance at a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

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