Aria Of Waukesha
Aria of Waukesha in WAUKESHA, WI — inspection on October 15, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
DON-B stated there are two alarm systems.
One alarm is for the Wanderguard system and if a resident is wearing a Wanderguard and tries to exit the front of the building, an alarm will sound 24/7.
The second alarm is sounded when the doors are locked, and anyone opens the doors without disarming the alarm with a code.
Surveyor asked when the doors are locked. DON-B stated, the doors are locked at 8:00 PM, and unlocked at 6:30 AM, seven days a week.
Surveyor asked what the receptionist coverage is. DON-B stated the reception area is staffed 7:30 AM to 8:00 PM during the week and 8:00 AM to 4:00 PM on the weekends.
Surveyor asked if residents without Wanderguards would be able to leave the facility without an alarm sounding between the hours of 6:30 AM and 7:30 AM during the week or 6:30 AM and 8:00 AM on the weekends or between 4:00 PM and 8:00 PM and weekends. DON-B stated, This is not a prison and residents who have not been identified of having risk for elopement have the right to leave when they want to.
Surveyor acknowledged understanding but questioned how the facility would know if residents who are not at risk were leaving without an alarm nor anyone at the reception area to observe. DON-B stated, the residents will sign in and out. DON-B stated, the facility installed cameras following R1's elopement on 9/26/25 and both DON-B and NHA-A receive notifications on their cell phone whenever anyone enters or leaves the facility.On 10/9/25 at 9:25 AM, Surveyor informed DON-B and NHA-A of the serious concern related to R1 eloping and the need for adequate supervision for all residents including R1.On 10/9/25 at 11:09 AM, NHA-A followed up with Surveyor and stated due to concerns brought up during survey, doors will now lock at 8pm and unlock at 8am.The facility's failure to provide adequate supervision for R1 allowed R1 to elope from the facility; R1 was found 20 miles away by his family.
The failure created a reasonable likelihood for serious harm or injury thus leading to a finding of immediate jeopardy.
The facility removed the immediate jeopardy on 9/26/25 when the facility implemented the following: -All facility residents were re-assessed to identify risk for elopement and ensure proper interventions were implemented.-Identified residents at risk for elopement and ensure person centered care plans are in place with preventative measures to include the specified level of supervision for residents at risk for elopement.-Reviewed elopement/missing resident policy to address the timing of searching for/reporting a missing resident to help ensure an expedited search.-Education was provided to all staff on following the facility's updated elopement policy, accuracy of elopement assessments, monitoring resident's at risk for elopement and timely response to door alarms.-Elopement risk assessments completed will be reviewed during clinical meeting to verify accuracy and ensure appropriate interventions were put in place.-New elopement risk assessments were completed for all facility residents.-Facility implemented cameras at facility entrance.-Reviewed updated facility policy and procedure on elopement and coordination with medical director.
Including updated elopement assessments, and addition of cameras at the facility entrance to ensure adequate resident supervision is in place to identify residents exiting the facility and to ensure facility policy and procedure meets current standard of practice.-Facility Maintenance will complete audits to ensure door alarms are properly functioning.
Audits will be completed weekly on all shifts.-IDT will review daily in clinical meeting any new admissions elopement assessments, incidents regarding changes in residents' behaviors, and document on eagle board to ensure proper assessments have been obtained and appropriate interventions have been implemented.
Audits will be conducted twice a week for 3 weeks, weekly for 3 weeks, every 2 weeks and x2 monthly x3. (sic) Results will be reviewed by QAPI Committee to determine compliance or additional follow up required.-An Ad Hoc QAPI completed 08/29/25.
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