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Good morning.I used Assisto to investigate the most recent survey data released by CMS and focused on what immediate jeopardy deficiencies were cited thus far in 2025. (Check out Assisto for yourself with a 30 day free trial here) This is what I uncovered... Total Deficiencies by Scope and Severity Severity J (Immediate Jeopardy): 40 occurrences Severity K (Immediate Jeopardy - Pattern): 6 occurrences Severity L (Immediate Jeopardy - Widespread): 10 occurrences
Total Deficiencies by F-Tag (Top Cited) F0689: Accident prevention & supervision (including elopements) – 24 occurrences F0600: Abuse, neglect,
timely emergency response, CPR issues – 9 occurrences F0880: Infection control & prevention – 5 occurrences F0678: CPR & advanced directive issues – 4 occurrences F0726: Staff training deficiencies – 3 occurrences F0584: Safe temperature and HVAC control – 3 occurrences F0684: Resident assessments & care plan interventions – 2 occurrences F0825: Provision of required therapies (speech therapy) – 1 occurrence F0656: Care plan implementation (wandering/aggression) – 1 occurrence F0578: Accurate advanced directive documentation – 1 occurrence F0835: Timely communication of infectious disease results – 1 occurrence F0773: Prompt notification of physician (infection control) – 1 occurrence F0692: Dietary management and choking prevention – 1 occurrence
Elevate your Safety and Compliance Whether you're an NHA operating a SNF or ED running a senior living campus, elopements remain your highest risk area. Today, let's dive into steps you can take in conjunction with your QAPI program to prevent elopements and prepare staff to respond appropriately if a resident is missing. Daily Actions:- Daily Safety Rounds: Conduct daily rounds to check the functionality of all security systems, including alarms, door locks, and surveillance cameras. Ensure that all exit doors are secure and alarm systems are active. Develop a checklist with dates and times that can easily be filled out during rounds to document your process.
- Staff
Briefings: Start each shift with a briefing for the staff, emphasizing the importance of vigilance in monitoring residents prone to elopement. Review any resident-specific concerns related to elopement risks and specific residents who may be at risk for elopement. Like the safety rounds, create an agenda to record the talking points and collect signatures.
Weekly Actions:- Review and Update Elopement Risk Assessments: Weekly review of elopement risk assessments for each resident, especially those who have shown tendencies or attempts to elope. Update care plans as needed to reflect changes in the resident's condition or behavior. Report to QAPI your compliance with the timely and accurate completion of elopement-related assessments based on your community's process and procedures.
- Staff Training Sessions: Conduct weekly
training sessions focused on elopement prevention strategies, recognizing resident cues for potential elopement, and emergency response procedures if an elopement occurs. Document topics and obtain signatures. Invite feedback from staff on ways to make the community safer. Ensure all employees know what to do if they notice a resident missing or a malfunctioning security system.
Monthly Actions:- Security System Audits: Perform a comprehensive audit of all security and monitoring equipment to ensure optimal working conditions. This includes checking battery life, software updates, and the integrity of physical barriers. ocument, document, document.
- Mock Elopement Drills: Organize monthly drills to simulate an elopement scenario. This helps assess the staff's readiness and the effectiveness of the current protocols and
systems.
- Review Incident Logs: Monthly review of any elopement-related incidents or near misses. Analyze these incidents to identify any patterns or systemic issues that need addressing. Use this data to refine strategies and improve staff training. Use real-life scenarios to provide further education and elopement drill scenarios in the future.
Continuous Improvement:- Feedback Mechanism: Establish a feedback loop where staff can report potential security lapses or suggest improvements without fear of reprisal. Encourage staff to provide feedback during your daily huddles and document suggestions and follow-ups.
- Family and Resident
Engagement: Regularly engage with residents and their families to better understand their needs and concerns, which can provide insights into potential elopement triggers.
Take Action Today—Before Surveyors Force Your Hand The data speaks for itself: Immediate Jeopardy citations tied to elopements and supervision are leading the pack in 2025. Don’t wait for a deficiency to force change. Build a
proactive culture of safety with tight processes, daily visibility, and ongoing staff engagement. When you hardwire elopement prevention into your QAPI plan, you're not just protecting your residents—you're protecting your license, your team, and your peace of mind. You’ve got the data—now lead with it.
Partners We Love Assisto Assisto has developed an AI-powered search engine that, for the first time, allows you to search and filter CMS survey data. If you are an operator looking to stay updated on where your state surveyors are and what deficiencies they cite in your state, Assisto is for you. For a short time, we are offering access to the portal for $18.90 per month after a 30-day free trial. Click here to sign up for early access and claim your free trial.
Whenever you're ready, there are a couple of ways I can help you. - Leverage our partnership with CEUSrEZ and purchase NAB-approved, online, self-paced, continuing education courses at a 20% discount here.
- Check out our free AI Chatbot trained on thousands of pages of regs and industry best practices. It's like having a surveyor on your team. Try it out here.
- Sign up for Assisto and keep track of the regulatory environment in your state. Know what deficiencies surveyors cite in real-time and ensure you're not at risk for the same tag. Sign up here.
Forward this newsletter, and we might give them a free coffee for signing up! Enjoy reading our newsletter? Forward this edition to a colleague and friend, and we will send five randomly selected new subscribers a free coffee using Thnks. Thanks for reading. Have a wonderful
day. Kevin Goedeke, Publisher and Founder
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