Dove Healthcare - Superior

Inspectors wroteThe facility did not prepare food in accordance with professional standards for food service safety which had potential to affect all 58 residents. -Foods items in kitchen not labeled with an expiration or use-by date.-Thermometers in 3 kitchen freezers were not functioning properly.-Cook K washed dishes, contaminating [NAME] K's clothes while prepping/serving food.-Cook M touched food with contaminated gloves while preparing ready to eat food.-Cook K prepared lunch meals without taking the temperature of all foods before serving. This is evidenced by: Example 1 Surveyor reviewed the facility policy titled Food Safety Requirements dated last revised 02/26 which states: .1. B. Storage of food in a manner that helps prevent deterioration or contamination of the food, including growth of microorganisms. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the garbage in dumpster was covered. This had the potential to affect all 58 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain mechanical and/or electrical equipment in safe operating condition, having the potential to affect all 58 residents in the facility. Surveyor observed top of a freezer in the kitchen broken with orange duct tape and being held shut with syrup bottles to keep the lid closed.

Inspectors wroteBased on observation, interview and record review, [NAME] K did not follow a recipe to make pureed and mechanical soft chicken and noodles for 8 of 8 residents who receive pureed and mechanical soft diets out of 58 residents. This resulted in the potential for 4 residents (R22, R46, R54, and R58) not receiving the nutrients necessary at lunch meal to meet nutritional needs and 4 of 15 residents (R14, R29, R53 and R25) verbalized food was not palatable.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections which had the potential to affect all 29 residents on the first floor.-Personal soaps and shampoos were in the basket hanging in the shower.-A disposable razor was present in the basket hanging in the shower.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 of 15 residents (R5) stored medication safely and securely. R5 was observed to leave nicotine lozenges on the dining room table and not stored safely or securely.

Inspectors wroteBased on interview and record review, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 (Cook O) of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when one employee's (Cook O) background information disclosure (BID) was not obtained before employee started working at facility.

Inspectors wroteBased on observation, interview and record review, the facility did not develop and implement a comprehensive care plan for one resident (R10) of 15 sampled residents reviewed for comprehensive care plans. The facility did not develop and implement a person-centered comprehensive care plan to address R10's dysphagia (difficulty swallowing) needs. R10's care plan did not include alternative interventions or monitoring guidelines to address R10's choice to not comply with speech therapy recommendations to reduce risks of choking/aspiration.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 3 residents (R) reviewed for mobility/positioning (R34).-R34 requested a trapeze for bed mobility assistance, and it was not addressed timely.-R34 has a trapeze in place with no assessment conducted or documentation of R34 having a trapeze.-R34 had a decrease in bed mobility during Minimum Data Set (MDS) Assessment dates of 10/31/25 to 01/26/26.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure supervision to prevent choking for 1 (R10) of 15 residents reviewed. R10 was assessed to require supervision with meals due to choking risk. R10 did not have supervision in place and observations were made of R10 coughing with meals.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that an alleged abuse of R1 was reported to the State Agency (SA). The facility did not report the alleged abuse of Licensed Practical Nurse (LPN) D hitting R1 on the buttocks to the SA.

Inspectors wroteBased on interview and record review, the facility did not ensure a thorough investigation was conducted when receiving a report of alleged physical abuse. The facility did not thoroughly investigate to rule out abuse of a Resident (R1). No interviews were conducted with other residents to ensure there had been no further incidents of abuse, a thorough physical exam/skin assessment or a psycho-social exam were not conducted. The acting administrator was not notified of the incident.

Inspectors wroteBased on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This affected 1 out of 3 residents (R) reviewed. (R4) Certified Nurse Assistant (CNA) E did not doff contaminated gloves after emptying urine from catheter into graduate before continuing R4's cares.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 62 residents in the facility. -The facility did not have a water management program to reduce the risk of growth and spread of Legionella and other opportunistic waterborne pathogens. -Facility surveillance does not provide adequate evidence of tracking and monitoring infections. -Residents with known infections were not placed on precautions or placed on incorrect precautions. -Bins for discarding personal protective equipment (PPE) were placed in the hallways. Soiled PPE was hanging outside of the bins and exposed. -Clean linens were not covered during transport. [...]

Inspectors wroteBased on interview and record review, the facility did not provide written notice of transfer to the resident or their representative and did not send a copy of the notice of transfer to the hospital to a representative of the Office of the State Long-Term Care Ombudsman for 6 of 6 residents (R) reviewed for hospitalization. (R58, R68, R10, R25, R57, and R41)

Inspectors wroteBased on interview and record review the facility did not provide written notice of bed-hold policy to the resident or their representative for 5 of 6 residents (R) reviewed for hospitalization. (R58, R68, R25, R57, and R41)

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not ensure staff followed transfer precautions and supervision when needed to prevent accidents which had the potential to affect 21 out 62 residents. -Surveyor observed Certified Nurse Assistant (CNA) U bathe R57 in bath house without a call system in place for emergencies during bath/shower cares. -R41 was at risk for falls. Facility did not implement new interventions put into place post falls. -Staff ambulated R41 without gait belt in place during ambulation transfer process. -R58 had a history of frequent falls with major injury and the facility failed to ensure adequate supervision and implementation of interventions to prevent further falls.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that sufficient nursing staff was provided for the third floor to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (R). This has the potential to affect all 14 residents residing on the third floor. Residents on the third floor have had multiple falls with injuries. A resident (R19) had an unwitnessed fall and no staff responded to calls for help until Surveyor intervened. R9 who is frequently incontinent of urine did not receive assistance with repositioning or toileting for 4 1/2 hours.

Inspectors wroteBased on interview and record review, the facility did not ensure medication reviews were completed for 5 out of 5 residents (R) reviewed (R65, R17, R53, R41, and R61) for unnecessary medications. Medication reviews were not completed at least monthly by a licensed pharmacist and documentation of review was not maintained in the resident's medical records.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that snack/nourishment refrigerators on the first floor and third floor were maintained with the proper temperatures and food items are dated and labeled to prevent the potential for food-borne illness. This has the potential to effect all residents on the first floor and third floor.

Inspectors wroteBased on interview and record review, the facility did not provide reasonable accommodation of resident needs and preferences for 1 of 16 sampled residents (R7). -R7 was not provided a wheelchair to allow her to get out of bed while residing in the facility.

Inspectors wroteBased on interview and record review, the facility did not promote and facilitate resident self-determination through support of resident choice for 1 of 16 sampled residents (R10). R10 reported her dissatisfaction with male caregivers providing personal care assistance after the facility identified R10's preference for female caregivers only.

Inspectors wroteBased on observation, interview and record review, the facility did not develop and implement a comprehensive person-centered care plan addressing medical and nursing needs. This occurred for 1 of 16 residents reviewed (R25). -R25 did not have a care plan identifying interventions for controlling and preventing the spread of infection related to Extended Spectrum Beta Lactamase (ESBL) resistance.

Inspectors wroteBased on record review, observation and interview, the facility did not ensure a resident who required substantial assistance for repositioning and toileting received timely assistance for 1 of 4 residents (R) reviewed for Activities of Daily Living (ADLs) (R9). R9 who is frequently incontinent of urine did not receive assistance with repositioning or toileting for 4 1/2 hours.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 16 residents (R) reviewed for quality of care (R58). R58 had a witnessed fall and was transferred from floor to bed by Certified Nursing Assistant (CNA) before a Registered Nurse assessed the resident for injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care consistent with standards of practice, to prevent pressure injuries (PI) for 1 of 5 residents (R) reviewed for pressure injuries (R36). -R36 was at risk for development of pressure injuries and was not repositioned to reduce pressure for greater than 4 hours.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure residents with limited mobility received services to maintain or prevent further reduction in mobility for 1 of 1 resident (R) R23. R23's walking program was not developed to maintain or prevent reduction in mobility. Facility staff were not providing assist of 1 with front wheel walker and gait belt walking program. This is evidenced by: The facility policy, titled Restorative Nursing Program- Superior, dated April 2007 states: Maintenance Restorative Program Definition: This program is designed for those residents who through assessment require interventions with the goal to maintain present functioning. Due to the resident's physical or cognitive condition the assessment is that the resident will not progress and may be expected to decline. Example: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents with indwelling foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) from the catheter for 1 of 1 resident (R) R25 reviewed for catheter. -Urology recommended foley be removed when R25's strength increased; facility removed foley the following day. -No monitoring after removal of foley catheter.

Inspectors wroteBased on observations, record review and staff interviews, the facility did not ensure 1 of 1 resident (R) reviewed who required oxygen and respiratory care was provided such services consistent with professional standards of practice, the resident's comprehensive person-centered care plan, and physician orders (R2). -On 03/11/25, Certified Nurse Assistant (CNA) S did not connect portable oxygen tank to R2 when CNA S placed R2 in dining room for breakfast. -Facility did not attempt a weaning schedule R2 off of oxygen as able.

Inspectors wroteBased on observation, interview and record review, the facility did not provide pharmaceutical services, including procedures that ensured the accurate acquiring, dispensing, administering, storage, and disposal of all drugs and biologicals. The facility did not ensure controlled medications were disposed of timely and per appropriate standard of practice or agency policy for 1 out of 1 resident (R) 60.

Inspectors wroteBased on observations, interview and record review, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional practice. This had the potential to affect 6 out of 6 residents (R) (R2, R34, R36, R40, R62, R69) for proper storage. 7 new unopened insulin pens, 1 unopened injectable solution, 1 unopened vaccine, and 1 unopened oral suspension that are temperature sensitive were found in an out of temperature range refrigerator on second floor. On second floor refrigerator, temperature logs are incomplete for 4 out of the 5 last months.

Inspectors wroteBased on interview and record review, the facility did not have documentation included in the resident's medical record that the resident either received or did not receive the pneumococcal and/or the influenza vaccination for 2 of 5 residents (R) reviewed for immunizations (R41 and R53). -R41's record does not include evidence resident was offered pneumococcal vaccination. -R53's record does not include evidence resident was offered influenza or pneumococcal vaccination.

Inspectors wroteBased on interview and record review, the facility did not report an incident of a resident-to-resident altercation, when a resident (R) R5 grabbed wrist of R4, resulting in R4 being transferred to emergency room for x-rays and acquiring bruising to wrist, to the State Survey Agency or police department, immediately upon learning of the incident and did not submit the 5-day completed investigation within 5 days as required. The facility practice had the potential to affect 1 of 4 residents (R) reviewed for abuse (R4). This is evidenced by: The facility policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program last reviewed October 2024, states in part under section 7. Reporting/Response, To whom to report - To the Administrator, State survey agency, local law enforcement. An Adult Protective Services; [...]

Inspectors wroteBased on interview and record review, the facility did not conduct an investigation of a resident-to-resident altercation that occurred on 10/05/24, wherein resident (R) R5 grabbed wrist of R4, resulting in R4 being transferred to emergency room for x-rays. Immediately upon learning of the incident, the facility did not conduct an investigation, staff and residents were not interviewed, interventions and monitoring were not put into place to prevent reoccurrence until 10/09/24. The facility practice had the potential to affect 1 of 4 residents (R) reviewed for abuse (R4). This is evidenced by: The facility policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program last reviewed October 2024, states in part under section 7. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the preparation of food in a clean and sanitary environment with the potential to affect all 71 residents in the facility. Staff did not consistently monitor or document cooked food temperatures. Staff did not consistently date or label food items when opened. Staff did not consistently test or document parts per million (PPM) of the quaternary sanitizing solution. Staff did not consistently document refrigerator temperatures. Staff observed touching ready to eat food with contaminated gloves.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure each resident received adequate supervision for 1 resident (R) R10, reviewed for wandering and elopement potential.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 2 of 3 residents (R) (R2, R7), reviewed for respiratory care were provided care consistent with professional standards of practice. R2 and R7 require oxygen and have a physician's orders to change oxygen tubing weekly. These were not changed as ordered. This is evidenced by: Example 1 R2 was admitted to the facility with diagnoses that include emphysema, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. R2 utilizes continuous oxygen. On 10/08/24 and 10/09/24, Surveyor observed R2's oxygen tubing which was dated 9/26/24. R3's physician orders state in part, Oxygen: Change oxygen tubing weekly. Example 2 R7 was admitted to the facility with diagnoses that include hypertension, rhinitis, dysphagia and a history of pneumonia. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide food that is palatable. 3 of 11 sampled residents expressed concerns about the palatibility of their food. R3, R8, and R9 reported issues to surveyors with the quality of their food. This is evidenced by: On 10/08/23 at 12:35 PM, Surveyor sampled a test tray for palatability, The pumpkin bar that was served was approximately 1/8-1/4 inch thick; it was very dry and difficult to cut with a fork. The bar tasted dry, hard and bland. Surveyor observed R8 a short time later; she was speaking to another resident about the pumpkin bar. R8 stated, It's hard as a rock. A short time later she said to the other resident, Be careful you don't break a tooth. On 10/08/24 at 12:36 PM, during dining observation on 2nd floor, R3 wheeled up to Surveyor in a wheelchair and said, The breakfast here is either warm or rotten. [...]

Inspectors wroteBased on interview and record review, the facility did not complete a thorough investigation of a reportable incident for 1 of 1 resident (R2). The facility was unable to provide a clear and concise timeline of events. The facility completed limited staff interviews, resulting in a conflicting timeline of the incident.

Inspectors wroteBased on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development of communicable diseases and infections for 2 of 2 residents (R) (R1, R10) observed during transfers and 1 of 1 resident, (R1) observed during incontinence cares. *Staff did not perform proper hand hygiene during incontinence cares for R1 or after incontinence care before touching R1's bedding, pillow, and remote control. *Staff did not sanitize EZ stand after transferring R10 from chair to bed. *Staff did not sanitize Hoyer lift after transferring R1 from chair to bed.

Inspectors wroteBased on observation and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect 78 of the 78 residents residing in the facility at the time of the survey. The facility did not have a clear water management process or plan in effect to prevent transmission of Legionella infection. Certified Nursing Assistant (CNA) T picked up R74's nasal oxygen tubing from the floor and placed the contaminated tubing in R74's nose. Meal tray delivery was observed in which staff did not wash or sanitize their hands from one resident to the next. [...]

Inspectors wroteBased on record review and interview, the facility did not obtain written consent, explaining medication risks and benefits, options, and alternatives when psychotropic medications were initiated and every 15 months thereafter. The facility practices affected 4 of 5 residents reviewed for unnecessary medications (R35, R21, R51, R39). This is evidenced by: Surveyor requested and reviewed the facility policy titled Use of Psychotropic Medication with date implemented 11/04/2023. The policy in part reads: ~Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use . ~The written, informed consent of any patient shall first be obtained . ~Informed consent means written consent voluntarily signed by a patient who is competent and who understands the terms of the consent or by the patient's legal guardian . [...]

Inspectors wroteBased on interviews and record review, the facility did not involve residents and/or their representatives in the care planning process when changes were made during the Minimum Data Set (MDS) assessment periods. The facility practice affected 4 of 19 sampled and supplemental residents (R35, R21, R51 and R5). This is evidenced by: Surveyor requested and reviewed the facility policy titled Care Planning-Resident Participation with date implemented 08/02/23. The policy in part reads: ~The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals for care. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not distribute fluids in a manner to prevent contamination. The facility practice has the potential to affect 11 of 25 sampled and supplemental residents who are served meals in their rooms on the second floor (R38, R70, R12, R40, R53, R21, R68, R60, R57, R55 and R30). This is evidenced by: Surveyor requested and received the facility policy titled Food Safety Requirements with a date implemented 9/01/23. The policy in part states: ~Food Distribution means the process involved in getting food to the residents. ~Food safety practices shell be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with deliver of food to the resident. ~Foods and beverages shall be distributed and served in a manner to prevent contamination . Example #1: [...]

Inspectors wroteBased on observations and interviews, the facility did not ensure each resident is treated with a dignified existence by providing privacy while Resident (R31) was toileting and appropriate clothing was worn when R36 was in dining room. This occurred for 2 of 20 sampled and supplemental residents (R) R31 and R36.

Inspectors wroteBased on record review and interview, the facility did not conduct a Preadmission Screening and Resident Review (PASARR) for 2 of 3 residents reviewed (R12 and R15) within 30 days of admission to ensure individuals with a serious mental disorder received care and services in the most integrated setting possible. This is evidenced by: The facility policy, entitled Resident Assessment - Coordination with PASARR Program, with a date implemented of 09/01/23, reads in part The Level II resident review must be completed within 40 calendar days of admission. Example 1 Surveyor reviewed R12's record and noted R12 was admitted on [DATE] with diagnoses that included anxiety disorder, vascular dementia, bipolar disorder, and major depressive order. R12's orders include: 11/04/23: divalproex sodium 2 tablets once a day for major depression 11/05/23: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 18 sampled residents (R3) has a comprehensive individualized care plan for peripheral catheter, multiple drug resistant organisms (MDRO), or transmission based precautions (TBP) to meet the needs of the resident. This is evidenced by: R3 was admitted to the facility on [DATE] and has diagnoses that include spina bifida, post-surgical malabsorption, ileus, neurogenic bowel, resistance to vancomycin, neurogenic bladder, sepsis due to unspecified organism, sepsis due to enterococcus, sepsis due to other specified staphylococcus, calculus of kidney, and terminal atrophy of kidney. R3 has a peripherally inserted central catheter (PICC) line in right chest for intravenous (IV) fluid access and lab draws. [...]

Inspectors wroteBased on record review and interview, the facility did not review and revise the comprehensive care plan, for 1 of 18 sampled residents (R), R432, for increased pain/pain management or changes in activities of daily living (ADLs) for fractures of right and left humerus.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care, consistent with standards of practice, to prevent pressure injury, prevent infection, and prevent new pressure injuries from forming for 1 of 1 resident (R) reviewed for pressure injuries. (R36) -R36 was not repositioned or offered repositioning per care plan. -Facility failed to provide adequate cushion for wheelchair for resident with stage 3 pressure injury. -Facility failed to provide appropriate hand hygiene, glove changes, order of treatment, sanitizing table and lying down barrier for work area during wound care.

Inspectors wroteBased on interview, the facility failed to employ a full time dietary manager with the appropriate certifications. This has the potential to affect all 79 residents of the facility.

Inspectors wroteBased on observation and interview, the facility did not ensure each resident receives food prepared by methods that conserve nutritive value, flavor and appearance, and the food is palatable, attractive for 10 of 10 residents (R4, R6, R7, R8, R9, R10, R11, R12, R13, R14), and 1 of 1 test trays. Evidenced by: On 01/02/24 at 10:20 a.m., Surveyor interviewed R4 and asked about the food at the facility. R4 stated the food was awful. Tasted bland, and it was not always hot enough. On 01/02/24 at 10:42 a.m., Surveyor interviewed R6 and asked about the food at the facility. R6 stated R6 does not like the food. R6 stated the food is tasteless and if you mention you like something, they give it to you day after day. R6 stated the food is cold. On 01/02/24 at 11:05 a.m., Surveyor interviewed R7 and asked about the food at the facility. R7 stated the food is horrible and it has no flavor. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure no more than 14 hours between a substantial evening meal and breakfast the following day and when over 14 hours did not ensure a nourishing snack were served at bedtime to 11 of 11 residents (R) (R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14). This is evidenced by: On 01/02/24, Surveyor reviewed the facility mealtime hours. Breakfast is at 7:30 a.m., lunch is at 12:00 p.m., and dinner is at 5:00 p.m. On 01/02/24 at 5:00 p.m., Surveyor observed dining service for the dinner meal. On third floor the dinner cart was delivered to the floor at 5:12 p.m. and all dinner trays were delivered to the residents by 5:25 p.m. On second floor the dinner cart was delivered to the floor at 5:26 p.m., and all dinner trays were delivered to the residents by 5:37 p.m. On first floor the dinner cart was delivered to the floor at 5:42 p. [...]

Inspectors wroteBased on observations and interviews, the facility did not provide a sanitary and comfortable environment for residents who had dirty bathrooms, dirty floors, overflowing garbage for 13 of 55 residents (R) (R9, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, and R10). This is evidenced by: On 01/02/23 between 11:50 a.m. and 12:30 p.m., Surveyor toured facility third floor. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure all incidents involving potential abuse were thoroughly investigated for unexplained bruising for 1 of 3 residents, (R) reviewed (R27). This is evidenced by: The facility's Abuse, Neglect, and Exploitation Policy dated 10/01/23, revised 10/13/23 states: Policy: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 4. [...]

Inspectors wroteBased on record review and interview, the facility did not immediately consult with the resident's physician when the resident had a significant change for 1 of 1 resident (R) 8 reviewed for MD notification. R8 eloped from the facility; the physician was not consulted about this event.

Inspectors wroteBased on record review and interview, the facility did not review and revise the comprehensive care plan for 1 of 8 sampled residents (R), R8. R8's care plan was not updated after an elopement on 09/09/23.