Meadow Falls of Wickliffe

Based on observation, record review and interview, the facility failed to ensure medications were administered as ordered and per best practice guidelines. This finding affected two (Residents #14 and #17) of six resident records reviewed for medication administration.

Findings include:

1. Review of Resident #14's medical record revealed the resident was admitted on 08/30/22 with diagnoses including hypothyroidism, anemia and anxiety disorder.

Review of Resident #14's Mini Mental State Examination dated 03/11/26 revealed the resident exhibited intact cognition.

Review of Resident #14's physician orders revealed an order dated 04/07/26 for Omeprazole 40 milligrams (mg) one capsule by mouth once daily for heartburn and indigestion.

Review of Resident #14's medication administration records (MARS) revealed the Omeprazole was not administered on 06/04/26 or 06/05/26. The MARS revealed the medication was not available from the pharmacy.

Observation on 06/05/26 at 6:44 A.M. to 6:56 A.M. with Licensed Practical Nurse (LPN) #802 of Resident #14's morning medication administration revealed five medications were administered. The resident's Omeprazole was not administered as ordered. LPN #802 was observed on 06/05/26 at 6:56 A.M. to unlock Resident 14's door. The nurse called out the resident's name while the resident was lying in bed and informed the resident that his medications were available and then placed the cup of medications on the sink, turned off the light and left the room, locking the door behind her. LPN #802 confirmed Resident #14's Omeprazole was not available to administer.

Interview on 06/05/26 at 6:58 A.M. with LPN #802 stated Resident #14 was alert and oriented and able to take his own medications.

Interview on 06/05/26 at 1:00 P.M. with the Director of Nursing (DON) confirmed Resident #17 was not able to self-administer medications and the nurse was supposed to observe the resident taking his medications.

2. Review of Resident #17's medical record revealed the resident was admitted on 11/04/25 with diagnoses including unspecified lack of coordination, need for assistance with personal care and diffuse traumatic brain injury with loss of consciousness of unspecified duration.

Review of Resident #17's Mini-Mental State Examination form dated 03/03/26 revealed the resident exhibited severe cognitive impairment.

Review of Resident #17's physician orders revealed an order dated 05/03/26 for Aspirin enteric coated (EC) 81 mg give one tablet by mouth daily.

Review of Resident #17's MARS from 06/01/26 to 06/05/26 revealed the resident's Aspirin EC was administered daily.

Observation on 06/05/26 at 7:10 A.M. with LPN #804 of Resident #17's medication administration revealed six medications were administered. LPN #804 was observed crushing Aspirin EC 81 mg, Levothyroxine 175 mcg and Coreg 3.125 mg and placing the crushed medications in a cup of Miralax and water. The nurse then stirred the crushed medications along with the Miralax and administered the medications to the resident via a PEG tube.

Interview on 06/05/26 at 7:12 A.M. with LPN #804 revealed the Asprin EC was crushed, added to the Miralax and provided to the resident but should not have been crushed.

Review of the undated Medication Assistance policy revealed the purpose was to provide safe assistance with medication administration to residents, provide guidance to the staff for medication services, to provide guidance to the pharmacies who may wish to provide medication to the residents.

This violation represents non-compliance investigated under Complaint Number OH00170760.

Based on record review and interview, the facility failed to ensure immediate steps were taken and documented for Resident #58 upon changes in condition. This finding affected one (Resident #58) of six resident records reviewed for changes in condition.

Findings include:

Review of Resident #58's medical record revealed the resident was admitted on 02/24/24 with diagnoses including major depressive disorder, anxiety disorder and essential hypertension.

Review of Resident #58's Mini-Mental State Examination form dated 03/03/26 revealed the resident exhibited intact cognition.

Review of Resident #58's medical record and progress notes dated 04/19/26 did not have evidence of identification, assessment, intervention, documentation, communication, and follow-up for the resident's change in condition.

Review of Resident #58's hospital emergency room (ER) documentation revealed the resident was admitted to the hospital on 04/19/26 with weakness and a facial droop.

Resident #58's medical record and progress notes did not reveal documentation of the resident's return to the facility date or time, and the record did not have evidence a follow-up assessment was completed of the resident upon the resident's return to the facility. The medical record did not include the resident experiencing a fall upon return from the hospital and steps taken to assess the resident and fall interventions initiated.

Review of Resident #58's progress note dated 04/24/26 revealed the resident had been resting in her bed during the shift, was changed and repositioned. The sling was in place to the left arm. The daughter/power-of-attorney (POA) was here at bedside and will be making the follow up ortho appointment. The Certified Nurse Practitioner (CNP) assessed Resident #58 and gave orders for as needed Tramadol (narcotic pain medication).

Review of Resident #58's medical record and progress notes dated 04/28/26 did not have evidence of identification, assessment, intervention, documentation, communication, and follow-up for the resident's change in condition.

Interview on 06/05/26 at 8:32 A.M. with Resident #58's family revealed the resident returned to the facility on 04/23/26 after the 04/19/26 hospitalization. Resident #58 sustained a fracture to the left humerus and a contusion to the left hip on 04/23/26 following a fall in the facility upon her return from the hospital. Resident #58's family revealed none of this information was in the medical record. Resident #58's family revealed the resident went out to the hospital on 04/28/26 for hypoxia, which was not included in the medical record.

Review of Resident #58's progress note dated 05/30/26 revealed the resident was discharged from the facility with the daughter. The record did not specify if the resident was with the daughter upon discharge as she did not return to the facility per the family members.

Interview on 06/05/26 at 10:38 A.M. with the Director of Nursing (DON) confirmed Resident #58's medical record did not have evidence of the discharge to the hospital or interventions for the change in condition on 04/19/26, return to the facility on 04/23/26 including an assessment of the resident, discharge to the hospital on 04/23/26 following a fall including interventions, return to the facility assessment on 04/24/26 and discharge out to the hospital on 04/28/26 including interventions following the change in condition.

Interview on 06/05/26 at 12:19 P.M. with Resident #58's daughter revealed the resident did not return to the facility following the hospitalization on 04/28/26.

Review of the undated Change in Condition policy revealed the purpose of the policy was to ensure timely identification, assessment, intervention, documentation, communication, and follow-up for any resident experiencing a change in condition, in order to promote health, safety, and regulatory compliance.

This violation represents non-compliance investigated under Complaint Number OH00170760.

Based on record review and interview, the facility failed to ensure an accurate incident/accident log was maintained as required and Resident #58's fall with major injury was investigated. This finding affected one (Resident #58) of six residents reviewed for falls.

Findings include:

Review of Resident #58's closed medical record revealed the resident was admitted on 02/24/24 with diagnoses including major depressive disorder, anxiety disorder and essential hypertension.

Review of Resident #58's Mini-Mental State Examination form dated 03/03/26 revealed the resident exhibited intact cognition.

Review of Resident #58's medical record and facility incident/accident log dated 04/23/26 revealed it was absent of information regarding the resident falling.

Review of Resident #58's progress note dated 04/24/26 revealed the resident had been resting in her bed during the shift, was changed and repositioned. The sling was in place to the left arm. The daughter/power-of-attorney (POA) was here at bedside and will be making the follow up ortho appointment. The Certified Nurse Practitioner (CNP) assessed Resident #58 and gave orders for as needed Tramadol (narcotic pain medication).

Interview on 06/05/26 at 8:32 A.M. with Resident #58's family revealed the resident returned to the facility on 04/23/26 after the 04/19/26 hospitalization. Resident #58 sustained a fracture to the left humerus and a contusion to the left hip on 04/23/26 following a fall in the facility upon her return from the hospital. Resident #58's family revealed none of this information was in the medical record.

Interview on 06/05/26 at 1:00 P.M. with the Director of Nursing (DON) confirmed Resident #58's fall with major injury on 04/23/26 was not identified on the incident accident log and the facility did not have evidence a complete fall investigation was not conducted.

Based on staff interview and record review, the facility failed to ensure that Residents #6 and Resident #58 were free of financial exploitation. This affected two residents (Resident #6 and #58) out of three residents reviewed for resident rights and had the potential to affect all 57 residents residing in the facility.

Findings include:

1. Review of Resident #6's medical record revealed the resident was admitted on 02/24/24 with diagnoses including major depressive disorder, glaucoma, and essential hypertension.

Review of Resident #6's Mini-Mental State Examination form dated 03/04/26 revealed the resident exhibited moderately impaired cognition.

Review of Resident #6's Aide Plan of Care revealed Resident #6 required two-hour safety checks due to fall risk, transfer assist of one, and hands on assist for continence.

Review of Resident #6's payment ledger for 02/01/26 through 06/05/26 revealed Resident #6 was charged a prorated rate on 02/19/26 (the day the new company purchase went into effect) of $2,992.36 and $8,379.50 each month from 03/01/26 through 06/01/26. The ledger also revealed $8,379.50 was automatically withdrawn from Resident #58's account.

Review of the caregiver cheat sheet revealed Resident #6 was a check and change every hour, was blind, hard of hearing and there was a camera in the room.

Review of the facility's undated assisted living pricing monthly rates revealed the following: the basic rate for a studio apartment was $6,000.00, care plus rate was #6,400.00 and the extended rate was $6,800.00; the basic rate for a one bedroom apartment was $7,000.00, care plus rate was #7,200.00 and the extended rate was $7,800.00; and the basic rate for a two bedroom apartment was $8,000.00, care plus rate was $8,400.00 and the extended rate was $8,800.00.

Further review of the resident pricing revealed no definition for each level of service except for the basic rate which included meals, laundry weekly, housekeeping weekly, activities, cable, internet, trash removal, utilities are covered and personal care needs will be addressed after an assessment to indicate the need for personal care. The basic rate is structured as an all-inclusive model and if circumstances in which a resident would require specialized or higher acuity services fall outside the scope of routine activities of daily living (ADL) support, additional fees may apply.

Interview on 06/05/26 at 9:30 A.M. with Business Office Manager (BOM) #900 revealed that there was a flat rate based on levels of care and did not know the difference in tiers. BOM #900 stated that she recently transferred to the facility from a sister account. BOM #900 verified that the ledger for Resident did not match the monthly rates in the facility's resident admission packet. BOM #900 stated that corporate office in New York sends out the monthly bills. BOM #900 stated that the difference could not be medications because the pharmacy bills the residents directly due to insurance.

Phone interview on 06/05/26 at 10:13 A.M. with Regional Director of Operations (RDO) #901 revealed that the former company itemized billing because they had an ala cart method. She stated that residents who were residents of the former company were billed at the same price. She stated that she could not state what services were provided for the former company's billing because of the ala cart structure.

Interview on 06/05/26 at 11:00 A.M. with Resident #6's daughter revealed that her mother has had a reoccurring UTI for a few months. She stated that her mom had to be on intravenous (IV) antibiotic because of the UTIs. Daughter stated that her mother is always incontinent of urine and since her UTIs, Resident #6 is occasionally incontinent of bowel. Daughter stated that she had a care conference with the facility, and it was stated that Resident #6 would be changed two times throughout the night related to her incontinence. She stated that she shared the camera footage with the facility to show that Resident #6 was not changed throughout the night. Daughter stated that Resident #6 was charged $8,379.00 per month.

Interview on 06/05/26 at 11:56 A.M. with Caregiver (CG) #803 revealed that Resident #6 were both check and changes every two hours. CG #803 stated that there was no documentation of check and changes. CG #803 stated that Resident #6 had a camera in her room.

Review of the facility's policy dated 06/24/13 with the most current revision date with the most recent revision date of 05/2021 titled, Abuse

Based on record review and interview, the facility failed to ensure all personnel had a physical by the first day of work. This had the potential to affect all 64 residents residing in the facility.

Findings include:

Review of the employee file for Caregiver #215 revealed the caregiver received orientation on 03/27/26. Caregiver #215 was on the schedule for 03/27/26, 03/28/26, 03/29/26 and 03/31/26. However, Caregiver #215's physical was not completed until 04/03/26.

Review of the employee file for Licensed Practical Nurse (LPN) #220 revealed the nurse received general orientation on 03/24/26. LPN #220's Nurses Orientation Checklist was signed off on 03/24/26 and 03/25/26. LPN #220 was on the schedule for 03/24/26, 03/25/26, 03/26/26 and 03/27/26. However, LPN #220's physical was not completed until 03/31/26.

Interview on 04/08/26 at 3:43 P.M. with Regional Compliance Officer #250 verified Caregiver #215 and LPN #220 worked in the facility before completing their physicals.

This violation represents non-compliance investigated under Complaint Number OH00170214.

Based on observation, interview and policy review, the facility failed to ensure food was stored, prepared and served in a kitchen maintained in a sanitary manner to prevent contamination and risk of foodborne illness. This had the potential to affect all 62 residents residing in the facility, as the facility identified zero residents who did not eat by mouth (NPO). The census was 62.

Findings include:

On 10/30/25 at 8:20 A.M. an initial tour of the kitchen was conducted with Dietary Manager (DM) #333. Ecolab Sink and Surface Cleaner test strips to test for proper sanitation levels of chemicals at the three-sink manual dishwash station expired 06/2024. An interview at the time of the observation with DM #333 verified the expired test strips. DM #333 also stated they were unaware of that test strips had an expiration date.

The floor was noted to have dried macaroni under the handwash station located next to the fryer. There was a balled-up piece of plastic wrap under the fryer and a build-up of black grease under the fryer. There was visible dirt and food debris in between the fryer and the griddle. DM #333 stated the debris was stuck to the floor and unable to be removed. DM #333 further stated the facility was looking into a company to deep-clean the kitchen.

The walk-in refrigerator revealed a five-pound bag of shredded Italian blend cheese that was opened and unlabeled. There was an eight-ounce package of sliced Swiss cheese opened and unlabeled. A one-gallon bottle of Marsala wine was located on the dry storage shelf. The Marsala wine was opened and unlabeled. The Marsala wine had an expiration date of 11/15/24. The bin of sugar was noted to have a Styrofoam bowl in it. DM #333 verified the aforementioned findings at the time of the observations. DM #333 stated the Styrofoam bowl was used to scoop the sugar.

A review of the policy titled, Labeling-DS04.028, dated 09/2024, revealed all food items must be labeled and dated before storing.

A review of the policy titled, Kitchen Cleaning dated 07/2024 revealed all kitchens and food preparation areas must be cleaned according to federal, state and local regulations. The policy further revealed food service equipment, food service areas are to be clean and sanitized.

This citation represents continued noncompliance from survey completed 05/15/23 and 07/15/24.

Based on record review and interview, the facility failed to evacuate residents capable of self-evacuation in at least two fire drills a year on each shift as required. This had the potential to affect all 62 residents residing in the facility. The facility census was 62.

Findings include:

On 10/30/25 at 3:00 P.M. a review of fire drills for the year revealed drills conducted on 10/31/24 day shift, 11/18/24 afternoon shift, 12/27/24 night shift, 01/31/25 day shift, 02/10/25 afternoon shift, 03/18/25 night shift, 04/30/25 day shift, 05/27/25 afternoon shift, 06/22/25 night shift, 07/31/25 day shift, 08/27/27/25 afternoon shift, and 09/23/25 night shift. Further review revealed evacuation of residents took place on only two drills for the year which occurred on 10/31/24 day shift and 11/18/24 afternoon shift.

On 10/30/25 at 3:30 P.M. an interview with Maintenance Director (MD) #322 verified evacuations on only two drills for the year which occurred 10/31/24 day shift and 11/18/24 afternoon shift. MD #322 stated he thought evacuations only needed to take place two times a year.

Based on observation, record review, and interviews the facility did not ensure Resident #80 was provided a safe and secure environment at all times to prevent elopement from the memory care unit. This affected one resident (Resident #80) of four residents reviewed for elopement. The facility census was 64. Findings include: Review of the medical record for Resident #80 revealed an admission date of 10/01/25 with diagnoses including Alzheimer's disease, urinary tract infection, insomnia, hypertension and anxiety. Review of the Physician/Healthcare Provider Plan of Care dated 09/30/25 revealed Resident #80 was cognitively impaired. Review of the Personal Service Assessment dated 10/01/25 revealed Resident #80 demonstrated anxious, compulsive, disruptive or obsessive behavior requiring additional attention. It was also marked for attempts to exit building without needed supervision. This form appeared to trigger the Service Plan for goals and interventions. Review of the Service Plan initiated on 10/01/25 revealed Resident #80's behaviors would be managed with assistance. Interventions included staff were to be alert to resident's patterns and reasons for exit attempts and involve meaningful activities prior to those points in time and to redirect resident away from exits using a gentle voice and preferred activity. Review of a progress note dated 10/05/25 at 10:52 P.M. and authored by agency Licensed Practical Nurse (LPN) #500 revealed Resident #80 eloped at approximately 6:35 P.M. and the nurse found her in the parking lot at 6:37 P.M. The nurse tried to guide her back in but the resident would not listen. The resident was aggressive when her daughter arrived. Resident #80 refused medication from the nurse but did take them from the daughter. The daughter was able to get her back in the building. Certified Nurse Practitioner was made aware and ordered a urinalysis. Review of a progress note dated 10/08/25 at approximately 6:54 P.M. revealed the emergency alarm was heard, staff responded immediately to exit doors and observed Resident #80 exiting through a second door off of the service hall and continued to the parking lot. She was combative when approached refusing to come back inside. Redirection was unsuccessful. Resident #80's daughter was notified and she was on her way in. Resident #80 began walking toward the main road then laid down on the ground. Nurse manager and squad was notified and officers responded to the scene. The daughter left the premises with Resident #80 who received evening and next day's medications from the nurse. Physician was notified. Review of the incident log revealed Resident #80 eloped on 10/05/25 at 6:35 P.M. and 10/08/25 at 6:50 P.M. Review of a progress note on 10/09/25 at 5:30 P.M. revealed Resident #80's daughter called the nurse to ask for assistance getting her out of the car and into the facility. The resident was combative and yelling, hitting the daughter and nurse. The nurse suggested the daughter take her to the emergency room for evaluation. Incident was reported to ED (Executive Director). Review of a witness statement from Agency LPN #500 interviewed on 10/23/25 at 11:00 A.M. and 10/26/25 at 11:15 A.M. by District Director of Clinical Services (DDCS) #400 revealed a door alarm went off by dining room, disarmed as dietary aid was in outside hall. LPN #500 went to look for Resident #80 who had been pacing halls. She looked in her room and saw Resident #80 through the window in the parking lot. She reached the resident within a couple of minutes. Called daughter from portable phone to let her know and to get her assistance to get her back in the building as resident was looking for son's car. Daughter arrived in ten minutes and talked resident into coming in the building. Review of a witness statement from Maintenance Director #322 interviewed on 10/24/25 at 10:15 A.M. by DDCS #400 revealed he talked to the nurse who was there at that time and was told the alarm went off on the door by the elevators. The nurse told him Resident #80 had been pushing on that door multiple different times that evening. He stated the door alarmed but staff were too far away to get to the door on time. He stated it could take 30 seconds to get to the door from the nursing station. Review of a witness statement from Agency Care Partner #550 interviewed on 10/26/25 at 3:30 P.M. by DDCS #400 revealed they stated she heard the alarm go off but was aware the nurse went outside. Review of the Assisted Living Incident Investigation Summary revealed it was dated 10/27/25 regarding the elopement on 10/05/25 where Resident #80 exited the building unattended. It indicated staff were interviewed between 10/23/25 and 10/27/25, door alarms were checked to ensure working on 10/24/25 and the incident did not reflect that abuse or misappropriation occurred. An interview on 10/30/25 at 10:54 A.M. with the Executive Director (ED) revealed the presumption was, on 10/05/25, Resident #80 got out through the service hallway door nearest the kitchen out to the parking lot and walked along the front of the building. Staff had seen her through her bedroom window and immediately got to her within minutes. The ED stated the resident was able to understand the emergency door handle saying to push for 15 seconds to release. There was no alarm on the door near the kitchen area because it was in the staff area. The ED stated she believed Resident #80 got out the same way on 10/08/25. An interview on 10/30/25 at 12:48 P.M. with DDCS #400 and the ED revealed they had to go through corporate for everything and they did not typically hand over their investigation. They stated there were different people who handled different parts of the investigation. The ED stated the company did not use cameras and the facility was not able to determine root cause. The ED verified the documentation for the investigation was completed weeks after the elopement incidents on 10/05/25 and 10/08/25 for Resident #80 and the ED had no evidence of increased checks being completed after the incidents. A phone interview on 10/30/25 at 1:15 P.M. with Resident #80's daughter revealed she took her mom to a local hospital on 10/09/25 where Resident #80 was diagnosed with a urinary tract infection. The daughter stated Resident #80 had not been at her home with her on 10/05/25, but stayed at the facility where she eloped on 10/05/25. She stated she waited with her mom at the facility until she fell asleep. She stated she moved her mom's belongings out of the facility on 10/13/25. An observation on 10/30/25 at approximately 2:00 P.M. of the Memory Care Unit (MCU) revealed it was a secured unit where residents could walk freely throughout the unit. The front and back doors to enter and exit the unit were secured. The area surrounding the MCU had two elevators and a service hallway with doors to the kitchen, laundry and two exit doors to the outside parking lot. A phone interview on 10/30/25 at 2:26 P.M. with Care Partner (CP) #301 revealed they were instructed to monitor the memory care (MC) door and not let anyone get out after elopement on 10/05/25. CP #301 stated on 10/08/25 she was assisting another resident back to her room for care when she heard the alarm go off. She stated by the time she got to the memory care door, Resident #80 was in the service hall area almost out a second door near the kitchen. A dietary aide was by her. She stated the resident was combative and would not come back in. CP #301 stated the other CP (#320) was on break and the nurse was watching the other residents in the dining room. Soon after, the nurse joined CP #301 outside with Resident #80 when the dietary aide came in to stay with the residents. CP #301 verified Resident #80 had been able to elope off the MCU. A phone interview on 10/30/25 at 2:38 P.M. with LPN #402 revealed she received report about an elopement and to keep an eye on the resident and the door. She stated she was with other residents in the dining room which was around the corner from the exit. She stated Resident #80 sounded the door alarm on 10/08/25 around 6:50 P.M. stating it was hard to always have an eye on her. LPN #402 initially said both CPs ran to the door and hallway but, then corrected herself and stated Oh, it was only one CP who went to the door. She stated the dietary aide came in to say Resident #80 was outside with staff and would not come back in. LPN #402 went outside to assist but the resident was combative and using her walker to keep staff from her. The LPN was attempting to offer coffee and redirect but Resident #80 was getting more agitated. LPN #402 called the Assistant Director of Nursing (ADON) and the daughter. The ADON stated to call a squad. The squad showed up as well as police and the daughter. The resident got in daughter's car after some time and they sat outside for awhile. The daughter requested to take her mom home overnight. Medications were signed out to daughter. A phone interview on 10/30/25 at 2:50 P.M. with CP #401 revealed she believed the facility needed someone to sit and watch Resident #80. She stated the MCU had three residents who required a mechanical lift which took time away from supervising other residents. In addition, staff were busy redirecting other residents. She stated it was hectic in MCU. A phone interview on 10/30/25 at 5:55 P.M. with CP #320 revealed she was at lunch on 10/08/25 when Resident #80 eloped. She tried to check on her every 30 minutes. Resident #80 was in the living room prior to CP #320 going to lunch. Resident #80 used the restroom by the office. CP #320 clocked out at 6:45 P.M. and back in at 7:17 P.M. CP #320 also stated they had three residents who used a mechanical lift so it was hard to redirect Resident #80 and she was combative. A phone interview on 11/03/25 at 8:24 A.M. with LPN #345 revealed both elopements happened on second shift stating it was most likely related to sundowning. She stated they were trying to get a urinalysis on her because of her behavior and tried to do more frequent checks and keep Resident #80 busy but did not specify how. A phone interview on 11/03/25 at 8:32 A.M. with CP #313 revealed she only worked with Resident #80 a couple of times. She stated she stayed in her room except for meals. She did not recall any training on missing residents. A phone interview on 11/03/25 at 10:01 A.M. with Program Manager #311 revealed she would try to engage Resident #80 and learn more about her. She tried to distract her with activities such as helping with making cookies and painting her nails. PM #311 stated she normally left for the day at 5:00 P.M. After that, CPs put on the T.V. for the news or residents did independent activities. A phone interview on 11/03/25 at 11:17 A.M. with LPN #330 revealed a nurse called her from the parking lot for both elopements involving Resident #80. After the first elopement they checked the function of the doors and did more frequent checks (hourly). LPN #330 stated the daughter put a tracker in Resident #80's shoes and had access to that information but nursing did not. LPN #330 believed one elopement was at the back door (near the elevators in service hall) and the other one was by the front door of Memory Care Unit but she was not certain. Review of the facility policy titled Missing Resident PolicyBased on observation, record review, and interviews the facility did not ensure Resident #80 was provided a safe and secure environment at all times to prevent elopement from the memory care unit. This affected one resident (Resident #80) of four residents reviewed for elopement. The facility census was 64.

Findings include:

Review of the medical record for Resident #80 revealed an admission date of 10/01/25 with diagnoses including Alzheimer's disease, urinary tract infection, insomnia, hypertension and anxiety.

Review of the Physician/Healthcare Provider Plan of Care dated 09/30/25 revealed Resident #80 was cognitively impaired.

Review of the Personal Service Assessment dated 10/01/25 revealed Resident #80 demonstrated anxious, compulsive, disruptive or obsessive behavior requiring additional attention. It was also marked for attempts to exit building without needed supervision. This form appeared to trigger the Service Plan for goals and interventions.

Review of the Service Plan initiated on 10/01/25 revealed Resident #80's behaviors would be managed with assistance. Interventions included staff were to be alert to resident's patterns and reasons for exit attempts and involve meaningful activities prior to those points in time and to redirect resident away from exits using a gentle voice and preferred activity.

Review of a progress note dated 10/05/25 at 10:52 P.M. and authored by agency Licensed Practical Nurse (LPN) #500 revealed Resident #80 eloped at approximately 6:35 P.M. and the nurse found her in the parking lot at 6:37 P.M. The nurse tried to guide her back in but the resident would not listen. The resident was aggressive when her daughter arrived. Resident #80 refused medication from the nurse but did take them from the daughter. The daughter was able to get her back in the building. Certified Nurse Practitioner was made aware and ordered a urinalysis.

Review of a progress note dated 10/08/25 at approximately 6:54 P.M. revealed the emergency alarm was heard, staff responded immediately to exit doors and observed Resident #80 exiting through a second door off of the service hall and continued to the parking lot. She was combative when approached refusing to come back inside. Redirection was unsuccessful. Resident #80's daughter was notified and she was on her way in. Resident #80 began walking toward the main road then laid down on the ground. Nurse manager and squad was notified and officers responded to the scene. The daughter left the premises with Resident #80 who received evening and next day's medications from the nurse. Physician was notified.

Review of the incident log revealed Resident #80 eloped on 10/05/25 at 6:35 P.M. and 10/08/25 at 6:50 P.M.

Review of a progress note on 10/09/25 at 5:30 P.M. revealed Resident #80's daughter called the nurse to ask for assistance getting her out of the car and into the facility. The resident was combative and yelling, hitting the daughter and nurse. The nurse suggested the daughter take her to the emergency room for evaluation. Incident was reported to ED (Executive Director).

Review of a witness statement from Agency LPN #500 interviewed on 10/23/25 at 11:00 A.M. and 10/26/25 at 11:15 A.M. by District Director of Clinical Services (DDCS) #400 revealed a door alarm went off by dining room, disarmed as dietary aid was in outside hall. LPN #500 went to look for Resident #80 who had been pacing halls. She looked in her room and saw Resident #80 through the window in the parking lot. She reached the resident within a couple of minutes. Called daughter from portable phone to let her know and to get her assistance to get her back in the building as resident was looking for son's car. Daughter arrived in ten minutes and talked resident into coming in the building.

Review of a witness statement from Maintenance Director #322 interviewed on 10/24/25 at 10:15 A.M. by DDCS #400 revealed he talked to the nurse who was there at that time and was told the alarm went off on the door by the elevators. The nurse told him Resident #80 had been pushing on that door multiple different times that evening. He stated the door alarmed but staff were too far away to get to the door on time. He stated it could take 30 seconds to get to the door from the nursing station.

Review of a witness statement from Agency Care Partner #550 interviewed on 10/26/25 at 3:30 P.M. by DDCS #400 revealed they stated she heard the alarm go off but was aware the nurse went outside.

Review of the Assisted Living Incident Investigation Summary revealed it was dated 10/27/25 regarding the elopement on 10/05/25 where Resident #80 exited the building unattended. It indicated staff were interviewed between 10/23/25 and 10/27/25, door alarms were checked to ensure working on 10/24/25 and the incident did not reflect that abuse or misappropriation occurred.

An interview on 10/30/25 at 10:54 A.M. with the Executive Director (ED) revealed the presumption was, on 10/05/25, Resident #80 got out through the service hallway door nearest the kitchen out to the parking lot and walked along the front of the building. Staff had seen her through her bedroom window and immediately got to her within minutes. The ED stated the resident was able to understand the emergency door handle saying to push for 15 seconds to release. There was no alarm on the door near the kitchen area because it was in the staff area. The ED stated she believed Resident #80 got out the same way on 10/08/25.

An interview on 10/30/25 at 12:48 P.M. with DDCS #400 and the ED revealed they had to go through corporate for everything and they did not typically hand over their investigation. They stated there were different people who handled different parts of the investigation. The ED stated the company did not use cameras and the facility was not able to determine root cause. The ED verified the documentation for the investigation was completed weeks after the elopement incidents on 10/05/25 and 10/08/25 for Resident #80 and the ED had no evidence of increased checks being completed after the incidents.

A phone interview on 10/30/25 at 1:15 P.M. with Resident #80's daughter revealed she took her mom to a local hospital on 10/09/25 where Resident #80 was diagnosed with a urinary tract infection. The daughter stated Resident #80 had not been at her home with her on 10/05/25, but stayed at the facility where she eloped on 10/05/25. She stated she waited with her mom at the facility until she fell asleep. She stated she moved her mom's belongings out of the facility on 10/13/25.

An observation on 10/30/25 at approximately 2:00 P.M. of the Memory Care Unit (MCU) revealed it was a secured unit where residents could walk freely throughout the unit. The front and back doors to enter and exit the unit were secured. The area surrounding the MCU had two elevators and a service hallway with doors to the kitchen, laundry and two exit doors to the outside parking lot.

A phone interview on 10/30/25 at 2:26 P.M. with Care Partner (CP) #301 revealed they were instructed to monitor the memory care (MC) door and not let anyone get out after elopement on 10/05/25. CP #301 stated on 10/08/25 she was assisting another resident back to her room for care when she heard the alarm go off. She stated by the time she got to the memory care door, Resident #80 was in the service hall area almost out a second door near the kitchen. A dietary aide was by her. She stated the resident was combative and would not come back in. CP #301 stated the other CP (#320) was on break and the nurse was watching the other residents in the dining room. Soon after, the nurse joined CP #301 outside with Resident #80 when the dietary aide came in to stay with the residents. CP #301 verified Resident #80 had been able to elope off the MCU.

A phone interview on 10/30/25 at 2:38 P.M. with LPN #402 revealed she received report about an elopement and to keep an eye on the resident and the door. She stated she was with other residents in the dining room which was around the corner from the exit. She stated Resident #80 sounded the door alarm on 10/08/25 around 6:50 P.M. stating it was hard to always have an eye on her. LPN #402 initially said both CPs ran to the door and hallway but, then corrected herself and stated Oh, it was only one CP who went to the door. She stated the dietary aide came in to say Resident #80 was outside with staff and would not come back in. LPN #402 went outside to assist but the resident was combative and using her walker to keep staff from her. The LPN was attempting to offer coffee and redirect but Resident #80 was getting more agitated. LPN #402 called the Assistant Director of Nursing (ADON) and the daughter. The ADON stated to call a squad. The squad showed up as well as police and the daughter. The resident got in daughter's car after some time and they sat outside for awhile. The daughter requested to take her mom home overnight. Medications were signed out to daughter.

A phone interview on 10/30/25 at 2:50 P.M. with CP #401 revealed she believed the facility needed someone to sit and watch Resident #80. She stated the MCU had three residents who required a mechanical lift which took time away from supervising other residents. In addition, staff were busy redirecting other residents. She stated it was hectic in MCU.

A phone interview on 10/30/25 at 5:55 P.M. with CP #320 revealed she was at lunch on 10/08/25 when Resident #80 eloped. She tried to check on her every 30 minutes. Resident #80 was in the living room prior to CP #320 going to lunch. Resident #80 used the restroom by the office. CP #320 clocked out at 6:45 P.M. and back in at 7:17 P.M. CP #320 also stated they had three residents who used a mechanical lift so it was hard to redirect Resident #80 and she was combative.

A phone interview on 11/03/25 at 8:24 A.M. with LPN #345 revealed both elopements happened on second shift stating it was most likely related to sundowning. She stated they were trying to get a urinalysis on her because of her behavior and tried to do more frequent checks and keep Resident #80 busy but did not specify how.

A phone interview on 11/03/25 at 8:32 A.M. with CP #313 revealed she only worked with Resident #80 a couple of times. She stated she stayed in her room except for meals. She did not recall any training on missing residents.

A phone interview on 11/03/25 at 10:01 A.M. with Program Manager #311 revealed she would try to engage Resident #80 and learn more about her. She tried to distract her with activities such as helping with making cookies and painting her nails. PM #311 stated she normally left for the day at 5:00 P.M. After that, CPs put on the T.V. for the news or residents did independent activities.

A phone interview on 11/03/25 at 11:17 A.M. with LPN #330 revealed a nurse called her from the parking lot for both elopements involving Resident #80. After the first elopement they checked the function of the doors and did more frequent checks (hourly). LPN #330 stated the daughter put a tracker in Resident #80's shoes and had access to that information but nursing did not. LPN #330 believed one elopement was at the back door (near the elevators in service hall) and the other one was by the front door of Memory Care Unit but she was not certain.

Review of the facility policy titled Missing Resident Policy

Based on record review, interview, policy review, and emergency services run report review, the facility failed to provide a safe and secure environment in the memory care unit to ensure Resident #46 could not exit via two exit doors, one of which was alarmed without staff knowledge. This affected one of 11 residents residing on the memory care unit.

Findings include:

Review of medical record for Resident #46 revealed an admission date of 08/02/23. Diagnoses included unspecified dementia without disturbances and hypertension. Resident #46 was alert to self and location.

Review of Resident #46's Service Plan revealed the resident was at risk for falls and wandering. Resident #46 had anxious, disruptive, and obsessive behaviors.

Review of the Personal Service Assessment dated 03/13/24 revealed Resident #46 had a behavior of wandering into other resident rooms and removing items, required assistance with toileting, showering, and dressing. Resident #46 was independent for locomotion via a manual wheelchair.

Review of a post fall progress note dated 09/03/24 timed 7:00 P.M. revealed Resident #46 had an unwitnessed fall and was found unresponsive with physical signs of head injury. Emergency Medical Serivec (EMS)/911 was called immediately. Resident #46 exited through a memory care unit door and then through an exterior door. The nurse was unable to turn Resident #46 due to position on stairs. Emergency Medical Technicians (EMTs) took over care upon arrival and initiated cardiopulmonary resuscitation (CPR) measures. Resident #46 was transferred into ambulance for further medical assist and then transported to hospital.

Observation on 09/12/24 at 9:10 A.M. revealed the door Resident #46 exited was located in the back of the memory care unit. The door was keypad protected (if code not entered prior to opening door alarm sounded). Upon exiting the door, the door locked and could not be re-entered. Standing on the landing there were stairs leading upwards and an exit door to the right. Upon exiting the door to the right, there were eight concrete steps leading to the parking lot.

Interview on 09/12/24 at 11:57 A.M. with Resident Care Assistant (RCA) #102 revealed during the evening on 09/03/24 staff and residents were in the day area watching television and socializing. Resident #46 propelled herself in her wheelchair over to RCA #102 and talked for a while (approximately 10 minutes). Resident #46 left the day area self propelling her wheelchair down the hallway toward her bedroom which was normal for her. A short time later RCA #102 heard an alarm sounding. RCA #102 went to one of the four doors in the memory care unit which was located by the elevators. Licensed Practical Nurse (LPN) #127 was already at this door checking to see if a resident had exited, they did not observe any residents. LPN #127 and RCA #102 went to the day area and completed a head count and realized two residents were missing (Residents #46 and #2). LPN #127 and RCA #102 went down the hallway checking resident rooms and common areas. RCA #102 went to Resident #46's room and the resident was not there, RCA #102 continued to the next room and observed Resident #2 walking in her room without her walker so she stopped to assist Resident #2 so she would not fall. Then, LPN #127 came running up the hallway directing RCA #102 to contact emergency services. RCA #102 went outside and observed Resident #46 lying face down on the concrete stairs. RCA #102 said Resident #46 was unresponsive and pulseless. They could not move Resident #46 due to her position on the stairs. Emergency services arrived, began CPR and transported Resident #46 to the hospital.

Interview on 09/14/24 at 10:56 A.M. with RCA #107 revealed on the evening of 09/03/24 Resident #46 propelled herself over to her and they chatted for about 10 minutes. After chatting, Resident #46 said she was going to her room to take a nap which was normal. RCA #107 stated approximately five minutes later the alarm sounded. All staff working in the memory care unit (RCA #107, RCA #102 and LPN #127) started looking for Resident #46. LPN #127 and RCA #107 found Resident #46 lying on the stairs. Resident #46 was unresponsive and had no pulse.

Interview on 09/14/24 at 11:38 A.M. with LPN #127 revealed on 09/03/24 she was starting the medication pass when she heard the alarm sound. LPN #127 ran to the annunciator panel to indentify the source of the alarm. The panel read priority one and two but did not identify the location of the alarm. LPN #127 went to the door by the elevator and observed no residents, then she directed the RCA to do a head count and the count revealed two residents missing. LPN #127 stated one RCA went down one hall while she went down another eventually locating Resident #46. LPN #127 found Resident #46 lying on the outside stairs face down. LPN #127 directed staff to contact emergency services. LPN #127 stated she could not move Resident #127 due to the resident's position. LPN #127 stated Resident #46 had no history of hanging around exit doors, pushing on the doors or following staff when exiting the unit. LPN #127 said family recently visited Resident #46 and accidentally opened a secured door which sounded the alarm. LPN #127 stated she thought that might have been the trigger for Resident #46 to exit the unit.

Interview with the Administrator revealed after the incident additional sensors were placed on the exit doors on the memory care unit. The sensor would send an alert to pagers held by all staff on the unit. Staff were to check all doors and the annunciator panel when the signal was received.

Review of the annuciator alarm report from the day of the incident (09/03/24) revealed multiple alerts were indicated on the annunciator panel between 6:58 P.M. and 7:15 P.M.

Review of the emergency service run report dated 09/03/24 revealed the call from the facility was received at at 7:11 P.M. The dispatch note indicated resident fell outside, not breathing. EMS arrived on scene at 7:15 P.M. The narrative history text revealed units arrived on scene to find Resident #46 lying face down at the bottom of 3-4 concrete steps pulseless and apeneic. Manual CPR was initiated. The run report indicated Resident #46 had a pulse upon arrival to hospital. Additional notes on the report indicated staff stated they heard an alarm go off around 7:00 P.M. and did not find Resident #46 until around 7:10 P.M. Resident #46 was in a wheelchair which was next to her when EMS arrived. Resident #46 had a large laceration to the forehead with coagulated blood upon arrival. Resident #46 also had a laceration around her bottom lip with coagulated blood around her mouth.

Review of the facility policy titled Missing Resident dated 2021 revealed a missing resident required immediate associate attention. If associates discovered a resident's whereabouts were unknown, associates were to immediately begin to follow the procedures of the Missing Resident Policy. A visual (face to face) observation of the missing resident was considered confirmation that the resident had been found. The policy indicated to follow the steps below until the resident was found.

Check the Sign-In/Sign-Out book

Conduct thorough interior search of community including, but not limited to, all resident rooms, common areas, closets, stairwells, offices, and rest rooms. Consider even small spaces such as under beds and behind furniture.

If found, complete an Incident Report. If not found, continue to the next step.

Follow procedure in Missing Resident Response Worksheet. Associates were to initiate a head count of all residents. A head count was defined as the visual inspection/face-to-face observation and counting of the residents. A head count of residents was required to confirm and validate the presence of every resident.

Conduct thorough exterior search of the immediate grounds. Again, consider small hiding spaces such as behind bushes, culverts, etc.

This violation represents non-compliance investigated under Complaint Number OH00157778.