Lorain Estates Senior Living

Based on observation and staff interview, the facility failed to keep dryers free of lint and debris. This had the potential to affect all residents. The facility census was 65.

Findings include:

Observation on 07/09/25 at 10:02 A.M. of the memory care laundry room revealed one washer and one dryer. Behind the dryer was a build up of lint. Also behind the dryer was an empty gallon container of laundry soap, an empty disinfectant spray bottle, and two socks.

Interview with Resident Assistant (RA) #513 on 07/09/25 at 10:02 A.M. confirmed there was a build up of lint behind the dryer, and there was also a gallon container of laundry soap, and empty disinfectant spray bottle, and two socks. RA #513 was unsure how often behind the dryers were cleaned and stated that third shift does the laundry.

Interview with Maintenance Director (MD) #503 on 07/09/25 at 12:30 P.M. revealed environmental services are supposed to clean behind the dryers weekly, however there was no log or schedule provided when asked.

Requested policy from MD #503 on 07/09/25 at 3:15 P.M. for dryer maintenance, however the facility was unable to provide a policy.

Based on review of the alarm transmission receipts and staff interview, the facility failed to obtain transmission receipts after fire drills for four (09/30/24, 11/29/24, 03/12/25, and 06/11/25) out of 12 months reviewed for fire alarm transmission receipts. This had the potential to affect all residents. The facility census was 65.

Findings include:

Review of the transmission receipts after fire drills were conducted revealed on 09/30/24,11/29/24, 03/12/25, and 06/11/25 transmission receipts were not obtained from the alarm company.

Interview on 07/09/25 at 2:30 P.M. with Maintenance Director (MD) #503 confirmed transmission receipts were not obtained from the alarm company after fire drills were conducted on 09/03/24, 11/29/24, 03/12/25, and 06/11/25.

Requested policy on 07/09/25 at 2:30 P.M. for fire safety from MD #503, the facility was unable to provide a policy.

Based on facility fire safety review and staff interview, the facility failed to conduct annual fire prevention training courses for employees. This had the potential to affect all residents. The facility census was 65.

Findings include:

Review of the facility fire safety book revealed no annual fire prevention training courses completed by employees.

Interview on 07/09/25 at 11:30 A.M. with Maintenance Director (MD) #503 revealed he was unaware staff needed annual training for fire prevention and furthermore confirmed there was no annual fire prevention training courses complete.

Requested policy from MD#503 for fire safety on 07/10/25 at 11:30 A.M. and the facility was unable to provide.

Based on record review, staff interviews, family interview, observation, review of facility self-reported incidents (SRI), and review of written statements, the facility failed ensure residents were transferred safely and in a manner to prevent injury. This affected two (Resident #8 and #12) of three residents reviewed for transfers. The facility census was 67.

Findings include:

1. Review of the medical record for Resident #8 revealed an admission date of 12/10/24. Diagnoses included Parkinson's disease, dementia, hypertension, high cholesterol, and chronic obstructive pulmonary disease.

Review of the resident assessment dated 01/30/25 revealed Resident #8 was severely cognitively impaired. The resident used a walker and was independent with transfers. Depending on the living room chair they sat in, they may have needed assistance getting out of the chair with a gait belt.

Review of the facility SRI revealed on 03/23/25 at 6:00 P.M. Resident #8 reported Caregiver #498 had hit her. Upon investigation, Resident #8 had bruising on their forearms which appeared to be from hand placement during improper transfers. During interviews, some caregivers admitted to transferring residents improperly and observing other caregivers transferring improperly, holding residents by the forearms.

Review of the written statement, dated 03/24/25, provided by Caregiver #855, revealed the staff member had observed other staff transferring residents by holding onto their forearms to lift them.

Review of the nursing progress notes dated 03/26/25 and timed 9:39 A.M. revealed a bruise was noted on Resident #8's lower arm. Upon investigation, it was determined the bruise came from improper transfers.

Interview on 04/03/25 at 10:52 A.M. with Caregiver #855 revealed a lot of staff members would transfer residents by holding onto their forearms and pulling them up. Caregiver #855 reported seeing Resident #8 transferred by staff members holding onto her forearms and pulling her up. Caregiver #855 reported Resident #8 would have bruises on her arms and Caregiver #855 knew it was from her being transferred by her arms.

Interview on 04/03/25 at 11:32 A.M. with Caregiver #600 revealed the staff member had witnessed another staff member transferring Resident #8 by holding onto her forearms on either 03/28/25 or 03/29/25.

Interview on 04/03/25 at 2:06 P.M. with Resident #8's daughter revealed Resident #8 had some bruises on her arms which looked like fingerprints.

Observation on 04/03/25 at 2:27 P.M. with Resident #8's daughter revealed Resident #8 had multiple bruises on each of her forearms.

2. Review of the medical record for Resident #12 revealed an admission date of 07/26/24. Diagnoses included vascular dementia, chronic kidney disease, gastro-esophagael reflux disease, heart failure, vertigo, chronic obstructive pulmonary disease, aphasia, insomnia, depression, and anxiety.

Review of the resident assessment dated 03/17/25 revealed Resident #12 was severely cognitively impaired. The resident required physical assistance of one staff member via gait belt for transfers.

Review of the facility SRI revealed that on 03/23/25 at 6:00 P.M. another resident (Resident #8) had reported Caregiver #498 had hit her. Upon investigation, Resident #8 and Resident #12 had bruising on their forearms which appeared to be from hand placement during improper transfers. During interviews, some caregivers admitted to transferring residents improperly and observing other caregivers transferring improperly, holding residents by the forearms.

Review of the written statement, dated 03/24/25, provided by Caregiver #855, revealed the staff member had observed other staff transferring residents by holding onto their forearms to lift them.

Review of the written statement, dated 03/24/25, provided by Caregiver #902, revealed the staff member had transferred Resident #12 by holding onto their forearms.

Review of the nursing progress notes dated 03/25/25 and timed 3:33 P.M. revealed staff noted bruises to left and right arms/hands. Upon investigation, it was determined this was due to improper transfers with staff.

Interview on 04/03/25 at 10:52 A.M. with Caregiver #855 revealed a lot of staff members would transfer residents by holding onto their forearms and pulling them up. Caregiver #855 verified this was not the proper way to transfer residents.

Observation on 04/03/25 at 4:53 P.M. with the Director of Nursing revealed Resident #12 had bruises on the top of both of her lower arms and a bruise on her right hand.

This violation represents non-compliance investigated under Complaint Number OH00164224.

Based on record review, staff interviews, review of facility self-reported incidents (SRI), review of written statements, and policy review, the facility failed to ensure residents were free from verbal abuse. In addition, the facility failed to timely report allegations of verbal abuse and failed to implement their policy to immediately protect residents from further abuse. This affected two (Resident #5 and #8) of three residents reviewed for abuse. The facility census was 67.

Findings include:

1. Review of the medical record for Resident #5 revealed an admission date of 03/14/21. Diagnoses included dementia, hypertension, depression, gastro-esophageal reflux disease, ataxic gait, and hypernatremia.

Review of the resident assessment dated 03/06/25 revealed Resident #5 was severely cognitively impaired.

Review of the SRI dated 03/26/25 revealed on 03/23/25 at 6:00 P.M., another resident (Resident #8) reported Caregiver #498 hit her. During the course of the investigation, two caregivers reported seeing Caregiver #498 being verbally abusive toward residents on the memory care unit. The facility substantiated verbal abuse toward residents by Caregiver #498.

Review of the written statement, dated 03/24/25, provided by Caregiver #600, revealed Caregiver #498 would yell at, curse at, and make threats to residents. Caregiver #600 reported Caregiver #498 became angry when Resident #5 asked for snacks. Caregiver #600 reported observing Caregiver #498 saying I will lay your explicit on the floor

Based on observation, medical record review, review of a local police department (LPD) incident run sheet, resident interview, family interview, staff interviews, ice cream parlor owner (ICP) interview and review of the facility policy, the facility failed to provide adequate supervision to prevent Resident #56, who had a diagnosis of Alzheimer ' s disease with severe cognitive impairment and a history of wandering, from eloping from a facility organized community outing. This resulted in Real and Present Danger and placed the resident at risk for the potential for serious harm, injury and/or death on 08/23/24 at approximately 2:30 P.M., when facility staff and residents arrived at an ice cream parlor and Resident #56 was not provided direct supervision. Without staff knowledge, Resident #56 wandered away from the group. When Activities Assistant (AA) #272 noticed the resident was missing, staff began searching the area around the ice cream parlor and were unable to locate Resident #56. The LPD received a call from a concerned individual at a laundromat, approximately 0.5 miles from the ice cream parlor, who reported a confused person was wanting a ride home. The caller stated the person was not sure of her name or where she lived. When facility staff were unable to locate Resident #56, Residential Experience Director (RED) #205 reported the resident missing to the LPD. The LPD was dispatched to the laundromat, confirmed Resident #56 ' s identity and notified RED #205 the resident was found and provided her location. Facility staff picked Resident #56 up from the laundromat. Due to inadequate supervision, Resident #56 was missing for approximately one hour, was confused and lost in an area approximately 30 miles away from the facility and walked approximately 0.5 miles along a heavily traveled two-lane road with a speed limit of 35 miles per hour (mph). This affected one (#56) of one resident reviewed for elopement, with the potential to affect six additional residents (#49, #54, #55, #58, #63, and #66) identified by the facility to be at risk for elopement and who participated in community outings. The facility census was 68. On 09/04/24 at 1:10 P.M., the Executive Director (ED) and Health Service Director (HSD) #201 were notified Real and Present Danger began on 08/23/24 at 2:30 P.M. when Resident #56 wandered off from a supervised community outing without staff knowledge. Resident #56 was subsequently located approximately 0.5 miles away at a laundromat. During the community outing, staff failed to provide adequate supervision, which placed Resident #56 at risk for potential serious injury, harm, and/or death to include, but not limited to, the risk of being hit by a car while being lost, confused and walking along a two-lane road with speed limits of 35 mph. The Real and Present Danger was removed on 08/24/24 when the facility implemented the following corrective action: On 08/23/24, Licensed Practical Nurse (LPN) #208 assessed Resident #56 for injuries, with no injuries noted. LPN #208 interviewed Resident #56, who indicated she was looking for the kids when she wandered away from the community outing. On 08/23/24, the ED initiated an investigation into the incident. On 08/26/24, the investigation was completed, and the root cause was determined to be inadequate supervision provided to Resident #56 by the life enrichment staff during the community outing. Beginning on 08/24/24, all community outings for memory care residents was placed on hold pending implementation of additional corrective actions. On 08/29/24, an Interdisciplinary Team (IDT) meeting was held to review and update Resident #56 ' s plan of care. In attendance were the ED, HSD #201, Vice President of Clinical Operations (VPCO) #400 and Regional Director of Operations (RDO) #405. The IDT reviewed the elopement policy and developed further interventions to prevent future incidents of elopement on community outings. Beginning on 08/29/24, the ED will complete audits of all memory care resident outings for three months to ensure all corrective action procedures are followed. Beginning on 08/29/24, the ED and RED #205 will ensure all community outings for memory care residents will be in the immediate area of the facility. Beginning on 08/29/24, the ED and RED #205 will ensure community outing supervision levels for memory care residents is two staff to one resident. Beginning on 08/29/24, RED #205 will ensure sufficient staff is available for community outings and assign staff to provide direct supervision for specific memory care residents. By 09/06/24, RED #205 will order lanyards for each memory care resident to be worn for identification purposes during community outings. The information on the lanyards will include name, responsible party name and phone number, and facility name and contact information. RED #205 will be responsible for ensuring lanyards are worn by memory care residents during each community outing. By 09/06/24, the ED or RED #205 will provide education to all AAs and bus drivers on changes made to supervision levels and lanyard use during community outings for memory care residents, as well as the elopement policy. Any negative findings on audits completed by the ED will result in a temporary hold on community outings for memory care residents until re-education is provided to pertinent staff. The ED is responsible for on-going compliance. Although the Real and Present Danger was abated on 08/24/24, the violation continues as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #56 revealed an admission date of 07/06/22. Diagnoses included arthritis, Alzheimer ' s disease and cataracts. Review of the semi-annual assessment, dated 07/17/24, revealed Resident #56 had impaired cognition. Resident #56 was independent with ambulation. While Resident #56 was assessed to not have wandering behavior, she was identified as easily distracted. Review of the elopement risk assessment, dated 07/17/24, revealed Resident #56 was at moderate risk for elopement. Review of the plan of care, dated 08/24/24, revealed Resident #56 was at risk for elopement. Interventions included ensure staff was always with the resident during activities outside of the secured memory care unit and encourage the resident to participate in all activities. Review of a progress note dated 08/23/24, and completed by the ED, revealed on 08/23/24 at 2:30 P.M., six residents (#01, #06, #08, #45, #56, and #58) and three employees (RED #205, AA #272 and Bus Driver [BD] #276) arrived at an ice cream parlor to meet an additional ten residents and two staff from a sister facility to socialize. At 3:20 P.M., RED #205 notified the ED that AA #272 noticed Resident #56 was unaccounted for. BD #276 was instructed to stay with the residents while AA #272 began searching for the resident. The ice cream parlor was notified of the missing resident and began looking through security video. RED #205 notified the police at 3:31 P.M. The police received a report from a concerned individual who spotted Resident #56 at a laundromat approximately 0.5 miles away. The police officer stayed with Resident #56. At approximately 3:40 P.M., the resident was picked up by the van. Resident #56 was unharmed, confused and stated, I wanted to go see the kids. The ED notified Resident #56 ' s family. Resident #56 returned from the outing. It was stated the resident wandered off and was found a mile away. Resident #56 was crying and stated she was tired and wanted to lay down. The resident was assessed for injuries and skin issues with no concerns noted. Review of the LPD Incident Run Sheet, dated 08/23/24, revealed the nature of the incident was a missing person. On 08/23/24 at 3:15 P.M., a caller at the laundromat stated a confused female asked her for a ride home and was not sure of her name or where she lived. The caller stated she (Resident #56) looked scared. At 3:26 P.M., a report of a missing elderly female with dementia, in her late 80 ' s and wearing a tan sweatshirt and blue jeans, was received. At 3:27 P.M., units were dispatched to the laundromat and at 3:41 P.M., the resident was back in facility custody. Review of the post-elopement form, dated 08/26/24, revealed the area of the ice cream parlor was busy. Residents were conversating, eating and sharing painted rocks. Interventions used during the elopement included assigning staff to certain areas and notifying the police. The intervention that worked was notifying the police. There were no changes to the resident ' s baseline behavior. Observation on 09/03/22 at 9:00 A.M. revealed Resident #56 was able to ambulate without difficulty; however, she needed cuing on where to sit. Interviews on 09/03/24 from 10:41 A.M. to 11:38 A.M. with Licensed Practical Nurse (LPN) # 212, Resident Assistant (RA) #216, RA #219, RA #225 and RA #236 revealed Resident #56 did not like to sit for long periods of time and would get up and wander around the secured unit. Additionally, the staff stated Resident #56 would follow other residents who attempted to exit the unit. Interview on 09/03/24 at 11:20 A.M. with Resident #56 revealed she remembered going out for ice cream, but did not recall the events of that afternoon and asked if something happened. Interview on 09/03/24 at 12:10 P.M. with AA #272 revealed she was on the community outing on 08/23/24. AA #272 stated she initially paired Resident #56 and Resident #58 to be buddies throughout the outing. At the ice cream parlor, both residents were seated at the same table. AA #272 took Resident #58 to socialize with a resident from their sister community. This left Resident #56 by herself. AA #272 remembered Resident #56 eating her ice cream. AA #272 stated she had her back to Resident #56, while interacting with another resident, and did not notice when she wandered off. AA #272 was uncertain how long Resident #56 was gone. Following the incident, AA #272 stated Resident #56 indicated she was ok and was very quiet on the bus ride back to the facility. AA #272 stated she should have been more aware of the situation as Resident #56 previously wandered off during an in-house activity into the enclosed courtyard and was unable to get back into the building. Interview on 09/03/24 at 12:38 P.M. with BD #276 revealed once the two groups (facility staff and residents and sister facility staff and residents) got together at the ice cream parlor and started to intermingle, it was easy to lose track of the residents due to all the people. BD #276 stated he was unaware of Resident #56 ' s history of wandering off and should have paid more attention. Interview on 09/03/24 at 1:58 P.M. with RED #205 verified Resident #56 eloped during a community outing, approximately 30 miles away from the facility. RED #205 stated the precipitating factor to the incident was that residents were not assigned to certain staff members. Between the two facilities, RED #205 stated there were 16 residents and five staff members. AA #272 noticed Resident #56 was missing, a search was initiated, and the police were notified. RED #205 stated the owner of the ice cream parlor offered to look at the security video but she did not view it. RED #205 confirmed Resident #56 was located at a laundromat approximately 0.5 miles away from the ice cream parlor. RED #205 stated Resident #56 was quiet on the way back to the facility and stated she wanted to go see the kids. Interview on 09/03/24 at 2:54 P.M. with the ED revealed the IDT reviewed Resident #56 ' s elopement and identified corrective action, to include education to activities staff. In addition, a new process was being implemented in which memory care residents would wear a lanyard with identifying information, including name, facility contact information and the resident ' s responsible party contact information. The ED stated the IDT determined the root cause of the incident was related to supervision. Interview on 09/03/24 at 3:01 P.M. with HSD #201 revealed when she was notified of Resident #56 ' s elopement, she contacted the resident ' s family. HSD #201 stated the family indicated they were fine with the elopement. HSD #201 stated Resident #56 ' s care plan was updated to ensure staff were always with the resident during activities outside of the secured memory care unit. HSD #201 stated RED #205 was in the process of training activities staff on the new procedures. Interview on 09/03/24 at 5:00 P.M. with ICP #500 revealed when she heard that a person had wandered off, she had her husband review the security video. ICP #500 stated Resident #56 was seen standing up by the picnic table and started swaying back and forth. Resident #56 then walked to the front of building and headed north down the street. ICP #500 stated she informed facility staff of the direction Resident #56 went in, and they had everyone get in the bus and went in that direction. ICP #500 stated no one from the facility viewed the video and it was no longer available to get more details related to the incident. Interview on 09/04/24 at 10:28 A.M. with Resident #56 ' s son revealed he and his sister were upset about staff letting his mother walk away from a supervised outing and were happy she was found safe. Review of facility policy titled Elopement-Missing ResidentBased on observation, medical record review, review of a local police department (LPD) incident run sheet, resident interview, family interview, staff interviews, ice cream parlor owner (ICP) interview and review of the facility policy, the facility failed to provide adequate supervision to prevent Resident #56, who had a diagnosis of Alzheimer ' s disease with severe cognitive impairment and a history of wandering, from eloping from a facility organized community outing. This resulted in Real and Present Danger and placed the resident at risk for the potential for serious harm, injury and/or death on 08/23/24 at approximately 2:30 P.M., when facility staff and residents arrived at an ice cream parlor and Resident #56 was not provided direct supervision. Without staff knowledge, Resident #56 wandered away from the group. When Activities Assistant (AA) #272 noticed the resident was missing, staff began searching the area around the ice cream parlor and were unable to locate Resident #56. The LPD received a call from a concerned individual at a laundromat, approximately 0.5 miles from the ice cream parlor, who reported a confused person was wanting a ride home. The caller stated the person was not sure of her name or where she lived. When facility staff were unable to locate Resident #56, Residential Experience Director (RED) #205 reported the resident missing to the LPD. The LPD was dispatched to the laundromat, confirmed Resident #56 ' s identity and notified RED #205 the resident was found and provided her location. Facility staff picked Resident #56 up from the laundromat. Due to inadequate supervision, Resident #56 was missing for approximately one hour, was confused and lost in an area approximately 30 miles away from the facility and walked approximately 0.5 miles along a heavily traveled two-lane road with a speed limit of 35 miles per hour (mph). This affected one (#56) of one resident reviewed for elopement, with the potential to affect six additional residents (#49, #54, #55, #58, #63, and #66) identified by the facility to be at risk for elopement and who participated in community outings. The facility census was 68.

On 09/04/24 at 1:10 P.M., the Executive Director (ED) and Health Service Director (HSD) #201 were notified Real and Present Danger began on 08/23/24 at 2:30 P.M. when Resident #56 wandered off from a supervised community outing without staff knowledge. Resident #56 was subsequently located approximately 0.5 miles away at a laundromat. During the community outing, staff failed to provide adequate supervision, which placed Resident #56 at risk for potential serious injury, harm, and/or death to include, but not limited to, the risk of being hit by a car while being lost, confused and walking along a two-lane road with speed limits of 35 mph.

The Real and Present Danger was removed on 08/24/24 when the facility implemented the following corrective action:

On 08/23/24, Licensed Practical Nurse (LPN) #208 assessed Resident #56 for injuries, with no injuries noted. LPN #208 interviewed Resident #56, who indicated she was looking for the kids when she wandered away from the community outing.

On 08/23/24, the ED initiated an investigation into the incident. On 08/26/24, the investigation was completed, and the root cause was determined to be inadequate supervision provided to Resident #56 by the life enrichment staff during the community outing.

Beginning on 08/24/24, all community outings for memory care residents was placed on hold pending implementation of additional corrective actions.

On 08/29/24, an Interdisciplinary Team (IDT) meeting was held to review and update Resident #56 ' s plan of care. In attendance were the ED, HSD #201, Vice President of Clinical Operations (VPCO) #400 and Regional Director of Operations (RDO) #405. The IDT reviewed the elopement policy and developed further interventions to prevent future incidents of elopement on community outings.

Beginning on 08/29/24, the ED will complete audits of all memory care resident outings for three months to ensure all corrective action procedures are followed.

Beginning on 08/29/24, the ED and RED #205 will ensure all community outings for memory care residents will be in the immediate area of the facility.

Beginning on 08/29/24, the ED and RED #205 will ensure community outing supervision levels for memory care residents is two staff to one resident.

Beginning on 08/29/24, RED #205 will ensure sufficient staff is available for community outings and assign staff to provide direct supervision for specific memory care residents.

By 09/06/24, RED #205 will order lanyards for each memory care resident to be worn for identification purposes during community outings. The information on the lanyards will include name, responsible party name and phone number, and facility name and contact information. RED #205 will be responsible for ensuring lanyards are worn by memory care residents during each community outing.

By 09/06/24, the ED or RED #205 will provide education to all AAs and bus drivers on changes made to supervision levels and lanyard use during community outings for memory care residents, as well as the elopement policy.

Any negative findings on audits completed by the ED will result in a temporary hold on community outings for memory care residents until re-education is provided to pertinent staff.

The ED is responsible for on-going compliance.

Although the Real and Present Danger was abated on 08/24/24, the violation continues as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.

Findings include:

Review of the medical record for Resident #56 revealed an admission date of 07/06/22. Diagnoses included arthritis, Alzheimer ' s disease and cataracts.

Review of the semi-annual assessment, dated 07/17/24, revealed Resident #56 had impaired cognition. Resident #56 was independent with ambulation. While Resident #56 was assessed to not have wandering behavior, she was identified as easily distracted.

Review of the elopement risk assessment, dated 07/17/24, revealed Resident #56 was at moderate risk for elopement.

Review of the plan of care, dated 08/24/24, revealed Resident #56 was at risk for elopement. Interventions included ensure staff was always with the resident during activities outside of the secured memory care unit and encourage the resident to participate in all activities.

Review of a progress note dated 08/23/24, and completed by the ED, revealed on 08/23/24 at 2:30 P.M., six residents (#01, #06, #08, #45, #56, and #58) and three employees (RED #205, AA #272 and Bus Driver [BD] #276) arrived at an ice cream parlor to meet an additional ten residents and two staff from a sister facility to socialize. At 3:20 P.M., RED #205 notified the ED that AA #272 noticed Resident #56 was unaccounted for. BD #276 was instructed to stay with the residents while AA #272 began searching for the resident. The ice cream parlor was notified of the missing resident and began looking through security video. RED #205 notified the police at 3:31 P.M. The police received a report from a concerned individual who spotted Resident #56 at a laundromat approximately 0.5 miles away. The police officer stayed with Resident #56. At approximately 3:40 P.M., the resident was picked up by the van. Resident #56 was unharmed, confused and stated, I wanted to go see the kids. The ED notified Resident #56 ' s family. Resident #56 returned from the outing. It was stated the resident wandered off and was found a mile away. Resident #56 was crying and stated she was tired and wanted to lay down. The resident was assessed for injuries and skin issues with no concerns noted.

Review of the LPD Incident Run Sheet, dated 08/23/24, revealed the nature of the incident was a missing person. On 08/23/24 at 3:15 P.M., a caller at the laundromat stated a confused female asked her for a ride home and was not sure of her name or where she lived. The caller stated she (Resident #56) looked scared. At 3:26 P.M., a report of a missing elderly female with dementia, in her late 80 ' s and wearing a tan sweatshirt and blue jeans, was received. At 3:27 P.M., units were dispatched to the laundromat and at 3:41 P.M., the resident was back in facility custody.

Review of the post-elopement form, dated 08/26/24, revealed the area of the ice cream parlor was busy. Residents were conversating, eating and sharing painted rocks. Interventions used during the elopement included assigning staff to certain areas and notifying the police. The intervention that worked was notifying the police. There were no changes to the resident ' s baseline behavior.

Observation on 09/03/22 at 9:00 A.M. revealed Resident #56 was able to ambulate without difficulty; however, she needed cuing on where to sit.

Interviews on 09/03/24 from 10:41 A.M. to 11:38 A.M. with Licensed Practical Nurse (LPN) # 212, Resident Assistant (RA) #216, RA #219, RA #225 and RA #236 revealed Resident #56 did not like to sit for long periods of time and would get up and wander around the secured unit. Additionally, the staff stated Resident #56 would follow other residents who attempted to exit the unit.

Interview on 09/03/24 at 11:20 A.M. with Resident #56 revealed she remembered going out for ice cream, but did not recall the events of that afternoon and asked if something happened.

Interview on 09/03/24 at 12:10 P.M. with AA #272 revealed she was on the community outing on 08/23/24. AA #272 stated she initially paired Resident #56 and Resident #58 to be buddies throughout the outing. At the ice cream parlor, both residents were seated at the same table. AA #272 took Resident #58 to socialize with a resident from their sister community. This left Resident #56 by herself. AA #272 remembered Resident #56 eating her ice cream. AA #272 stated she had her back to Resident #56, while interacting with another resident, and did not notice when she wandered off. AA #272 was uncertain how long Resident #56 was gone. Following the incident, AA #272 stated Resident #56 indicated she was ok and was very quiet on the bus ride back to the facility. AA #272 stated she should have been more aware of the situation as Resident #56 previously wandered off during an in-house activity into the enclosed courtyard and was unable to get back into the building.

Interview on 09/03/24 at 12:38 P.M. with BD #276 revealed once the two groups (facility staff and residents and sister facility staff and residents) got together at the ice cream parlor and started to intermingle, it was easy to lose track of the residents due to all the people. BD #276 stated he was unaware of Resident #56 ' s history of wandering off and should have paid more attention.

Interview on 09/03/24 at 1:58 P.M. with RED #205 verified Resident #56 eloped during a community outing, approximately 30 miles away from the facility. RED #205 stated the precipitating factor to the incident was that residents were not assigned to certain staff members. Between the two facilities, RED #205 stated there were 16 residents and five staff members. AA #272 noticed Resident #56 was missing, a search was initiated, and the police were notified. RED #205 stated the owner of the ice cream parlor offered to look at the security video but she did not view it. RED #205 confirmed Resident #56 was located at a laundromat approximately 0.5 miles away from the ice cream parlor. RED #205 stated Resident #56 was quiet on the way back to the facility and stated she wanted to go see the kids.

Interview on 09/03/24 at 2:54 P.M. with the ED revealed the IDT reviewed Resident #56 ' s elopement and identified corrective action, to include education to activities staff. In addition, a new process was being implemented in which memory care residents would wear a lanyard with identifying information, including name, facility contact information and the resident ' s responsible party contact information. The ED stated the IDT determined the root cause of the incident was related to supervision.

Interview on 09/03/24 at 3:01 P.M. with HSD #201 revealed when she was notified of Resident #56 ' s elopement, she contacted the resident ' s family. HSD #201 stated the family indicated they were fine with the elopement. HSD #201 stated Resident #56 ' s care plan was updated to ensure staff were always with the resident during activities outside of the secured memory care unit. HSD #201 stated RED #205 was in the process of training activities staff on the new procedures.

Interview on 09/03/24 at 5:00 P.M. with ICP #500 revealed when she heard that a person had wandered off, she had her husband review the security video. ICP #500 stated Resident #56 was seen standing up by the picnic table and started swaying back and forth. Resident #56 then walked to the front of building and headed north down the street. ICP #500 stated she informed facility staff of the direction Resident #56 went in, and they had everyone get in the bus and went in that direction. ICP #500 stated no one from the facility viewed the video and it was no longer available to get more details related to the incident.

Interview on 09/04/24 at 10:28 A.M. with Resident #56 ' s son revealed he and his sister were upset about staff letting his mother walk away from a supervised outing and were happy she was found safe.

Review of facility policy titled Elopement-Missing Resident