Eden Vista of Stow

Based on record review, interview, observation, and policy review the facility failed to ensure medications were administered as ordered and appropriately documented. This affected two of the three sampled residents (Residents #24 and #11). Facility census was 69.

Findings include:

1. Record review revealed Resident #24 was admitted on 10/04/24 with diagnoses of transient cerebral ischemic attack, hemiplegia and hemiparesis, chronic kidney disease stage three, and type two diabetes mellitus. Review of the service plan with an effective date of 11/29/24 revealed Resident #24 had no cognitive deficit.

Review of the Medication Information form revealed Resident #24's medications were reconciled however the form was not signed or dated so the date of completion and individual who completed the reconciliation could not be verified.

Review of current physician orders revealed Resident #24 was ordered lisinopril 40 milligram (mg) every morning for hypertension, pregabalin 25 mg twice daily for neuropathy, Protonix 25 mg every morning for gastroesophogeal reflux disease, amlodipine besylate 10 mg for hypertension, hydrochlorathiazide 25 mg every morning for hypertension, tamsulosin 0.4 mg at bedtime for benign prostatic hyperplasia, trazadone 50 mg at bedtime for insomnia, Eliquis 5 mg twice daily (blood thinner), guaifenesin extended release (ER) 600 mg twice daily for congestion, Trulicity pen injector 3 mg subcutaneously (SQ) every Tuesday for diabetes, Insulin Glargine Solostar pen injector 16 units SQ every 12 hours for diabetes, Humalog injection solution (Insulin Lispro) inject per sliding scale before meals for diabetes, loperamide 2 mg every eight hours as needed for diarrhea, and ondansetron HCL 4 mg every six hours as needed for nausea and vomiting for five days (ordered 01/03/25).

Review of the January 2025 Medication Administration Record (MAR) revealed Resident #24 did not receive the 4:00 P.M. dose of Eliquis 5 mg on 01/14/25; guaifenesin ER 600 mg on 01/14/25; blood sugar check or Humalog insulin (sliding scale) on 01/14/25 at 7:00 A.M., 11:00 A.M., and 4:00 P.M. This was evidenced by the field left blank on the MAR.

Review of the February 2025 MAR revealed Resident #24 did not receive a blood sugar check or Humalog insulin (sliding scale) on 02/16/25 at 7:00 A.M. This was evidenced by the field left blank on the MAR.

Review of the March 2025 MAR revealed Resident #24 did not receive amlodipine besylate 10 mg, hydrochlorathiazide 25 mg on 03/18/24 and 03/19/25; lisinopril 40 mg on 03/15/25, 03/17/25, 03/18/25 and 03/19/25; Protonix 20 mg on 03/15/25, 03/17/25, and 03/18/25; Eliquis 5 mg on 03/08/25. The reason listed was medication not available from pharmacy.

Interview on 03/19/25 at 10:44 A.M. with Resident #24 revealed medications were not administered as ordered, his medications were misplaced for a while. Resident #24 further indicated on the morning of 03/19/25 the nurse only located one medication, so only one was administered but there should have been four. Resident #24 was unable to identify which medications were not received.

Interview on 03/19/25 at 3:12 P.M. with Licensed Practical Nurse (LPN) #135 revealed some medications were unavailable for Resident #24 because they had not been reordered from the pharmacy. LPN #135 stated I have nothing to give him. I gotta call the pharmacy. LPN #135 revealed the pharmacy sent 14-day supplies, so medications had to be reordered every two weeks.

Observation of the medication cart that held Resident #24's medications on 03/19/25 at 3:38 P.M. revealed the cart only contained pantoprazole (Protonix) 20 mg, loperimide 2 mg, ondansetron HCL 4 mg and trazadone 50 mg.

Interview with the Executive Director/Wellness Director on 03/20/25 at 10:45 A.M. confirmed the March 2025 MAR showed medications were not available from pharmacy and based on the January and February 2025 MARs, it could not be confirmed Resident #24 received his medications as evidenced by the blank fields.

2. Record review for Resident #11 revealed an admission date of 09/26/24 with diagnoses of hypomagnesemia, end stage heart failure, and type 2 diabetes mellitus with diabetic chronic kidney disease.

Review of the physician orders for January 2025 revealed Resident #11 had orders for Lantus Solostar subcutaneous solution pen-injector 80 units at bedtime, Humalog KwikPen subcutaneous solution pen-injector to inject per sliding scale, and NovoFine Autocover Pen Needle, inject 1 device subcutaneously four times a day.

Review of the January 2025 Medication Administration Record (MAR) revealed sliding scale Lantus Solostar insulin was not administered on 01/22/25 at 7:00 A.M. or 11:00 A.M. due to the facility not having test strips to check Resident #11's blood sugar.

Review of the progress note dated 01/22/25 revealed Licensed Practical Nurse (LPN) #153 notified Nurse Practitioner (NP) #164 that Resident #11 did not have a blood glucose tests at 7:00 A.M. or 11:00 A.M. and that his 4:00 P.M. glucose test was done at 6:30 P.M. due to waiting for the arrival of glucose test strips from the pharmacy. The blood sugar check at 6:30 P.M. revealed a blood sugar of 404 at which time LPN #153 administered 12 units of insulin. Resident #11 had no signs or symptoms of hypo or hyperglycemic reaction which included lightheadedness or dizziness. No new orders were received at that time.

Review of progress note dated 03/03/25 revealed LPN #153 reordered Resident #11's Lantus insulin and requested it be drop shipped because the facility's starter box was depleted of Lantus insulin. The pharmacy agreed to have it dropped shipped.

Review of the Medication Administration Policy and Procedure revised 05/31/22 revealed Step #18 complete the medication administration by correctly documenting medication administration.

This violation represents non-compliance investigated under Complaint Number OH00163519 and OH00163245.

Based on record review and interview the facility failed to ensure necessary diabetic supplies were in the facility to provide appropriate diabetic care. This affected one (Resident #11) of three residents reviewed for diabetic supplies. Facility census was 69.

Findings include:

Record review for Resident #11 revealed an admission date of 09/26/24 with diagnoses of hypomagnesemia, end stage heart failure, and type two diabetes mellitus with diabetic chronic kidney disease.

Review of the physician orders for January 2025 revealed Resident #11 had orders for Lantus Solostar subcutaneous solution pen-injector 80 units at bedtime, Humalog KwikPen subcutaneous solution pen-injector to inject per sliding scale, and NovoFine Autocover Pen Needle, inject 1 device subcutaneously four times a day.

Review of the progress note dated 01/22/25 revealed Licensed Practical Nurse (LPN) #153 notified Nurse Practitioner (NP) #164 that Resident #11 did not have blood glucose tests at 7:00 A.M. or 11:00 A.M. and that his 4:00 P.M. test was done at 6:30 P.M. due to waiting for the arrival of glucose test strips from the pharmacy. The blood sugar check at 6:30 P.M. revealed a blood sugar of 404 at which time LPN #153 administered 12 units of insulin. Resident #11 had no signs or symptoms of hypo or hyperglycemic reaction which included lightheadedness or dizziness. No new orders were received at that time.

Review of the January 2025 Medication Administration Record revealed sliding scale Lantus Solostar insulin was not administered on 01/22/25 at 7:00 A.M. or 11:00 A.M. due to the facility not having test strips to check Resident #11's blood sugar.

Interview on 03/20/25 at 11:35 A.M. with the Executive Director/Wellness Coordinator confirmed glucose test strips were not available.

This violation represents non-compliance investigated under Complaint Number OH00163519.

Based on record review and interview the facility failed to ensure Resident #24 was given a sufficient supply of medications while on a leave of absence out of state. This affected one of three sampled residents. Facility census was 69.

Findings include:

Record review revealed Resident #24 was admitted 10/04/24 with diagnoses of transient cerebral ischemic attack, hemiplegia and hemiparesis, chronic kidney disease stage three, and type two diabetes mellitus. Review of the service plan with an effective date of 11/29/24 revealed Resident #24 had no cognitive deficit.

Review of January 2025 Medication Administration Record (MAR) revealed Resident #24 was ordered lisinopril 40 milligram (mg) every morning for hypertension, pregabalin 25 mg twice daily for neuropathy, Protonix 25 mg every morning for gastroesophogeal reflux disease, amlodipine besylate 10 mg for hypertension, hydrochlorathiazide 25 mg every morning for hypertension, tamsulosin 0.4 mg at bedtime for benign prostatic hyperplasia, trazadone 50 mg at bedtime for insomnia, Eliquis 5 mg twice daily (blood thinner), guaifenesin extended release (ER) 600 mg twice daily for congestion, Trulicity pen injector 3 mg subcutaneously (SQ) every Tuesday for diabetes, Insulin Glargine Solostar pen injector 16 units SQ every 12 hours for diabetes, Humalog injection solution (Insulin Lispro) inject per sliding scale before meals for diabetes.

Review of progress note dated 02/21/25 authored by Registered Nurse (RN) #109 revealed Resident #24 stated he was leaving for Florida on 02/24/25 and would be gone for two weeks but listed a return date of 03/03/25 which meant he would be gone for seven days instead of two weeks. A notation was included in the progress note which stated I will put together his medications. Please verify/confirm before giving them to resident.

Review of progress note dated 03/01/25 by authored by an agency nurse revealed Resident #24 left the facility with family at 5:00 P.M. to go to Florida, would remain on leave for 11 days, and his daughter had his medications.

Further review of the progress notes revealed no information on when Resident #24 returned to the facility.

Interview on 03/19/25 at 11:48 A.M. with the Executive Director (ED)/Wellness Director revealed an insufficient amount of medications for Resident #24 were sent with him when he went on leave with his family. The ED revealed Resident #24 left for vacation on 02/24/25 and was to be gone for 11 days. While on vacation Resident #24 ran out of all medications including insulin because the nurse did not provide enough medications to last for the duration of the vacation. The ED contacted the physician who called in an order for insulin to a pharmacy nearest to Resident #24 and the remaining medications were overnighted to Resident #24 at the facility's expense.

Review of a copy of a photo copy of the tracking receipt confirmed a charge for overnight delivery but the date of the transaction could not be verified because it was not included in the photocopy.

Interview on 03/20/25 with Registered Nurse (RN) #109 revealed she packed Resident #24's medications for vacation based on the dates of leave Resident #24 provided. RN #109 was unable to recall those dates. RN #109 further explained the nurse on duty when Resident #24 left for vacation should have confirmed the correct amount of medications were packed. RN #109 had no knowledge of what nurse was present the day/time Resident #24 left the facility.

This violation represents non-compliance investigated under Complaint Number OH00163519.

Based on record review and interview the facility failed to ensure Resident #24's record contained information about an incident related to an insufficient supply of medications provided while on leave from the facility. This affected one of three residents whose records were reviewed. Facility census was 69.

Findings include:

Record review revealed Resident #24 was admitted 10/04/24 with diagnoses of transient cerebral ischemic attack, hemiplegia and hemiparesis, chronic kidney disease stage three, and type two diabetes mellitus. Review of the service plan with an effective date of 11/29/24 revealed Resident #24 had no cognitive deficit.

Review of progress note dated 02/21/25 authored by Registered Nurse (RN) #109 revealed Resident #24 stated he was leaving for Florida on 02/24/25 and would be gone for two weeks but listed a return date of 03/03/25 which meant he would be gone for seven days instead of two weeks. A notation was included in the progress note which stated I will put together his medications. Please verify/confirm before giving them to resident.

Review of progress note dated 03/01/25 by authored by an agency nurse revealed Resident #24 left the facility with family at 5:00 P.M. to go to Florida, would remain on leave for 11 days, and his daughter had his medications.

Further review of the progress notes revealed no information on when Resident #24 returned to the facility.

Interview on 03/19/25 at 11:48 A.M. with the Executive Director (ED)/Wellness Director revealed an insufficient amount of medications for Resident #24 were sent with him when he went on leave with his family. The ED revealed Resident #24 left for vacation on 02/24/25 and was to be gone for 11 days. While on vacation Resident #24 ran out of all medications including insulin because the nurse did not provide enough medications to last for the duration of the vacation. The ED contacted the physician who called in an order for insulin to a pharmacy nearest to Resident #24 and the remaining medications were overnighted to Resident #24 at the facility's expense.

Review of a copy of a photo copy of the tracking receipt confirmed a charge for overnight delivery but the date of the transaction could not be verified because it was not included in the photocopy.

Interview on 03/20/25 with Registered Nurse (RN) #109 revealed she packed Resident #24's medications for vacation based on the dates of leave Resident #24 provided. RN #109 was unable to recall those dates. RN #109 further explained the nurse on duty when Resident #24 left for vacation should have confirmed the correct amount of medications were packed. RN #109 had no knowledge of what nurse was present the day/time Resident #24 left the facility.

Further review of Resident #24's records revealed there was no information regarding the incident.

This violation represents non-compliance investigated under Complaint Number OH00163519.

Based on review of the medical record and staff interviews, the facility failed to ensure physician orders were reconciled appropriately upon admission to identify Resident #73 was to have her oxygen saturation checked every shift. This affected one resident (#73) out of three residents reviewed for oxygen therapy.

Findings Include:

Review of the medical record revealed Resident #73 was admitted to the facility on 12/06/24. Diagnoses included Sjogren Syndrome (an immune system illness that causes dry eyes and dry mouth), interstitial pulmonary disease, chronic respiratory failure, gastrointestinal hemorrhage, gastric ulcer, cirrhosis of the liver, hypertension, anxiety disorder, severe protein calorie malnutrition, dysphagia, and rheumatoid arthritis. She was discharged to another facility on 01/21/25.

Review of the Service Plan dated 11/21/24 revealed Resident #73 was oriented and was able to make her own decisions.

Review of the admission orders from transfer, provided by the Executive Director (ED), dated 12/03/24 revealed Resident #73 had orders for continuous oxygen at eight liters per minute via nasal cannula. There were additional order instructions to check placement and record oxygen saturation every shift.

Review of the physician's orders revealed Resident #73 had orders dated 12/06/24 for continuous oxygen at eight liters per minute via nasal cannula and vital signs and a weight every 30 days. There was no evidence of an order to check oxygen saturation every shift.

Review of the health status note dated 12/07/24 at 2:27 A.M. revealed the oxygen saturation for Resident #73 was 99 percent via nasal cannula.

Review of the health status note dated 12/08/24 at 11:52 P.M. revealed the oxygen saturation for Resident #73 was 95 percent via nasal cannula with eight liters.

Review of the vital signs documentation in Point Click Care (the electronic charting system) dated 12/18/24 at 8:46 A.M. revealed the oxygen saturation for Resident #73 was 95 percent.

Review of the health status note dated 12/30/24 at 9:15 A.M. revealed Resident #73 was sent to the nearest hospital for excessive hematemesis (vomiting blood) and loose stool. She was unable to take her morning medication.

Review of the health status note dated 12/30/24 at 1:15 P.M. revealed Resident #73 returned to the facility after being diagnosed with rhinovirus (the common cold) and diarrhea. Her oxygen saturation was 93 percent via nasal cannula.

Review of the health status note dated 01/02/25 at 1:29 P.M. revealed the occupational therapist reported to the nurse that the oxygen saturation for Resident #73 was in the low 80's, but she was not having any respiratory distress. The nurse checked her oxygen saturation, and it was 87 percent on eight liters of oxygen via nasal cannula. A message was left for the Nurse Practitioner and staff was just waiting on a return call. There was no further documentation that the facility followed up with the Nurse Practitioner.

Review of the health status note dated 01/09/24 at 5:39 P.M. revealed Resident #73 was sent out to the emergency room due to excessive coughing and coughing up blood from her nose and throat. It stated Resident #73 had a previous medical diagnosis of esophageal varices.

Review of the health status note dated 01/10/24 at 1:34 A.M. revealed Resident #73 returned from the emergency room at 12:30 A.M. Her oxygen situation was 98 percent on eight liters and there were no new orders.

On 02/18/25 at 10:30 A.M. an interview with the ED confirmed the initial admission orders were reconciled incorrectly and they did not check her oxygen saturation every shift. She stated the nurse who reconciled the orders no longer worked at the facility.

On 02/20/25 at 11:04 A.M. an interview with Wellness Director #300 verified there was no documentation the nurses followed up with the Nurse Practitioner or physician after leaving a message related to Resident #73 on 01/02/25 when her oxygen saturation was in the low 80's. There were no additional orders.

This violation represents non-compliance investigated under Complaint Number OH00162119 and Complaint Number OH00162388.

Based on observations, review of the facility policy, and staff interviews, the facility failed to maintain a clean and sanitary kitchen. This affected all residents in the facility. The census was 72.

Findings included:

Observation on 02/13/25 at 1:50 P.M. with the Executive Director revealed the following observations:

a. The floor was visibly dirty and had food debris around the perimeter.

b. The three compartment sink had slices of turkey laying in it.

c. The two waffle makers were dirty with dried batter.

. The inside of the microwave was dirty with a buildup of food.

e. The warming cart had food debris on the floor of it.

f. The stainless steel two tier table that the coffee and juice machine was on, was dirty with spilled coffee and juice and buildup of food debris.

g. The tiered metal rack the spices were on, was dirty underneath it with several containers of spices and a buildup of dirt and food debris.

h. Two trash cans did not have lids.

i. The large container of flour, sugar, oats, and breadcrumbs had a large buildup of dirt on the outside or them, they were sticky to the touch and the breadcrumbs had a scoop laying inside of it.

j. The area where the dishwasher was had gnats flying around.

k. The top of the stove where the burner was, had a buildup of food debris and there was food splatter down the side of the stove.

l. The outside door of the walk-in cooler was black with a buildup of dirt and the floor in the walk-in cooler was dirty and had food debris scattered on the floor.

m. Boxes were piled up on the floor in the freezer.

n. A large whole ham, that was partially unwrapped with a chunk cut out of it, was sitting on the rack with the rest of the unopened meat thawing out.

o. A package of bacon was open to air with no date when it was opened, a package of sliced deli turkey wrapped in plastic wrap with no date as to when it was opened, there was a large five pound bag of shredded cheddar cheese that was open to air and not dated as to when it was opened, slices of provolone cheese wrapped in plastic wrap were not dated when opened, American cheese slices were not dated as to when it was opened, and there was sliced salami wrapped in plastic wrap not dated when it was opened.

An interview on 02/13/25 at 1:50 P.M., with the Executive Director confirmed the above findings and she stated the kitchen should not look this bad.

Review of the facility policy titled, Sanitation and Cleaning Schedule, dated 08/15/23 revealed the dietary department would be responsible for maintaining sanitary conditions in the kitchen and all storage and dining areas, including all equipment located and/or utilized in these areas. All dry storage must be clean and free of clutter, including personal items, so that dry goods, canned goods, packaged and disposables were free from contaminants. All food items must be dated upon receiving and dated and sealed when opened. All refrigerated and prepared food must be covered, labeled and dated with a use by date that was a maximum of seven days from the date of preparation. Frozen food must be stored at least six inches off the floor and all equipment must be cleaned and sanitized with an approved sanitizer after each use.

This violation represents non-compliance investigated under Complaint Number OH00162119.

Based on medical record review, review of hospital records, review of a facility investigation, review of the Akron/Canton Airport weather data, review of staff schedules, review of facility policy, and interview, the facility failed to ensure comprehensive and individualized measures were in place to prevent Resident #63 from eloping from the facility. The facility failed to complete an accurate elopement risk assessment, failed to provide adequate supervision/intervention and failed to conduct routine safety checks to prevent Resident #63, who resided on the facility secure memory care unit, had a diagnosis of dementia, impaired decision making skills, and had a previous history of elopement, from exiting the facility through his bedroom window without staff knowledge. This resulted in a Real and Present Danger and actual harm on 02/08/25 after approximately 12:50 A.M. when Resident #63 left the facility through his bedroom window and was missing until 02/08/25 at 11:54 A.M. The facility identified Memory Care unit staff, including Care Associate (CA) #100, CA #102 and CA #103 failed to conduct routine safety checks on Resident #63 during the time period it was identified he was missing. Facility staff did not realize the resident was missing until 02/08/25 at 8:40 A.M. when Licensed Practical Nurse (LPN) #105 went to give Resident #63 his medications. Resident #63 was located by staff on 02/08/25 at 11:54 A.M. in the woods beside the facility with numerous abrasions on his hands and arms which were bleeding. The resident was subsequently transferred to the hospital for an evaluation, where he was found to have a body temperature of 94.6 degrees Fahrenheit (F) indicating hypothermia and multiple abrasions. The temperature outside overnight on 02/08/25 was 19 degrees Fahrenheit (F). This affected one resident (#63) and had the potential to affect six additional residents (#52, # 55, #58, #60, #64, and #68) who were identified to be independently mobile and resided on the Memory Care unit. The facility census was 72.

On 02/18/25 at 2:30 P.M. the Executive Director (ED) and Regional Director of Operations #201 were notified Real and Present Danger occurred on 02/08/25 after approximately 12:50 A.M. when facility staff failed to provide adequate supervision and/or safety interventions resulting in Resident #63 being found on 02/08/25 at 11:54 A.M. outside of the facility, in the woods, with hypothermia and bleeding abrasions.

The Real and Present Danger was abated on 02/19/25 when the facility implemented the following corrective actions:

On 02/08/25 at 8:54 A.M., the facility staff completed a head count and verified there were no other missing residents. The Assisted Living (AL) residents were verified by CA #142 and CA #144. The Memory Care (MC) residents were verified by CA #103 and CA #104. Both AL and MC were entirely verified by Licensed Practical Nurse (LPN) #105. There were 21 residents in Memory Care and 72 total residents in the facility on 02/08/25.

On 02/08/25 at 9:00 A.M., the Executive Director (ED) conducted an in-service with all staff present on the Elopement policy and procedure. The in-service was repeated on 02/13/25 at 10:42 A.M. and again on 02/15/25 at 8:21 P.M. to ensure all staff received it. All new hires were to receive the Elopement policy and procedure and sign an acknowledgment upon hire and with onboarding training. The Elopement policy and procedure included that staff were to check MC residents every two hours.

On 02/08/25 at 10:23 A.M., Resident #63's physician (Physician #216) and guardian were notified of the incident.

On 02/08/25 at 11:50 A.M., Resident #63 returned to the facility on foot after facility staff and local authorities were in search of the resident and working through the proper resident elopement process steps. Business Office Director #130 called 911 emergency services at 11:55 A.M. and Resident #63 was sent via ambulance at 12:09 P.M. to a local hospital for a clinical and psychiatric assessment.

On 02/08/25 at 12:30 P.M., the ED placed a screw in Resident #63's room window to prevent it from opening more than one inch. One inch was utilized for Resident #63 to not allow for a hand or large item to be utilized to open the space. At 1:15 P.M., the ED verified all Memory Care unit resident room windows had working stoppers that would not allow the window to open more than three inches. The facility identified tools utilized by Resident #63 to remove the original window stoppers which were removed from his room, along with all other items that could be utilized to assist with elopement. The tools removed from Resident #63's room included one wrench, one pair of pliers, two children's safety style scissors and five mini screwdrivers. The items were removed by Sales Director #121 and Activities Director #122. Resident #63's room would be audited daily for four weeks for any other items that could be utilized for elopement purposes. All Memory Care resident rooms were verified to not have any tools present by Sales Director #121 on 02/08/25. The entire memory care neighborhood, common spaces, and resident rooms would be audited for any tools daily for four weeks by Memory Care Director #304.

On 02/08/25 at 12:50 P.M., the ED checked all eight exit doors and five exit door alarms to ensure they were working properly. The Memory Care neighborhood had one set of double doors to enter the unit (two doors, one alarm), an exit door to the courtyard off the main dining room (one door, one alarm), an exit door from the activity room to the courtyard (one door, one alarm), one set of double doors at the end of the hallway directly off the living room (two doors, one alarm), and another set of double doors that lead to the driveway on the right side of the community (two doors, one alarm).

On 02/08/25 at 6:12 P.M. Resident #63 returned from the hospital to his previous room in the facility. Resident #63 was immediately placed on every 30-minute checks from staff. On 02/19/25 Resident #63 was placed on every 60-minute checks. The ED and Wellness Director #300 would audit these checks every shift for four weeks to ensure compliance and completion.

On 02/10/25 Resident #63 had an elopement assessment completed to reveal his elopement score was high risk.

On 02/10/25 CA #100, LPN #101, CA #102, CA #103, CA #104 and LPN #105 received disciplinary actions for failing to check on a memory care resident.

On 02/13/25 Regional Director of Operations #210, the ED, and Wellness Director #300, completed a root cause analysis of Resident #63's elopement. The elopement was determined to be a move-in process review oversight by former Wellness Director #215 and the Executive Director. The information that was listed in the resident's referral paperwork and progress notes from the previous facility Resident #63 transitioned from, included a previous elopement and the manner in which the elopement occurred. This was not on the Service Plan Report for Resident #63 and his elopement assessment did not reflect a previous elopement.

On 02/18/25 the Maintenance Designee initiated audits daily for four weeks to be completed to ensure all windows opened no further than three inches. Any negative findings would be addressed immediately with the Executive Director and reported to Wellness Director #300 to track and trend.

On 2/18/25 at 3:23 P.M., the Wellness Director #300 and Memory Care Director #304 checked all residents who were at risk for elopement to ensure current pictures and face sheets were in place. The Wellness Director #300 also checked all Service Plan Reports and assessments for residents at high risk for elopement.

On 02/19/25, Wellness Director #300 completed new Elopement Risk assessments on all community residents. All residents identified to have high risk for elopement were reviewed with appropriate assessments and Service Plan Reports in place.

On 02/19/25, Resident #63's Service Plan Report was updated to reflect no tools of any kind were to be in the resident's possession.

On 02/19/25, education began and would continue until it captured all shifts and staff, that Memory Care residents were not to be in possession of tools, and any found should be obtained immediately and reported to the ED. The education would also be provided to newly hired staff upon onboarding.

On 02/19/25, Physician #216 was made aware of the corrective actions taken in response to the elopement of Resident #63. The physician would be conducting an Expert Evaluation on this resident as well to determine proper psychiatric intervention as appropriate.

On 02/24/25 the facility would conduct an ad hoc Quality Assurance Performance Improvement (QAPI) with the ED, Business Office Director #130, Wellness Director #300, Memory Care Director #304, Activity Director #122, Sales Director #121, and Maintenance Man #115. In addition, the Executive Director or designee would address any trends identified quarterly and as needed. An action plan would be developed and implemented to ensure compliance.

Although the Real and Present Danger was abated on 02/19/25, the violation remains as the facility was in the process of implementing and monitoring corrective actions.

Findings included:

Review of Resident #63's medical record revealed the resident was admitted to the facility on 10/24/24 with diagnoses including hypertension, vitamin D deficiency, psychotic disturbance, mood disorder, anxiety, and dementia.

Review of a progress notes, from the previous facility where Resident #63 resided, faxed to the facility on 10/15/24 at 2:27 P.M. (prior to admission), revealed on 09/26/24 at 1:15 A.M. Resident #63 was not in his room, his window was opened, and the screen had been taken out. The nurse and the resident assistant went outside to see if the resident was smoking but he was nowhere to be seen. The resident assistant suggested the staff go to the bar to see if he was there. After 15 minutes the resident assistant returned with the resident. The note dated 09/26/24 at 12:52 P.M. stated staff spoke with Resident #63's guardian regarding the incident during the night. They explained the resident would be receiving a 30-day written notice due to safety concerns and that they would work with him to find appropriate placement.

Review of the Admission Service Plan dated 10/24/24 revealed Resident #62 was oriented, did not always recognize when to make decisions, but would follow directions. The resident required frequent attention due to attempts to exit the community. It noted the resident ambulated independently. The plan did not include any individualized or comprehensive interventions to address the resident's previous attempts to exit the community.

Review of the Service Plan Report dated 10/27/24 revealed Resident #63 had a behavior problem related to anxiety and exit seeking behaviors. Interventions included to assess and anticipate the resident's needs, explain all procedures to the resident before starting and allow the resident adequate time to adjust to changes, provide opportunity for positive interaction, and to provide empathetic listening and attention. The service plan did not include any safety/supervisory interventions and/or address any potential environmental factors which might contribute to the resident's exit seeking behaviors.

Review of the Admission Elopement Risk Review assessment dated 11/08/24 revealed the assessment was inaccurate in that it failed to include Resident #63 had a dementia diagnoses, failed to identify the resident had a history of elopement or wandering, and noted the resident did not exhibit any wandering behaviors.

Review of a Mental Status questionnaire dated 11/08/24 revealed Resident #63 had mild or no cognitive impairment. This questionnaire appeared to be inconsistent with the resident's diagnosis, previous service plans and service plan subsequently completed on 11/26/24.

Review of the Service Plan dated 11/26/24 revealed Resident #63 required staff to occasionally orient the resident due to being forgetful at times and he did not always recognize when to make decisions but would follow directions. The plan noted the resident had no issues with wandering, or he wandered within the residence, and the resident had memory loss and/or dementia related to cognition. The focus intervention was to cue, reorient, and supervise as needed, and included the resident had exit seeking behaviors.

Record review revealed no changes made to the resident's service plan dated 11/26/24 to include any safety/supervisory interventions and/or address any potential environmental factors which might contribute to the resident's exit seeking behaviors.

Review of a quarterly wellness review dated 01/24/25 revealed the Memory Path for Resident #63 indicated he was low risk for overall memory impairment. It indicated the resident had no subjective complaints or memory deficit, no trouble remembering names, appointments, repetitive words, or becoming easily frustrated, was at a low risk for elopement and had no issues with wandering.

Review of a Health Status Note dated 02/08/25 and timed 2:20 P.M. revealed the ED (who was also a Licensed Practical Nurse) received a call from the facility (on 02/08/25) at 8:54 A.M. from CA #104, who was working in the memory care unit, who stated that she went into the room of Resident #63, and it seemed as if there was a person lying in bed, but upon approaching the bed, it was empty and stuffed with blankets and pillows to resemble a body. While they were on the phone, CA # 104 sent the ED pictures of the window. The resident's window was opened past the point of the safety bars, the safety bars on the outside were broken off, and the screen was laying outside. The ED told her to call a code-yellow (indicating elopement) immediately, obtain a head count, and forgo the 30-minute wait period and just call 911 immediately. 911 was called at 9:00 A.M. The resident's guardian was called at 9:56 A.M. and he called back at 10:23 A.M., stating this was what Resident #63 did, and he was not surprised. All available staff were out looking for Resident #63. The facility was able to figure out the resident had been to a local Pub in Stow at 2:30 A.M. for last call drinking whiskey then he was at a local gas station at 2:45 A.M. The note revealed the resident was last seen by a CA at midnight. On 02/08/25 at 11:50 A.M. staff members were walking back into the building from being out searching for the resident, and at 11:54 A.M. Sales Director #121 yelled that somebody was walking in the woods and ran out of the building to the woods on the side of the community. The staff all followed and got Resident #63 safely inside. Resident #63 had blood pouring from his wrists to his fingertips. He stated he got into an issue with a pricker bush. The resident had some slight indication of frostbite and lacerations everywhere. 911 was called, his guardian was called, and Regional Director of Operations #201 was called. The ED instantly started to warm him and clean his hands. 911 arrived at 12:09 P.M. for transport to the hospital. The medical record and progress notes did not indicate any vital signs were obtained (by facility staff) after the resident was found.

Review of the Akron Canton Regional Airport weather report revealed on 02/08/25 it was 19 degrees Fahrenheit (F) over night and 32 degrees F during the day.

Review of google maps revealed the distance from the facility to the local pub was 3.7 miles and the pub was located on a four-lane street.

Review of the hospital emergency room (ER) report dated 02/08/25 revealed Resident #63 was last seen at the facility around midnight. The report revealed the resident broke out of the facility via a window and went out on the town to a bar. He was outside all night after the bar closed. It noted the facility called the police around 10:00 A.M. when they discovered he was gone. Resident #63 was found outside with frost bite concerns on bilateral hands and scratches all over his body from the briar bushes. Emergency room diagnoses included cold exposure and multiple abrasions. The resident's body temperature upon arrival was 94.6 degrees F and came up to 97.2 degrees F after an hour in the ER.

Review of the facility investigation revealed the investigation consisted of the following (as well as the above progress note dated 02/08/25 and timed 2:20 P.M.):

Review of an undated unsigned texted message from CA #100 revealed the last time she remembered seeing Resident #63 was (on 02/07/25) between 10:00 P.M. and 12:00 AM. She stated Resident #63 was a self (indicating he was independent) so he was not a two-hour check. She stated the resident had on a grey sweater and dark pants. She stated the windows did not open all the way, not enough to slide your body out.

Review of a signed witness statement from CA #102 dated 02/08/25 revealed Resident #63 had become comfortable, and he was not as strict as he should have been with him. CA #102 revealed he had no clue what Resident #63 was planning. He stated on that night, during his rounds, everything seemed normal and after he was finished with his rounds (no time noted), he saw Resident #63 grabbing ice cream or a soda from the refrigerator which he did often.

Review of an undated handwritten signed witness statement revealed the nurse had asked CA #103 if she had seen Resident #63 because he usually just came to get his meal. CA #103 told the nurse she had not seen him.

Review of a handwritten signed witness statement from LPN #105 dated 02/08/25 revealed during the morning medication administration she went into the room of Resident #63 around 8:40 A.M. to give him his medication and he was not in the room. She went to ask the CA's if they had seen Resident #63 and they stated they had not seen him. They started to search the rooms and counted all the residents. A code yellow was called, and the staff began to assist with searching for Resident #63. 911 was called immediately. Review of the resident's medical record revealed no nursing progress note was entered by this nurse at the time the resident was first identified to be missing.

Review of an employee disciplinary form dated 02/10/25 revealed CA #100 was given a written warning for not providing two-hour checks on a memory care resident. The form noted the resident (#63) had eloped and was missing for a majority of the shift.

Review of an employee disciplinary form dated 02/10/25 revealed CA #102 was given a written warning for not providing two-hour checks on a memory care resident. The form noted the resident (#63) had eloped and was missing for a majority of the shift.

Review of an employee disciplinary form dated 02/10/25 revealed CA #103 was given a written warning for not completing walking rounds or providing two-hour checks on a memory care resident.

Review of an employee disciplinary form dated 02/10/25 revealed CA #104 was given a written warning for not completing walking rounds or providing two-hour checks on a memory care resident.

Review of an employee disciplinary form dated 02/10/25 revealed LPN #101 was given a written warning for not checking on a resident the entire shift and a resident (#63) had eloped. LPN #101 terminated her employment while receiving the disciplinary action.

Review of an undated typed verbal telephone statement from LPN #101 revealed she remembered giving him [Resident #63] his medication around 9:00 P.M. and he was sitting in the living room. She stated she left the Memory Care unit around 9:30 P.M. to finish her medication administration and the resident was going back to his room around that time.

On 02/13/25 at 3:00 P.M. an interview with CA #103 revealed Resident #63 liked to walk the hallway in the memory care, he came out for meals and activities. She stated she had never seen him try to get out of the facility. CA #103 revealed she did not check on Resident #63 the morning of 02/08/25 because she was the only CA who was on the Memory Care unit from 7:00 A.M. to 8:00 A.M. and she had to get everyone to breakfast. She stated the other aide [CA #104] did not arrive until 8:00 A.M.

Review of the time clock punch for CA #104 dated 02/08/25 revealed she clocked in to work at 7:45 A.M.

On 02/18/25 at 10:30 A.M. an interview with the ED revealed Resident #63 broke his window and went outside on 02/08/25 sometime after 12:00 A.M. The resident had been on facility camera by the exit door/dining room in the Memory Care unit around 9:50 P.M. and the CA saw him around 12:00 A.M. She stated they found out he went to a local pub (name provided) and had one drink (the bartender informed the ED they gave him one drink), but the resident left without paying for it. The ED revealed they found the resident in the woods behind the facility, he had scratches all over his arms and hands and was bleeding. She stated he was sent to the ER and returned to the facility later that day. During the interview, the ED confirmed staff had been disciplined as a result of this incident for not conducting every two-hour checks for Resident #63.

On 02/18/25 at 11:40 A.M. an interview with Resident #63 revealed he recalled the incident on 02/08/25 when he left the facility. The resident reported he left the facility to go meet a lady friend he knew. He stated she worked at the local pub (name provided), but she was not there so he did not stay. He stated he just walked around for a while before coming back to the facility.

On 02/18/24 at 1:45 P.M. an interview with the ED revealed Resident #63 was wearing pants, a sweatshirt, tennis shoes, and a coat when he was found. She also stated he was not intoxicated.

On 02/19/25 at 3:04 P.M. an interview with CA #100 revealed Resident #63 had come out to get his medications and the last time she saw him on 02/07/25 was between 10:00 P.M. and midnight (she was not sure of the exact time). CA #100 revealed staff did not go in the resident's room to check on him, but he would normally come out of his room a few times during the night; however, he did not that evening. She stated she did not think anything about it. She stated she left in the morning without checking on the resident or realizing he was not in the building.

On 02/19/25 at 3:20 P.M. an interview with Business Office Manager #130 revealed following the elopement incident, they found a small toolbox in the room of Resident #63. She stated the toolbox contained two pairs of children's scissors, one pair of pliers, one wrench and five mini screwdrivers.

On 02/19/25 at 3:40 P.M. an interview with CA #102 revealed he came to work at 7:00 P.M. on 02/07/25. He stated the last time he saw Resident #63 was around 12:50 A.M. on 02/08/25. He stated the resident usually came out for a snack or just to talk to staff a couple times throughout the night. He stated the resident kept his door locked and they did not check on him. He stated he just thought the resident was sleeping and that was why he had not been out of his room, but he confirmed he never went in to check on Resident #63. He stated staff did have a key to get into the (resident) rooms, but they had to sign it out. CA #102 further revealed he never saw the resident before he left in the morning because they did not check on him.

Review of the facility policy titled, Resident Service Plan

Based on observation and interview, the facility failed to ensure that medications were in a locked storage area. This had the potential to affect 36 residents residing in the non-memory care assisted living area. Facility census was 56.

Findings include:

Observation during tour of the facility with the Executive Director on 12/26/23 at 9:16 A.M. revealed the first-floor nurse's office door was open. Upon entering the office, the refrigerator that stored insulin was unlocked and the insulin could be accessed by anyone who entered the nurse's office. Observation on 12/26/23 at 1:48 P.M. revealed the nurse's office door was closed; however, it was unlocked and upon entering the refrigerator was unlocked and the insulin stored inside was accessible.

Based on record review and interview, the facility failed to obtain a tuberculosis (TB) screening for the Director of Wellness. This had the potential to affect all residents. Facility census was 56.

Findings include:

Review of the Director of Wellness' personnel record revealed no evidence TB screening had been completed upon hire. Interview on 12/26/23 at 5:05 P.M. with the Business Office Manager confirmed a TB screening was not completed upon hire and results of TB screening were not obtained from the previous employer.