The Landing of Long Cove

Based on medical record review, staff interview, and review of the facility policy, the facility failed to assess resident neurological status after resident falls. This affected one (Resident #28) of two residents reviewed for falls. The facility census was 55 residents.

Findings include:

Review of the medical record for Resident #28 revealed an admission date of 04/03/24 with diagnoses including diabetes, dementia, hypertension and atrial fibrillation.

Review of the functional assessment for Resident #28 dated 10/23/24 revealed the resident had moderately impaired cognition and required assistance with activities of daily living (ADLs.)

Review of nurse progress note for Resident #28 dated 01/31/25 revealed the resident had a fall in his room onto his left side and teh resident said he hit his head.

Review of the nurse progress note for Resident #28 dated 02/02/24 revealed the resident had an unwitnessed fall in his room and was found on his back.

Review of the medical record for Resident #28 revealed the record did not include neurological checks after the resident's falls on 01/31/25 and 02/04/25.

Interview on 02/06/25 at 3:30 P.M. with the Director of Nursing, (DON) confirmed Resident #28 had falls on 01/31/25 and 02/04/25 and the facility had not completed neurological checks of the resident following the falls and the nurses should have initiated them.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to administer medication as ordered by the physician. This affected one (Resident #28) of five residents reviewed for medication administration. The facility census was 55 residents.

Findings include:

Review of the medical record for Resident #28 revealed an admission date of 04/03/24 with diagnoses including diabetes, dementia, hypertension and atrial fibrillation.

Review of the functional assessment for Resident #28 dated 10/23/24 revealed the resident had moderately impaired cognition and required assistance with activity daily living (ADLs.)

Review of the monthly physician's orders for Resident #28 dated February 2025 to receive two drops of Systane100 eyedrop medication to both eyes at 8:00 A.M. each morning.

Observation on 02/05/25 at 8:50 A.M. of medication administration to Resident #28 per Licensed Practical Nurse (LPN) #20 revealed the resident was sitting in his recliner which was in an upright position. The LPN #20 repeatedly attempted to administer the ordered two drops of eyedrop medication into Resident #28 eyes, as the medication was not reaching the eye socket. LPN #20 made five unsuccessful attempts to administer the medication. Resident #28 repeatedly wiped the eyedrops from his face and became agitated and told the nurse she did not know what whe was doing.

Interview on 02/05/25 at 9:00 A.M. with LPN #20 confirmed she did not administer the entire dose of two eyedrops in each of the resident's eyes. LPN #20 confirmed she had not ensured Resident #28 was properly positioned in order to administer the eye drops.

Review of facility policy titled Eye Drop Administration undated revealed prior to eyedrop administration the resident's head should be tilted back and the lower eyelid should be pulled down to form a pouch.

Based on record review, staff interview, and review of the resident handbook, the facility failed to ensure pet vaccinations were current for a resident pet residing in the facility. This had the potential to affect all of the residents residing in the facility. The facility census was 55 residents.

Findings include:

Review of vaccination record of Resident #35 cat revealed the cat had required vaccinations due on 06/01/24.

Interview on 02/06/25 at 1:30 P.M. with Administrative Assistant (AA) #63 confirmed Resident #35's cat was past due for required vaccinations.

Review of facility resident handbook on page 14 undated revealed proof of required pet vaccinations was required prior to move in and annually. Furter review of the handbook revealed visitor with pets must provide appropriate vaccination information at entry.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to complete a thorough fall investigation after resident falls. This affected two (Residents #28 and #25) of two residents reviewed for falls. The facility census was 55 residents.

Findings include:

1.Review of the medical record for Resident #28 revealed an admission date of 04/03/24 with diagnoses including diabetes, dementia, hypertension and atrial fibrillation.

Review of the functional assessment for Resident #28 dated 10/23/24 revealed the resident had moderately impaired cognition and required assistance with activities of daily living (ADLs.)

Review of nurse progress note for Resident #28 dated 01/31/25 revealed the resident had a fall in his room onto his left side.

Review of the nurse progress note for Resident #28 dated 02/02/24 revealed the resident had a fall in his room and was found on his back.

Review of the medical record for Resident #28 revealed the record did not include investigations of the resident's falls on 01/31/25 and 02/04/25.

Interview on 02/06/25 at 3:30 P.M. with the Director of Nursing, (DON) confirmed Resident #28 had falls on 01/31/25 and 02/04/25 and the facility had not completed investigations of the falls.

2. Review of the medical record for Resident #25 revealed an admission date of 05/31/22 with diagnoses including hypertension, congested heart failure and atrial fibrillation.

Review of the functional assessment for Resident #25 dated 06/23/24 revealed the resident had intact cognition and was independent with ADLS.

Review of the nurse progress note for Resident #25 dated 01/21/25 revealed the resident notified the nurse he had fallen and was observed to have bleeding coming from his right ear and was sent to the hospital for an evaluation.

Review of the medical record for Resident #25 revealed the record did not include an investigation of the resident's fall on 01/21/25.

Interview on 02/06/25 at 3:30 P.M. with the DON confirmed Resident #25 had a fall on 01/21/25 and the facility had not completed an investigation of the fall.

Review of facility policy titled Resident Falls undated revealed the facility should complete an investigation each fall which included determining previous care plan interventions followed, time of the fall, new fall prevention interventions, staff witness interviews, and equipment involved.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff administered eye drops in a sanitary manner and failed to ensure staff performed appropriate hand hygiene. This affected one (Resident #28) of two residents observed for medication administration. The facility census was 55 residents.

Findings include:

Review of the medical record for Resident #28 revealed an admission date of 04/03/24 with diagnoses including diabetes, dementia, hypertension and atrial fibrillation.

Review of the functional assessment for Resident #28 dated 10/23/24 revealed the resident had moderately impaired cognition and required assistance with activities of daily living (ADLs.)

Review of the physician's orders for Resident #28 dated February 2025 revealed the resident had an order to receive two drops of Systane100 eye drops to both eyes at 8:00 A.M. each morning.

Observation on 02/05/25 at 8:50 A.M. of medication administration per Licensed Practical Nurse (LPN) #20 revealed the nurse donned gloves to administer eyedrops to Resident #28. After LPN #20 donned gloves, she touched the resident's clothing and a skin tear on the resident's left elbow and then administered the eyedrops. Following eye drop administration LPN #20 doffed the gloves and did not wash her hands.

Interview on 02/05/25 at 9:00 A.M. with LPN #20 confirmed she did not wash her hands after administering the eyedrops and removing the gloves. She stated she should have changed gloves and performed hand hygiene after touching the clothing and the skin tear prior to administering the eyedrops.

Review of facility policy titled Medication Administration undated revealed staff should wash hands thoroughly after removing gloves.

Based on record review and staff interview, the facility failed to establish and implement an effective water management program to prevent Legionella disease. This had the potential to affect all of the residents residing in the facility. The facility census was 55 residents.

Findings Include:

Review of the facility documents revealed they did not include a water management plan or monitoring procedures to prevent Legionella disease in the facility.

Interview on 02/06/25 at 5:09 P.M. with the Executive Director (ED) confirmed the facility did not have a Legionella water management plan and/or evidence of monitoring procedures. The ED further confirmed the facility had experienced no recent outbreaks of Legionella and the facility should have a written water management plan and monitoring documentation.

Based on observation, staff interview, and review of the facility policy, the facility failed to store foods safely to prevention food contamination. This had the potential to affect all 55 residents residing in the facility. The facility census was 55 residents.

Findings include:

Observation on 02/05/25 at 11:19 A.M. revealed the following food storage concerns: six containers of opened salad dressing with no open or use-by dates in the walk-in refrigerator, five packages of pasta without open dates in the dry storage area, two opened undated containers of food and a plate of food in the food preparation refrigerator, eight opened containers of undated ice cream in the freezer. Further observation revealed additional concerns: there was no temperature log in the freezer to ensure the freezer was routinely monitored for the correct temperature, there was an uncovered food mixer not in use, food scoops were stored in open bulk food containers.

Interview on 02/05/25 at 12:50 P.M. with Dietary Manager (DM) #60 confirmed the foods in the walk-in refrigerator, dry food area, the food preparation refrigerator, and the ice cream freezer were not properly dated with open dates. The DM verified all opened foods should be dated with an open and use by date. DM#60 confirmed there was no temperature log to ensure the freezer was monitored routinely for the correct temperature. DM #60 further confirmed food scoops should not be stored in open bulk food containers and food preparation equipment not in use should be stored covered.

Review of facility policy titled Storage undated revealed any food stored must show an identifying label, be covered and appropriately sealed, and dated after opening.

Based on observation, review of kitchen logs, staff interview, and review of the facility policy, the facility failed to maintain a sanitary kitchen. This had the potential to affect all of the residents residing in the facility. The facility census was 55 residents.

Findings include:

Observation on 02/05/25 at 11:50 A.M. revealed the following kitchen sanitation violations: two trash containers which were almost full with no lids, the kitchen door leading to the garbage area was ajar, Dietary Aides (DA) #31 and #41 did not have hair restraints, there was pink colored debris in the ice bin.

Review of the open-door log dated 02/05/25 revealed the kitchen exit door had been ajar from 6:01 A.M. to 11:35 A.M.

Review of the sanitation logs for the three-compartment sink revealed there were no records of testing for September 2024 through February 2025. There were no temperature logs for the dishwasher.

Interview on 02/05/25 at 12:50 P.M. of Dishwasher #18 confirmed there were dishwasher temperatures and or sanitization testing records for the three-compartment sink.

Interview on 02/05/25 at 12:55 P.M. with Dietary Manager (DM) #60 confirmed there should have been dishwasher temperature logs and sanitizer logs for the three-compartment sink. The DM #60 stated trash containers should be covered, the exit door should be closed at all times, and the ice bin needed to be cleaned of debris.

Review of facility policy titled Sanitation undated revealed the dietary director should establish and sustain the cleaning and sanitation standards for the kitchen.

Based on review of the lunch spreadsheet, observation, staff interview, and review of the facility policy, the facility failed to serve food portions as planned by the Registered Dietitian (RD). This had the potential to affect all of the residents residing in the facility. The facility census was 55 residents.

Findings include:

Review of the lunch menu spreadsheet for 02/05/25 revealed the meal was to consist of one cup of salad, one sandwich with four ounces of tuna, and one half cup of vegetables.

Observation on 02/05/25 at 12:50 P.M. revealed the Cook #29 served one quarter cup of vegetables and two ounces of tuna.

Interview on 02/05/25 at 12:50 P.M. with Cook #29 confirmed he did not know how to use the recipe to determine the planned portion for the tuna sandwich and he did not use the appropriate scoop for the vegetables as listed on the lunch menu spreadsheet. Cook #29 confirmed all residents were served a smaller portion of the tuna and vegetables than was planned by the RD.

Interview on 02/05/25 at 12:55 P.M. with Dietary Manager DM #60 confirmed all the resident were served small portions of the tuna and the vegetables and Cook #29 should have referred to the menu and the recipe to verify the correct portion size.

Review of facility policy titled Portion Control undated revealed the staff should consult the menu spreadsheet for portion size and utensils for serving.

Based on record review and staff interview, the facility failed to ensure fire drills were performed quarterly and at varied times during the work shift, and there were no resident evacuations for twelve months. This had the potential to affect all of the residents residing in the facility. The facility census was 55 residents.

Findings include:

Review of the fire drill records dated February 2024 to January 2025 revealed there was no first shift fire drills for April 2024 and no second shift fire drill for November 2024. Three of four fire drills on third shift were all performed in the same time frame, between 5:30 A.M. and 6:30 A.M. There was no evidence of resident evacuations from February 2024 through January 2025 for any of the fire drills.

Interview on 02/06/25 at 5:09 P.M. with the Executive Director (ED) confirmed the facility did not complete a first shift fire drill for April 2024 or a second shift fire drill for November 2024. The ED further confirmed the facility did not vary the times of the third shift fire drills and did not complete resident evacuations for any of the fire drills for February 2024 to January 2025.

Based on record review and staff interview, the facility failed to conduct annual fire safety training for employees. This had the potential to affect all of the residents residing in the facility. The facility census was 55 residents.

Findings include:

Review of the facility in-service records dated February 2024 through January 2025 revealed they did not include documentation of annual fire safety training for employees.

Interview on 02/06/25 at 5:09 P.M. with the Executive Director (ED) confirmed the facility had not completed annual fire safety training for employees from February 2024 to January 2025.

Based on observation and staff interviews the facility failed to prove carbon monoxide detectors for the secured unit. This had the potential to affect the twelve (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12) residing on the secured unit. The facility census was 55 residents.

Findings include:

Observation on 02/05/25 at 11:50 A.M. and on 02/6/25 at 1:00P.M revealed there was no carbon monoxide detector on the secured unit and there were two gas-powered clothes dryers on the unit.

Interview on 02/05/25 at 3:00P.M. with the Executive Director (ED) confirmed there were no carbon monoxide detectors on the secured unit. The ED further confirmed there should have been carbon monoxide detectors present and functioning on the unit due to the use of gas-powered clothes dryers.

Based on medical record review, observation and staff interview, the facility failed to ensure a safe resident smoking area. This affected one resident (Resident #15) of one facility-identified resident who smoked. The facility census was 55 residents.

Findings include:

Review of the medical record for Resident #15 revealed and admission date of 04/28/19 with diagnoses including nicotine dependence, paralysis of left side, hypertension, and adult failure to thrive.

Review of the functional assessment for Resident #15 dated 10/29/24 revealed the resident had intact cognition, was independent with activities of daily living (ADLs), and was assessed as independent with smoking.

Observation on 02/05/25 at 11:50 A.M. of the outside designated resident smoking area revealed there was an ashtray which was not capable of self-extinguishing which was overflowing with 20 cigarette butts. There were approximately 40 cigarette butts in a grassy area 20 feet from the facility. There was no receptacle in which to discard cigarette butts.

Interview on 02/05/25 at 1:30 P.M. the Executive Director (ED) confirmed the ashtray was not self-extinguishing and was overflowing with cigarette butts. The ED further confirmed the facility did not have a receptacle in which to discard cigarette butts and the grassy area was littered with cigarette butts.

Based on record review and staff interview, the facility failed to establish there was an annual grievance committee for resident complaint resolution. This had the potential to affect all of the residents residing in the facility. The facility census was 55 residents.

Findings include:

Review of the facility documents revealed the facility had no minutes or documentation of an annual grievance committee meeting composed of residents, staff and sponsors.

Interview on 02/05/25 at 5:09 P.M. with the Executive Director (ED) confirmed the facility had not established an annual grievance committee to review and resolve resident grievances.

Based on observation and staff interview, the facility failed to post the required notices and information for residents and visitors in a conspicuous place in the main entry area and on the secured entry area. This had the potential to affect all residents residing in the facility. The facility census was 55.

Findings include:

Observation on 02/06/25 at 1:23 P.M. of the common entry area of the facility and of the entry area of the secured unit revealed there were no postings of the rights of residents, no copy of the home's rules and its policies and procedures regarding the rights and responsibilities of residents, no list of residents' rights advocates, and no copies of three years of health inspection reports.

Interview on 02/06/25 at1:23 P.M. with Administrative Assistant (AA) #63 confirmed the required notices were not posted to the entry of the secured unit. AA #63 confirmed the facility was having some wall renovation in the entrance area, which would last during the next month, and the postings had been removed during renovations.

Interview on 02/06/25 at 3:00 P.M. with the Executive Director (ED) confirmed the wall renovations would take up to a month to complete and the facility required notices should have been posted during the renovations.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to maintain and clean and safe resident environment. This had the potential to affect all of the residents residing in the facility. The facility census was 55 residents.

Findings include:

Review of the medical record for Resident #28 revealed an admission date of 04/03/24 with diagnoses including diabetes, dementia, hypertension and atrial fibrillation.

Review of the functional assessment for Resident #28 dated 10/23/24 revealed the resident had moderately impaired cognition and required assistance with activities of daily living (ADLs.) and received continuous oxygen via nasal cannula.

Observations on 02/05/25 from 11:50 A.M. through 1:30 P.M. revealed the following concerns: there was no oxygen in use sign on Resident #28 door, the common area floors of unit 100 and 200 had debris and sticky substances on the floor, the fire rated self-closing doors to the kitchen and to the hair salon were held open by devices at the bottom of the doors, the door handle to the nurses' station door on the 200 was missing and a cloth had been placed in the door jamb, there was an unlocked treatment cart in the nurses' station which was accessible to residents, there was no soap in the handwashing sink of the 200 unit laundry room, there were uncovered dirty linen barrels in the 200 unit laundry room, the fire extinguishers in the kitchen and in the resident smoking area had no inspection date for January 2025.

Observations on 02/05/25 at 11:50 A.M. and on 02/06/25 at 1:30 P.M. of the secured dementia unit revealed there was alcohol-based hand sanitizer and hand lotion labeled as keep out of the reach of children in unlocked areas accessible to residents.

Observations during the breakfast and lunch meals in the main dining room with 15 to 20 residents present on 02/05/25 and on 02/06/25 revealed there were unlocked two bags of hazardous listed chemicals in the renovation area of the main dining room.

Interview on 02/05/25 at 11:50 A.M. with Licensed Practical Nurse (LPN) # 61 confirmed the handle to the door to the nurses' station door on the 200 unit had been missing for months and the cloth in the door jamb assisted in making the door work.

Interview on 02/05/25 at 11:51 A.M. with the Director of Nursing (DON) confirmed the following concerns: unlocked chemicals in the secured dementia unit, unfilled soap in laundry room, uncovered linen barrels in the laundry, the treatment cart in the 200 unit was unlocked and accessible to residents, no oxygen signage on Resident #28's room, the fire rated salon door held ajar. The DON confirmed all chemicals should be locked and the environment should be maintained and in good working order.

Interview on 02/5/25 at 1:30 P.M with Dietary Manager (DM) # 60 confirmed the chemicals in the dining room should be locked and removed from the area. DM #60 further confirmed the fire rated door to the kitchen should not be held ajar and the kitchen fire extinguisher had not been inspected since December 2024.

Review of facility policy titled Assisting with Oxygen undated revealed staff must storage oxygen according to regulations.

Based on observation, medical record review, review of a call for service report, interview with facility staff, review of an electronic mapping website, review of the facility alarm report, and review of the facility's elopement policy, the facility failed to ensure adequate supervision was provided to an exit seeking, cognitively impaired resident, to prevent elopement from the facility without staff knowledge. This resulted in Real and Present Danger and the potential for serious life-threatening harm, injuries and/or negative health outcomes for Resident #14, who was cognitively impaired and had exit seeking behaviors, when the timed egress doors were released due to the smoke alarm being activated and they were not reset for over nine hours. This allowed Resident #14, who resides on a secured Memory Care Unit (MCU), to exit the building without shoes and without staff knowledge and he got approximately 0.7 miles down the road and was returned to the facility by emergency services over an hour later. This affected one (Resident #14) of three residents reviewed for elopement. The facility identified 11 residents (#01, #02, #07, #08, #10, #11, #12, #13, #14, #15 and #17) who resided on the MCU and had behaviors of wandering. The facility census was 59.

On 07/25/24 at 1:45 P.M., the facility's Executive Director (ED) and Director of Nursing (DON) were notified Real and Present Danger began on 07/18/24 at approximately 11:07 P.M. when the timed egress doors were released in the MCU due to the smoke alarm being activated and they were not reset for over nine hours. As a result, this allowed Resident #14 who resides on the secured MCU who was cognitively impaired and assessed as at risk for elopement to exit the building on 07/19/24 at 8:39 A.M without shoes and without staff being aware and he traveled approximately 0.7 miles down the road. Resident #14 was found on 07/19/24 by a passerby who notified police dispatch at 9:29 A.M. Resident #14 was returned to the facility at 9:47 A.M. by emergency services. Resident #14 was not immediately assessed at the facility after the elopement.

The Real and Present Danger was abated on 07/26/24 when the facility implemented the following corrective actions:

· On 07/24/24, locks were placed on the two gates in the Memory Care courtyard by a construction contractor.

· On 07/24/24, low-voltage touch pads/locks were ordered and to be installed onto interior and exterior gates by a contracted company. Estimated installation time is 2-3 weeks as parts are on order.

· On 07/25/24, the ED implemented a procedure and protocol for battery-operated door sensor alarms to be installed, operating, and have audits in place for functionality. This alarm will act as an immediate warning in the event the fire system is activated. The ED is to add the TELS system (which is a technology-based system for scheduling and management of maintenance and repair services) for Maintenance Director #31 to ensure proper placement and function monthly and battery replacement every six months.

· On 07/25/24, the new procedure will be for the ED and/or the Maintenance Director #31 to be responsible for calling into the facility after hours if the fire system has been activated to ensure staff reactivates the door maglocks while on the phone with the ED/Maintenance Director #31.

· On 07/25/24, the ED/DON/Maintenance Director #31 will have conducted an in-service on how to engage maglocks on the doors on the MCU with all nurses. This in-service will include the usage of the key, reengaging when the fire system is reset and when a resident pushes on the door for 15 plus seconds deactivating the magnet. This will be audited by the ED/DON and/or Maintenance Director #31 weekly for four weeks.

· On 07/25/24, all staff will be trained by Maintenance Director #31 on reengaging the maglocks on hire and check off to be added to the onboarding packet. All staff to have annual training moving forward per policy.

· On 07/25/24, the new procedure going forward will be that the DON/Assistant Director of Nursing (ADON) will be conducting bi-annual screening of individuals within the Assisted Living for elopement risk. If at any time due to a change in condition, an assessment will be completed immediately to notate if the MCU is appropriate.

· On 07/26/24, nursing staff will be given an in-service on the Elopement Policy, elopement prevention, and proper documentation. Training will be conducted by the DON/ADON.

· On 07/26/24, all staff will be trained by the DON/ADON on the Elopement Policy and prevention.

· On 07/26/24, all high risk and like residents, which the facility identified 11 Residents (#01, #02, #07, #08, #10, #11, #12, #13, #14, #15 and #17), who resided on the MCU and wandered were assessed by the DON/ADON for elopement risk and the elopement risk and activities assessment was completed. Service plans to be updated. Like residents will be altered to a minimum of a quarterly assessment schedule to ensure appropriate interventions are in place and being utilized appropriately.

· On 07/26/24, staff will be increased with the utilization of either and/or both when available one additional Care Provider at mealtimes for additional support as residents begin finishing meals and exiting the dining area on their own as well as activity staff to

immediately begin an activity at the closing of meals for additional entertainment to minimize the desire to wander.

· On 07/30/24, interview with the ED revealed that the facility has had no further elopements.

· On 07/31/24, Resident #14 ' s medication to be reviewed by Physician #40 to ensure proper dosage and appropriate coverage. Laboratory tests to be obtained if indicated.

Although the Real and Present Danger was abated on 07/26/24, the violation remains as the facility is in the process of implementing on-going monitoring of the corrective actions and education of new staff.

Findings include:

Record review of Resident #14 revealed an admission date of 11/28/22 with pertinent diagnoses of gastroesophageal reflux disease, depression with anxiety, dementia without behavioral disturbances, insomnia, chronic pain, and essential hypertension.

Review of the change of condition nursing evaluation dated 12/23/23 revealed Resident #14 wanders and at times finds exit doors while wandering. He should be closely monitored while awake. Resident #14 requires total assistance with dressing, bathing and standby assist for toileting. Resident #14 requires standby assist for transferring and physical assist for personal hygiene. Resident #14 requires status checks every two hours around the clock, due to a recent hospitalization, history of falls, frequent medication changes, wandering/elopement status, behavior modification, and positioning needs. Resident #14 has continuous impaired judgement, occasionally wanders and is an elopement risk. He is not alert to surroundings and does not understand verbal communication.

Review of an Observation Note dated 04/08/24 at 7:24 P.M. revealed the writer was told by the agency nurse and care giver that Resident #14 was across the parking lot at the dog park with no shoes on. A witness at the park flagged the building down to get someone's attention. A caregiver and receptionist saw this and went to go and get him. A witness at the park stated that he came really fast out the back door of the MCU and came to the dog park. This writer gave this information to an oncoming nurse.

Review of an Observation Note dated 06/08/24 at 2:56 P.M. revealed to monitor Resident #14 for exit seeking behaviors. Resident #14 was able to go out of the facility and was found off the property. Resident #14 should be accounted for every one hour.

Review of an Observation Note dated 07/17/24 at 4:08 P.M. revealed the second-floor nurse was outside and noted Resident #14 walking outside, coming around the building from the outside area of memory care. Staff assisted the resident back into the building. A message was left for the resident's daughter.

Review of an Alarm Report revealed that on 07/19/24 at 8:39 A.M. the memory care outer doors were accessed.

Review of a Call for Service Report dated 07/19/24 revealed a call was received at 9:29 A.M for a man (Resident #14) on Irwin-Simpson Road/Snider Road in Deerfield Township 45040 with no shoes who is very confused and disoriented sitting in the grass now saying he fell to the ground and cannot get back up. At 9:37 A.M. it was confirmed that the man (Resident #14) was from the assisted living facility and returned by emergency services at 9:47 A.M.

Review of an Observation Note dated 07/19/24 at 10:10 A.M. revealed Resident #14 eloped from the facility this morning. The fire department returned Resident #14 to the facility. The Power of Attorney and DON have been notified.

Interview with Maintenance Director #31 on 07/24/24 at 11:10 A.M. revealed on 07/18/24 the air conditioner blower motor stopped functioning (burnt up) and it set off the smoke alarms. When the smoke alarms go off it releases all magnetic timed egress locks in the building. This happened on 07/18/24 on third shift at about 11:07 P.M. There are three-timed egress magnetic locks leading out of the locked MCU and two of them were not reengaged by a key afterwards. Someone did reengage the magnetic lock from the MCU that leads to the kitchen but the door leading out of the MCU in the front and back were not reengaged. He revealed when they do orientation he trains the staff, if the fire alarms go off you have to reset them, and the key is on the nurse ' s key ring.

Interview by phone with Caregiver #34 on 07/24/24 at 1:23 P.M. revealed she worked the MCU on 07/19/24 and was given information during report the fire alarms went off during the night. She believed she saw Resident #14 about 8:45 A.M. and she realized about 9:00 A.M. or 9:05 A.M. he was not in the building and got on the walkie talkie to notify staff.

Interview by phone with Licensed Practical Nurse (LPN) #35 on 07/24/24 at 1:42 P.M. revealed she worked the MCU on 07/19/24 and Resident #14 exit seeks probably three to four times a shift. LPN #35 stated she gave Resident #14 his medications between 8:30 A.M. and 9:00 A.M. She thinks she saw him around 9:00 A.M. She was made aware he was missing when they brought him back maybe right before 10:00 A.M. LPN #35 verified she did not notify Resident #14 ' s family of the elopement and stated she usually would call but the fire department brought him back and she was standing there when they called the daughter.

Interview by phone with Caregiver #36 on 07/24/24 at 2:00 P.M. revealed she worked the MCU on 07/19/24 and she gave Resident #14 a second tray. She stated they served breakfast about 8:30 A.M. to 9:00 A.M. that morning. She did not know he was missing until Maintenance Director #31 asked where he was a couple minutes before they brought Resident #14 back. She thought she saw him maybe around 9:00 A.M. or a little after.

Interview with Maintenance Director #31 on 07/24/24 at 2:31 P.M. revealed he checked the doors in the MCU after he was informed Resident #14 had gotten out on 07/19/24. He stated the side doors were locked in the MCU. The front door going out of the MCU into the facility and the back door going out were not reengaged after the smoke alarms went off. There is a timer overhead on the door that shows 15 if you press on the door release bar for a few seconds it starts a 15 second visible countdown and then the door releases and an alarm goes off. No one reset the doors so there would be no alarm and you would not have to wait 15 seconds you could just push the door and walk right out of the MCU. The magnetic lock is reset by using a key on each door and turning the key until the 15 is visible instead of dashes when it is not armed.

Interview with Executive Assistant #33 on 07/24/24 at 2:33 P.M. revealed she was working the desk on 07/19/24 and got a call around 9:30 A.M. from the police and they said they have Resident #14 and asked if he was a resident of the facility and she verified he was. The Emergency Medical Service brought him back to the facility around 10:00 A.M. that day.

Interview with Executive Assistant #33 on 07/24/24 at 2:45 P.M. verified that the back door of MCU was opened at 8:39 A.M. on 7/19/24 according to the Alarm Report.

Observation of Resident #14 on 07/24/24 revealed he resides in the locked MCU with coded locked doors to leave the unit. Resident #14 was spoken to and did not provide any coherent answers.

Interview with the DON on 07/25/24 at 11:04 A.M. verified the nurse did not do an assessment on Resident #14 when he returned to the facility on 07/19/24. The DON stated there were no

visible injuries on Resident #14 and he was assessed three days later on 07/22/24 by staff. The DON was asked for Resident #14 ' s elopement investigations, and she did not provide them.

Observation of the MCU on 07/25/24 at 2:30 P.M. revealed the area had a door that was secured via keypad. The door was able to lock and unlock via code entry on the keypad that is secured by a magnetic timed egress lock that opened the door if it was pushed on for a few seconds after a 15 second countdown. When the 15 second timed egress was not functioning, it showed dashes where the 15 second timer was usually shown. When the correct code was entered the door was unlocked. Once the door returned to a closed position the keypad automatically secured the door to ensure no unauthorized access to opening and closing the door.

Review of Google Maps (an electronic mapping website) application on 07/25/25 at 2:35 P.M. revealed the distance from the facility to the intersection of Irwin-Simpson Road/Snider Road in Deerfield Township 45040, where Resident #14 was found on 07/19/24, was 0.7 miles and would take approximately 15 minutes to walk.

Review of the Elopement Policy dated 04/01/23 revealed it addressed the steps for the investigation process and follow up checklist to be performed.

This violation represents non-compliance investigated under Complaint Number OH00156048.