Sunrise of Dublin

Based on medical record review, resident referral information, hospital notes, police reports, progress notes, policy review, medical provider interview, and staff interviews, the facility failed to provide adequate supervision to ensure Resident #22, who was cognitively impaired with suicidal ideations and identified to be at risk for elopement, did not elope from the secured memory care unit and did not carry through on suicidal ideations resulting in the resident eloping from the facility and once returned to the facility attempted to commit suicide. This resulted in Real and Present Danger when Resident #22 was placed at risk for serious life-threatening harm, injury, and/or death on 02/10/25 after her admission to the facility from a psychiatric hospital and verbalized her intent to leave the facility even if it meant in a body bag. On 02/11/25, the resident attempted to leave the facility by kicking a hole in the screen in her window. On 02/13/25, the resident left the secured dementia unit and left the facility unsupervised, walked seven minutes from the facility, crossed busy roads and attempted to secure transportation from a car dealership. The resident was returned to the facility by the police. The Real and Present Danger continued on 02/15/25 when Resident #22, while under the one-to-one supervision of a sitter, locked herself in her bathroom, broke a wine glass, and used the shards of glass to slit her wrist, groin, and bilateral sides of her neck. The bathroom door was broken open, nine-one-one (911) was called, and Resident #22 was transferred to the hospital where she required intubation, blood transfusion, and surgical repair of her wrist laceration. Resident #22 did not return to the facility. This affected one (#22) of three residents reviewed for abuse and neglect. The facility census was 73.

On 03/24/25 at 1:07 P.M., the facility Executive Director (ED), Resident Care Director (RCD)/Director of Nursing (DON), Resident Care Coordinator (RCC) (#550), and Administrator of a sister facility were notified Real and Present Danger began on 02/10/25 when the facility accepted Resident #22 as a new admission to the facility from a psychiatric hospital without obtaining the information pertinent to Resident #22's admission and treatment at the hospital so the facility could provide the care and services the resident required to remain safe in the facility once she was admitted. Resident #22 attempted to elope from the facility on 02/11/25 and expressed a desire to leave even if in a body bag. The Real and Present Danger continued when Resident #22 eloped from the facility on 02/13/25 at an unknown time and walked seven minutes away from the facility to a car dealership in a busy neighborhood. Once returned to the facility, Resident #22 was provided with an agency one-to-one sitter who on 02/15/25 permitted Resident #22 to enter the bathroom alone where the resident proceeded to lock the door for an extended period of time, requiring staff to break the lock of the door and find Resident #22 with multiple self-inflicted lacerations and sitting in a pool of blood with her head slumped into her lap. Resident #22 was transported to the hospital where she was noted to have lacerations to her wrists, neck, and leg. Resident #22 was intubated, received a blood transfusion, and required surgical consultation for the laceration to her right wrist.

The Real and Present Danger was abated on 03/26/25 when the facility implemented the following corrective actions:

On 2/17/25, the Memory Care Unit (MCU) elevator code was changed by Maintenance Assistant #322 and the keypad protector was installed.

On 2/17/25, the ED reinforced to all staff to never give door codes out to family or visitors. Maintenance Assistant #322 will monitor and adjust code as needed.

On 2/18/25, the ED conducted refresher training on Resident Rights for Abuse and Neglect to all staff. Education to continue upon hire and semi-annually.

On 2/18/25, a Town Hall meeting (team members) was conducted to include refresher training regarding Elopement/Suicide Ideations. This training was conducted by the ED and RCD/DON. Attending staff included: seven Department Heads, four Nurses, and 14 Care Managers.

On 02/18/25, staff were instructed by RCC #550 to carry the bathroom key fob (unlocks all bathrooms in the facility). RCC #550 will conduct audits weekly beginning 3/25/25 times four weeks to ensure compliance.

On 2/18/25, RCD/DON, RCC #550, and Wellness Nurses (direct care nurses) initiated review of current resident service plans and will update as needed.

On 2/18/25, Pre-move in standards and assessment were reviewed and refresher training provided to all staff. The Pre- move in standards and assessment included: Completion of comprehensive assessment for all potential new admissions including suicide risk assessment as indicated; and Completion of History and Physical - identify any new move ins with the following: Inpatient Stay at Psychiatric Hospital, Mental Health, History of behaviors including harm to self or others, elopement, suicidal ideation, resident to have ongoing treatment with mental health provider. All information to be reviewed with Regional Team to determine appropriateness of Move-in. The RCD/DON and/or nurse designee are completing the Pre-Move In assessment. Staff have been educated on the assessment during the onboarding process for RCDs/DONs and nurses. The ED has oversight of the process.

On 02/19/25 at 4:10 P.M. and again on 03/12/25 at 11:52 P.M., Elopement Drills were conducted. The community completes elopement drills monthly, each shift quarterly.

On 03/05/25, Thriveworks (psychiatric services) was initiated at the community to establish community services for those residents in need. In-person services were provided on 3/19/25 for Resident #29.

On 03/24/25, the Regional Director of Resident Care #600 and Regional Director of Operations #602 reviewed reportable events/timeliness of reporting to ensure compliance.

On 03/24/25, RCD/DON contacted Certified Nurse Practitioner (CNP) #500 in regard to the community's Real and Present Danger; however, had to leave a voicemail. The RCD/DON did speak to CNP #500 on 3/25/25. Direction was given by CNP #500 to ensure appropriate notification regardless of time of day.

Beginning on 03/25/25, the twenty-three (23) residents on the secured MCU were re-assessed with the facility suicidal risk assessments and no changes were needed to any resident care plans. On 3/27/25, the community will complete twenty-five (25) assisted living suicidal risk assessments and on 3/28/25, the community will complete twenty- five (25) assisted living suicidal risk assessments. The assessments are being completed by the RCD/DON for all 73 residents.

Beginning on 03/25/25, all residents will be assessed using the facility's assessment. The assessment includes demographics (includes history)/background/preferences, general assessment (includes vital signs, immunizations, vision, hearing, memory and cognition, mood and interaction, intimacy, sensation and sleep pattern), systems assessment (includes oral hygiene, cardiovascular/respiratory assessment, nutritional assessment and gastrointestinal/genitourinary, skin, musculoskeletal), medications & safety assessment (includes elopements/safety, falls, security, coordination of care), ADL assessment (mobility, transferring, assistive devices, grooming, oral care, dressing, assistance to the bathroom, bathing, dining, laundry, instrumental ADLs), and special instructions. The assessment is completed by the RCD/DON and/or nurse designee prior to moving in. Following the initial assessment, reassessments are completed annually and/or on change of condition. Based on ongoing observations, a change in condition of a resident may initiate a change and/or update to the resident service plan.

On 03/26/25, Missing Resident, Suicide Risk: Prevention, Management & Safeguarding Residents, and Incident and Event Reporting policies were reviewed with the ED, Regional Director of Operations #602, and Regional Director of Resident Care #600 and these policies were determined to be in compliance.

Beginning on 03/26/25 (and continuous) for Management of Events, the community will ensure significant adverse changes that would require proper steps to contact the primary care provider and responsible party. The RCD/DON and/or nurse designee are responsible to report these events to the ED and/or regional team.

Beginning on 03/26/25, the ED and/or designee will coordinate expectations/plan of service to ensure continuity of oversight with private sitter prior to services provided. RCD/DON and/or designee will document in the resident's record for use of private sitter.

Interview on 03/26/25 at 12:57 P.M. with LPN #306 revealed she had received education on suicide awareness, signs and symptoms, and what to do if a resident is expressing, they want to harm themselves or have a plan to harm themselves.

Interview on 03/26/25 at 1:05 P.M. with CM #393 revealed she received education on suicide awareness and the process of what to do if someone wants to harm themselves. Residents should not be left alone, and nursing should be notified.

Interview on 03/26/25 at 3:00 P.M. with LPN #340 revealed if a resident is stating they want to harm themselves or has a plan to harm themselves, staff is to stay with the resident at all times, use the walkie talkie to page the supervisor, who will then contact physician for orders.

Beginning on 03/27/25, the following refresher training is being initiated: Missing Resident, Suicide Risk: Prevention, Management & Safeguarding Residents, and Incident and Event Reporting. The above trainings are being conducted by the ED, RCD/DON and/or RCC #550. The community will have current staff participate in Abuse & Neglect online and in person. The above trainings will be completed by April 25, 2025, for the following staff: one Activity Assistant, one Maintenance Assistant, one Associate Director of Sales, one Business Office Coordinator, one Activity Volunteer Coordinator, four Concierges, one Cook, one Dining Services Director, one Director of Sales, two Dishwashers, four Housekeepers, two Life Enrichment Managers, two Night Supervisors, one Resident Care Coordinator, one Resident Care Director, three Servers, one Executive Director, one Wellness Nurse, 13 Licensed Practical Nurses (LPN), 27 Care Managers (CM) and nine Lead Care Managers. Per the ED, the extended refresher training completion date is due to a large number of as needed staff that will need to complete the training. Per the ED, all staff will have training completed prior to their next working shift.

On 03/27/25 and 03/28/25, Regional Memory Care Director #604 to conduct in-person training for all staff on managing challenging behaviors to current team members.

Although the Real and Present Danger was abated on 03/26/25, the violation continues as the facility is still in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance.

Findings include:

Medical record review revealed Resident #22 admitted to the facility on 02/10/25 with diagnoses including unspecified mood (affective) disorder, iron deficiency anemia, Type II diabetes, dementia, and anxiety.

Review of a hospital referral form dated 02/10/25 revealed Resident #22 was admitted to the facility from a psychiatric hospital setting. The referral did not have information on why Resident #22 required an inpatient psychiatric stay or physician progress notes regarding her history or what treatment she received at the hospital.

Review of a Brief Interview for Mental Status assessment dated 02/10/25 revealed Resident #22 had mildly impaired cognition. A pain assessment was also completed and revealed Resident #22 had a pain level of zero. Review of a memory care assessment dated 02/10/25 revealed Resident #22 had exit seeking behaviors, but did not have impaired safety awareness and needs were not more than the facility could handle.

Review of orders from the resident's physician at the hospital used for the resident's admission to the facility revealed Resident #22 was to receive donepezil (acetylcholinesterase inhibitor, used to treat dementia) 10 milligrams (mg) one time a day for dementia (order date 02/11/25), memantine (NMDA receptor antagonist, used to treat Alzheimer's dementia) tablet 5 mg orally two times a day related to dementia (order date 02/11/25), mirtazapine (antidepressant) tablet 15 mg orally at bedtime related to unspecified mood disorder (order date 02/11/25), and risperidone (atypical antipsychotic) tablet 1 mg orally at bedtime related to unspecified mood disorder (order date 02/11/25).

Review of a nursing note dated 02/11/25 at 11:10 A.M. written by the DON revealed staff were made aware by family that Resident #22 made several calls to them stating she would hurt herself if they did not come and take her home. While staff were assessing Resident #22, they identified her window was open and the screen was torn from the frame. Resident #22 stated, I will jump out the window and leave in a body bag if my family does not get me out of here. Resident #22's responsible party and Nurse Practitioner (NP) #500 were notified a sitter would need to be in place, and the party responsible requested Resident #22 be transferred to the hospital. The police arrived at the facility and transported Resident #22 to the hospital.

Review of a Suicide Risk Assessment dated 02/11/25 at 11:36 A.M. completed by the DON revealed Resident #22 had verbalized suicidal ideation or intent to do self-harm by stating, I will jump out the window and leave in a body bag if my family does not get me out of here. Resident #22 had a history of impulsivity and poor self-control, previous history of psychiatric diagnosis, history of abuse, and had a history of receiving psychiatric services. When asked if she had thought of suicide, a plan, and component available to carry out her plan, Resident #22 stated, yes. Resident #22 stated going home would keep her from harming herself because she has to work and has three dogs to care for. The police came to the facility to escort Resident #22 to the hospital, and she stated, you should have never brought me out here, now you'll never get me back inside. The police officer responded, you do not want to run. Resident #22 was then transported to the hospital.

Review of a nursing note dated 02/11/25 at 4:24 P.M. by the DON revealed the hospital social worker notified the facility Resident #22 denied intent to hurt herself and she would be transported back to the facility when transport was available. Resident #22's family was aware and agreed to pay for a 24-hour one-to-one sitter. All parties were aware and updated.

Review of hospital records dated 02/11/25 revealed Resident #22 presented to the hospital with suicidal ideation. Resident #22 had a history of dementia, anxiety, and alcohol abuse. Resident #22 stated she was going to jump out the window and her screen was cut. Resident #22 told hospital staff the screen was already cut, and she did not have suicidal ideation. A psychiatric consult was completed and stated Resident #22 had a history of 18 months of making suicidal statements to try to gain control over her environment, per the resident's daughter. Resident #22 had no history of suicide attempts, and she often forgets she makes suicidal statements. Resident #22's risk factors included making suicidal threats but not acting on them, psychiatric hospitalization, family history of suicide, history of trauma, non-compliance with medications, poor insight, poor judgement, chronic illness, substance use, impulsivity and anger, hopelessness and access to firearms. Her protective factors included no current suicidal ideation, no history of attempts, and no access to firearms. Resident #22 did not meet criteria for psychiatric admission due to suicidal statements being part of her dementia behaviors.

Review of a contract for Resident #22 to receive a caregiver (sitter) through agency staffing services dated 02/11/25 revealed no specific responsibilities of the caregiver or the facility, but did detail the billing process.

Review of a nursing note dated 02/12/25 by the DON revealed Resident #22 had verbalized suicidal ideation and was sent to the hospital for evaluation and treatment with a police escort (this had occurred on 02/11/25). At the hospital, Resident #22 denied making comments and attempting to climb out her window. Resident #22 returned from the hospital with no new orders and all parties were aware.

Review of a service plan dated 02/13/25 revealed Resident #22 was receiving anti-psychotic medications due to a diagnosis of (specify), and she required on-going/constant supervision interventions due to (specify). The areas of the service plan where it says specify were blank.

Review of a nursing note dated 02/13/25 at 7:57 A.M. by LPN #306 revealed she spoke with Resident #22's sitter (Agency Sitter [AS] #402), who reported the resident was good and slept all night with no concerns and was in the dining room eating breakfast. The sitter stated Resident #22 did not voice suicidal ideation or verbal aggression all night.

Review of a nursing note dated 02/13/25 at 4:52 P.M. by the DON revealed Resident #22 had expressed desire to harm herself but stated she had no intent to harm herself on reassessment.

Review of a police report dated 02/13/25 at 5:23 P.M. by Police Officer (PO) #145 revealed officers had been made aware of a confused person at a local car dealership. At 5:51 P.M., police received a call regarding a missing resident, Resident #22. Resident #22 was taken back to the facility at 6:09 P.M.

Review of a nursing note dated 02/13/25 at 6:19 P.M. by the DON revealed Resident #22 eloped from the facility without being accompanied by staff. Resident #22 was returned to the facility by police without incident with a full assessment completed upon return and no skin issues noted. Resident #22 stated she was glad to be back when she returned, and she resumed with a one-to-one sitter. The resident's responsible party and NP #500 were made aware.

Review of a change in condition assessment completed on 02/13/25 by the DON revealed Resident #22 was on medications that may affect mood/behavior including antipsychotics and anti-anxiety; had no change in orientation in the last 30 days; had verbalized repeatedly she would like to leave the facility and exhibited exit-seeking behavior; had a recent move into the community; tended to wander or exit seek, requires frequent validation, and eloped or wandered off in the last 90 days; no disruptive behaviors; she had expressed repetitive desire to harm self; had no attempted suicide or history of attempted suicide but did verbalize suicidal ideations; had impulsivity and poor self-control; did not have impaired safety awareness; and her safety/behavioral expression needs did not exceed the standards for the facility.

There was no additional information regarding how Resident #22 eloped or evidence a root-cause analysis was completed.

Review of a nursing note dated 02/15/25 at 2:33 A.M. by LPN #320 revealed Resident #22 was arguing with her sitter and opening her window. Resident #22 was very anxious. An intervention of reminding Resident #22 her sitter would remain with her at all times was used to which Resident #22 was argumentative. There were no additional interventions.

Review of a nursing note dated 02/15/25 at 3:21 P.M. by LPN #357 revealed Resident #22's sitter notified the nurse Resident #22 stated she wanted to kill herself. The DON was made aware. There was no evidence that any immediate interventions were completed at this time even though the resident had stated a desire to kill herself.

Review of a nursing note dated 02/15/25 at 3:51 P.M. by the DON revealed Resident #22 had reportedly stated she wanted to hurt herself, but she could not recall making the statement and denied intent a few minutes later. Resident #22 ate breakfast and lunch in her room and continued to have a 24-hour sitter in place.

Review of a police report dated 02/15/25 at 5:47 P.M. revealed officers responded to a call at the facility due to a report of a female resident locking herself in the bathroom. While on the way to the facility, they were made aware the bathroom door was forced open by staff and Resident #22 had cut herself. Upon arrival, medics had arrived and were working to stop the bleeding. Resident #22 was struggling with the medics and officers assisted the medics. There was blood throughout the hallway leading out of the bathroom as well as a large pool of blood in the bathroom. There was a broken wine glass in the restroom used to cause the lacerations and a note on the floor near the pool of blood which read, Baby Bear, you took everything from us, Mommy. There were also family photos near the blood on the floor of the restroom and additional family photos on the floor of the bedroom at the end of the hallway. Officers spoke with LPN #307 and AS #402 who stated AS #402 was sent from the agency to check on Resident #22 due to past suicidal tendencies. On 02/11/25, Resident #22 was placed on emergency admission (to the hospital). AS #402 stated she arrived at the facility around 8:00 A.M. and there was no mention of suicidal thoughts during her shift with Resident #22. AS #402 and LPN #307 both reported Resident #22 had gone to the restroom and stated she was constipated. After about an hour, LPN #307 went to get medication to assist with the constipation, but Resident #22 was still alert and stated she needed privacy. While LPN #307 attempted to get Resident #22 to open the door for medication, Resident #22 continuously refused. LPN #307 got permission from her supervisor to force the door open and CM #327 forced the door open, and they saw Resident #22 with lacerations in a pool of blood. Staff called 911 and used clothing to hold pressure on the lacerations until the medics arrived. At the hospital, officers provided an application for emergency admission and due to the circumstances, Resident #22 was admitted under criteria one: represents a substantial risk of physical harm to self as manifested by evidence of threats of, or attempts at, suicide or serious self-inflicted bodily harm.

Review of a witness statement dated 02/15/25 at 8:00 P.M. by AS #402 revealed AS #402 was working for a staffing agency and arrived at the facility at 8:00 A.M. While sitting with Resident #22, they talked about the resident wanting to go home, resident took her morning medications, and the afternoon went by fast. At about 5:20 P.M., Resident #22 locked herself in the bathroom so AS #402 was talking to her through the door. Resident #22 requested a nurse and when the nurse came, Resident #22 stated she was having a hard time in the bathroom and the nurse asked if she was ok. Resident #22 responded she was having a hard time in the bathroom and the nurse went to grab a coworker to open the door, they saw blood, police came, and Resident #22 was still talking when removed from the facility.

Review of a witness statement dated 02/15/25 by LPN #307 revealed AS #402 called her to Resident #22's room because resident had locked herself in the bathroom for an hour. LPN #307 rushed to the room and asked Resident #22 to open the door, but Resident #22 stated she was defecating and could not answer the door. After a few minutes, LPN #307 asked for Resident #22 to open the door again and the resident replied she needed privacy. LPN #307 asked Resident #22 if she was constipated, and the resident said yes so LPN #307 went to get medications to help. Resident #22 still would not open the door, even to get medications, so LPN #307 called her supervisor (DON), made her aware of the situation and received permission to force the door open. CM #327 forced the door open, and Resident #22 was found in a pool of blood, 911 was called, and the resident was taken to the hospital.

Review of a witness statement dated 02/15/25 by CM #327 revealed he was taking dinner to Resident #22's room and AS #402 stated Resident #22 had locked herself in the bathroom. CM #327 called the nurse over who instructed him to open the door. Once the door was open, they saw Resident #22 bleeding, he applied gloves and used clothes to apply pressure while the nurse called 911.

Review of a witness statement dated 02/15/25 by CM #341 revealed she had given another team member Resident #22's dinner to take to her room at approximately 5:30 P.M. The team member then came and grabbed the nurse and CM #341 because Resident #22 locked herself in the bathroom. CM #341 called out to Resident #22 and got no response, so she told her coworker to open the door. Once the door was opened, CM #341 stated she saw Resident #22 sitting on the bathroom floor with her head hanging down in her lap with blood on her and the bathroom floor. The coordinator was called and made aware of the situation.

Review of a nursing note dated 02/15/25 at 10:00 P.M. by LPN #307 revealed Resident #22's sitter informed the nurse the resident had locked herself in her bathroom for a while. When LPN #307 went and tried to persuade Resident #22 to open the door, she stated she was using the restroom and needed privacy and would come out when she was done. LPN #307 informed the DON and called 911. A care manager forced the door open and found Resident #22 in blood. Resident #22 was taken to the hospital.

Review of hospital notes dated 02/15/25 revealed Resident #22 presented to the hospital as a trauma alert after locking herself in the bathroom for approximately two hours and cutting herself in the neck and wrists, losing approximately two liters of blood. At 8:10 P.M., Resident #22's blood pressure was 70/43 millimeters of mercury (normal 120/80 mm/Hg), at 8:15 P.M. it was 70/59, at 8:20 P.M. it was 65/43, at 8:26 P.M. it was 60/41, and at 8:32 P.M. it was 66/44. Resident #22's neck had superficial lacerations on the left side of her neck and 6-centimeter superficial laceration to the right side of the neck with subcutaneous fat exposed, she had a large laceration to the right wrist, other scattered lacerations, and one laceration on the posterior right leg. Resident #22 presented via squad after a suicide attempt and the initial report was, she had superficial lacerations and was slightly confused. Resident #22 was upgraded to a trauma level one immediately due to lacerations on her neck and was not responding much initially. Due to her waning mental status, the decision was made to intubate, and secondary surgery was notable for the laceration on her right wrist. Resident #22 had a faint pulse. Resident #22 was ordered one unit of blood to improve blood pressure. Resident #22 was admitted to the intensive care unit. The right wrist laceration was deep with tendon involvement. Stitches were required for three lacerations to the neck, and two lacerations to the right medial thigh.

Review of an incident log revealed on 02/16/25 there was a self-harm/suicide attempt incident.

Review of a late-entry progress note dated 02/16/25 at 9:09 A.M. by the ED revealed Resident #22's family contacted ED on 02/13/25 via text at 6:04 P.M. in regard to getting Resident #22 placed in a Geri-psych hospital and was planning on contacting them on 02/14/25. On 02/14/25, the ED messaged Resident #22's family for an update and heard back at 4:08 P.M. that there were bad reviews of the facility, and they were going to attempt another facility and get transportation. On 02/15/25, the ED contacted the agency staff to see if they would transport Resident #22 to a psych facility for evaluation. During the conversation, the provider at the agency stated she had attempted to call her staff who was with Resident #22 and the resident answered the phone and stated she was upset and considering hurting herself, but after talking for about 10 minutes, she forgot she made the statements. The ED texted Resident #22's family who responded it was not surprising to them because she usually forgets making threats after a few minutes. Information regarding transportation was sent to Resident #22's family who thanked the ED.

Review of a nursing note dated 02/16/25 at 11:33 A.M. by LPN #375 revealed a dietitian from the hospital called and stated the hand surgeon had been in to see Resident #22 to set a date for surgery, several other wounds were assessed and wound care completed at bedside. Resident #22 was intubated upon admission to the hospital and was expected to be extubated, but she was still in the intensive care unit for surgical/wound care.

Review of a nursing note dated 02/24/25 at 10:52 A.M. by the DON revealed Resident #22 was sent out to the hospital on 02/15/25 and the family made the facility aware she would not be returning on this date.

Interview on 03/22/25 at 1:34 P.M. with the ED revealed he did not have exact times Resident #22 was last seen, staff realized she was missing, and the time she returned to the facility on 02/13/25. Staff were unable to find Resident #22 for dinner, so the missing resident protocol was initiated and included assigning staff areas to search the interior and exterior of the building. The ED stated he contacted the police early in the search, who brought her back 20-30 minutes after staff realized she was gone. A car dealership about a five-minute walk away called the police as well due to a confused woman walking around their lot asking for rides, and they made the connection. The ED was unable to recall the name of the car dealership. The ED stated Resident #22 was last seen 45-60 minutes prior to going missing. The ED stated all documentation regarding the investigation into Resident #22's elopement would be documented in nursing notes and the self-reported incident the facility completed on 02/15/25 was for Resident #22's attempted suicide. The ED stated the doors to the stairwells were checked and were not alarming, so the staff assumed Resident #22 used the elevator to exit the locked unit. The ED stated he emailed all families to educate them to ensure the elevator doors close prior to walking away from the area. The ED stated Resident #22 had a sitter with her on 02/15/25 when she performed self-harm. Resident #22 told the sitter she needed to use the bathroom, was really constipated and requested privacy. The sitter allowed Resident #22 to enter the bathroom alone, and she locked the door. Resident #22 reported to the sitter she was having a really hard time and by the time everyone arrived, and the door was opened, Resident #22 had multiple wounds. The DON was at the facility and did not know the extent of the wounds at the time of the incident. Resident #22 had cut both wrists, her groin, and attempted to cut her carotid. Resident #22 wrapped a wine glass in a towel and broke it, then used the shards to make the lacerations. The ED stated he was unaware Resident #22 had behaviors including suicidal ideations until after the screen in her window was kicked out and she threatened to jump (on 02/11/25). The ED stated at that point, family reported to the facility Resident #22 had been threatening to harm herself approximately 18 months, but she was a master manipulator.

Interview on 03/22/25 at 3:23 P.M. with CM #327 revealed on 02/15/25, Resident #22 had a sitter in her room, and he delivered the dinner tray to her room. Upon arrival, CM #327 stated the sitter was on the couch next to the bathroom door and he asked where Resident #22 was. Resident #22 was locked in the bathroom. CM #327 stated he checked on Resident #22 by talking to her through the door and the resident reported she was using the restroom. CM #327 stated he was concerned because Resident #22's voice sounded weak, like she was in danger. CM #327 stated he was the one to open the door and Resident #22 was lying in blood. CM #327 stated he applied pressure to her wounds until the squad arrived.

Interview on 03/22/25 at 3:29 P.M. with CM #341 revealed she was in the dining room and had CM #327 take dinner to Resident #22's room. CM #341 stated she and the nurse were summoned by CM #327 to go to Resident #22's room because Resident #22 was locked in the bathroom. CM #341 stated she was trying to talk to Resident #22 through the door and she did not respond, so she told CM #327 to open the door. CM #327 replied that the door was locked, and CM #341 told him to break the door. CM #327 opened the door and Resident #22 was sitting on the floor with blood all around her. CM #341 stated she said Resident #22's name and she did not respond. CM #341 stated they then tried to find where the blood was coming from. CM #341 stated Resident #22 was sitting on the floor with her knees pulled up to her chest and her head resting in her lap. CM #341 stated CM #327 grabbed Resident #22's hand and found the bleeding was coming from her wrist and pressure was applied. CM #341 stated she called her supervisor while the nurse called 911. CM #341 stated she saw a broken wine glass in Resident #22's bathroom and she likely used a shard of glass to cut herself because when the squad arrived, they removed a piece of glass from Resident #22's hand. CM #341 stated when she came into the room, she observed AS #402 on her phone but was not aware who she was talking to.

Interview on 03/22/25 at 3:35 P.M. with CM #379 revealed she was working when Resident #22 eloped on 02/13/25 but she was busy in the kitchen preparing for dinner. CM #379 stated the staff searched the facility after being alerted Resident #22 was missing. CM #379 stated Resident #22 usually had a sitter with her, but she was not sure where the sitter was. CM #379 was not able to recall the last time she saw Resident #22 before she went missing. CM #379 stated she was working on 02/15/25 when Resident #22 attempted suicide as well but she was in the kitchen. CM #379 stated the sitter alerted her colleagues of concerns and they went to Resident #22's room. CM #379 stated she stayed in the kitchen to supervise the other residents during mealtime.

Interview on 03/22/25 at 3:48 P.M. with Police Officer (PO) #159 revealed he responded to the call when Resident #22 attempted suicide. PO #159 stated the call was for a female who locked herself in the bathroom and by the time he arrived at the facility, she had quit responding so staff broke the door and found her in a puddle of blood. PO #159 stated upon arrival, he witnessed Resident #22 fighting with medics who then transported her to the hospital, and she was pink-slipped (emergency psychiatric admission). PO #159 stated staff reported to him Resident #22 was in the bathroom for an extended period for constipation and was having a hard time. PO #159 stated staff told him Resident #22 was in the bathroom for an hour prior to staff attempting to open the door and get her out. There was an aide assigned to Resident #22 for her safety. PO #159 stated Resident #22 had broken a wine glass and used it to cut herself and he was not sure how the wine glass got to the bathroom. PO #159 stated there were also family pictures in her bathroom. PO #159 stated Resident #22 was conscious but had lost a lot of blood from her wrists and both sides of her neck. PO #159 stated other reports including police involvement with Resident #22 included a call from 02/11/25 when she stated she was going to jump out the window and leave in a body bag, and on 02/13/25 when she eloped from the facility and walked to a car dealership.

Interview on 03/22/25 at 4:07 P.M. with Administrator #202 revealed the facility did not have a specific admission process, policy or procedure. Administrator #202 stated the facility accepts anyone up to end-of-life care within the regulations. Administrator #202 stated the DON does an on-site visit and if there are no concerns, the resident can be admitted. If there is a concern, they consult with a physician.

Interview on 03/24/25 at 9:59 A.M. with the DON revealed Resident #22 was admitted to the facility from a psychiatric hospital who reported her needs were related to alcohol induced dementia. The DON stated Resident #22 was sent to the emergency room for evaluation on 02/11/25 for suicidal ideation, was cleared and returned to the facility where a one-to-one sitter was in place. The sitter was discontinued after 24 hours because Resident #22 was doing well. The sitter started back after Resident #22 had an elopement and was there to make sure she did not leave the facility again. The DON confirmed when Resident #22 started expressing suicidal thoughts again, a conversation should have been had with the sitter to discuss the expectations. The DON also confirmed it is the facility's responsibility to ensure resident safety.

Interview on 03/24/25 at 10:51 A.M. with the DON revealed the facility had altered their admission process to be more thorough when accepting residents with a psychiatric history but there was nothing in writing.

Interview on 03/24/25 at 12:11 P.M. with the DON and Administrator #205 revealed if the facility has a resident with suicidal ideations, the physician is notified and the resident is sent for psychiatric evaluation but if the resident does not have a plan, the hospital will send them back because they are not a threat to themselves. The DON stated the facility makes sure the residents are safe, their room is safe, and everyone around them is safe. The DON stated if someone has suicidal ideation, documentation should be completed on what steps the facility has taken to ensure resident safety. The DON confirmed there was no documented evidence of a thorough investigation into Resident #22's elopement (02/13/25) and attempted suicide including timelines, referral information, one-to-one sitter information, service plan, lack of documentation for room safety to remove all potential weapons, and a lack of policy and procedures.

Interview on 03/25/25 at 9:15 A.M. with the DON revealed the facility is not sure where the wine glass Resident #22 used to harm herself came from because the facility does not use wine glasses with thin stems, and she initially thought it was a broken flower vase. The DON stated Resident #22's family had moved in some personal items, and it could have included wine glasses. The DON stated the staff do use master keys, but they were at the nurse's station at the time of the incident. The DON stated all staff are now required to have the master key and bathroom keys in case of emergency.

Interview on 03/25/25 at 2:01 P.M. with LPN #307 revealed she was working on 02/13/25 when Resident #22 eloped from the facility. LPN #307 stated she was passing medication downstairs and returned upstairs to pass medications on the locked unit during dinner time. LPN #307 stated when she got upstairs, the care managers told her they could not locate Resident #22, so they searched the rooms. After being unable to locate Resident #22, LPN #307 called the ED, and they searched the facility for Resident #22 for about 30 minutes. LPN #307 stated after searching, the ED called the police who had located Resident #22 at a car dealership. LPN #307 stated she had seen Resident #22 at the beginning of her shift and from being made aware she was missing to when she returned, and Resident #22 was gone for about an hour. LPN #307 stated she also worked on 02/15/25 when Resident #22 harmed herself. LPN #307 stated when she came on for her shift at about 3:00 P.M., she saw Resident #22 wandering the halls and the sitter was not close enough to Resident #22, so she instructed the sitter to stay closer to the resident. LPN #307 stated after that, the sitter took Resident #22 to her room. LPN #307 stated during dinner; the sitter requested she come talk to the resident because she had locked herself in the bathroom for about an hour. LPN #307 stated she talked to Resident #22 through the door, and she reported she was pooping and needed privacy. LPN #307 stated she called her supervisor to let her know and was instructed to try to get the door open again. LPN #307 stated she went to the door and asked Resident #22 to open it, and she declined again. LPN #307 stated she asked if Resident #22 was constipated, and resident stated she was. LPN #307 went to the medication cart to get medications to help with constipation to try and get Resident #22 to open the door again. When she returned to the room, LPN #307 stated the aide told her Resident #22 quit responding so LPN #307 called 911. While she called 911, a care manager forced the door open, and they found Resident #22 had hurt herself in the bathroom with broken glass. LPN #307 stated she was unsure how Resident #22 even had a glass. LPN #307 stated Resident #22's wrists were cut, and pressure was applied. LPN #307 stated Resident #22 was awake, but she was weak and bleeding.

Interview on 03/26/25 at 10:34 A.M. with NP #500 revealed she was not notified of Resident #22 stating she wanted to leave in a body bag, kicking out the screen, and threatening to jump out of her window. NP #500 stated she was told Resident #22 had expressed a desire to leave the facility. NP #500 stated she should be made aware of the start or end of residents having a sitter. NP #500 emphasized she is new with this company, but her expectation would be to provide orders to start and end a sitter. NP #500 confirmed she did not give any orders for Resident #22 to have a sitter at any time. NP #500 stated she was not made aware of the elopement on 02/13/25 until sometime from 02/17/25 - 02/19/25. NP #500 stated prior to Resident #22 eloping, she had examined the resident for an initial history and physical. NP #500 stated Resident #22 was oriented and did not express she wanted to harm herself, but did state she wanted to leave the facility. NP #500 stated when Resident #22 eloped, she should have been made aware immediately at the time the event occurred. NP #500 stated there is an on-call system for providers, but she was unable to locate any other providers being made aware of events or giving orders regarding Resident #22. NP #500 stated when Resident #22 made statements of wanting to harm herself on 02/15/25, she was not made aware. NP #500 stated she was made aware Resident #22 attempted suicide after the fact, on or about 02/19/25 or 02/20/25. NP #500 stated she was told Resident #22 had been in the bathroom for a long time, she had a sitter in place, but she had used a sharp object to cut her arms and neck. NP #500 stated that when she has a resident who is suicidal, her expectation is for them to be sent to the emergency room for evaluation. NP #500 stated she does not know the facility protocol but would think the facility should ensure the resident's room is safe because it is common sense. NP #500 stated for residents who are at risk of eloping, the facility should utilize a locked unit or frequent checks, and they should document any interventions.

Review of a policy titled Missing Resident (dated 10/10/24) revealed when a resident is identified as missing, the ED shall be notified immediately and take the lead of the investigation. ED should print the face sheet and notify within proper timeframes required by state law appropriate law enforcement, resident's family/responsible party, case manager, primary care physician, and regulatory agencies. Upon a resident's return to the facility, there should be an assessment completed and documented, an elopement risk evaluation, and all actions and notifications made should be documented.

Review of the facility's Elopement Management Program revealed the immediate steps in responding to a missing resident is to identify the command lead, access the missing resident search kit, assign search areas to team members, conduct the search, and use the missing resident worksheet as guidance to document the event. After the event, the ED should notify family, regional team, primary care provider, law enforcement, and state agency as specified by law. The event should be reviewed weekly during interdisciplinary team meetings.

Review of a policy titled Abuse, Neglect & Exploitation - Prevention, Reporting and Investigation (dated 02/14/22) revealed neglect is defined as the failure to provide goods and services necessary to protect the resident from health and safety hazards.

This violation represents non-compliance investigated under Complaint Number OH00163105.

Based on observation, staff interview, and policy review, the facility failed to store food in a safe and sanitary manner. This had the potential to affect 64 of all 64 residents residing in the facility. The census was 64.

Findings include:

The kitchen was toured on 01/22/24 from 8:25 A.M. to 8:46 A.M. Observation of the walk-in refrigerator revealed various chopped fruits and a clear liquid that were unlabeled and undated. Further observation revealed a whole grain mustard container with an open or use by date of 12/18/23 and garlic oil that was labeled with an open or use by date of 10/11/23. There was opened and undated ketchup that was labeled and stored in a clear plastic bin with a lid, an unlabeled and undated white sauce in a clear plastic bin, and an opened lidded container containing a thick red paste with no label or date. Observation of the walk-in freezer revealed a frozen breaded patty without a label or date. The frozen breaded patty was open and exposed to air. Additionally, in the walk-in freezer, was a bag containing small breaded nuggets that was unlabeled and undated, and the bag was opened and exposed to air.

An interview with Cook #59 on 01/22/24 at 8:34 A.M. confirmed the multiple opened containers were unlabeled and undated, and the whole grain mustard and garlic oil was dated outside the use by dates in the walk-in refrigerator. Cook #59 also confirmed the opened food items in the walk-in freezer were unlabeled, undated, and exposed to air.

Review of an undated policy titled, Food Storage, Preparation, and Service

Based on observation and staff interview, the facility failed to place food scraps and trash in garbage cans with tightfitting lids. This had the potential to affect 64 of 64 residents residing in the facility. The census was 64.

Findings include:

During multiple observations on 01/22/24 at 8:25 A.M., 8:35 A.M., 10:10 A.M., and 11:08 A.M., used food scraps and garbage were observed behind the tray line and next to the oven in a garbage receptacle without a lid. The trash receptacle was in a food preparation area and food scraps and garbage were exposed to air.

On 01/22/24 at 8:34 A.M., an interview with Cook #59 verified trash cans should be covered when not in use, and confirmed the trash receptacle containing food scraps was uncovered, exposed to air, and in a food preparation area.

Based on review of fire drill reports and staff interview, the facility failed to perform fire drills every three months on each shift at varied times. This had the potential to affect 64 of 64 residents residing in the facility. The census was 64.

Findings include:

Review of fire drill reports revealed first shift fire drills were performed on 01/03/23 at 9:00 A.M., on 05/11/23 at 9:25 A.M., on 09/05/23 at 1:50 P.M., and on 10/12/23 at 1:58 P.M. Review of second shift fire drill reports revealed drills were performed on 02/12/23 at 7:45 P.M., on 04/21/23 at 6:18 P.M., on 06/09/23 at 4:20 P.M., on 07/26/23 at 7:55 P.M., and on 08/03/23 at 3:59 P.M. Review of third shift fire drill reports revealed drills were performed on 03/05/23 at 6:20 A.M., on 11/12/23 at 4:00 A.M., and on 12/03/23 at 6:50 A.M. There were no fire drills performed between the hours of 12:00 A.M. and 4:00 A.M. and between 7:55 P.M. and 12:00 A.M.

Interview on 01/22/24 at 1:36 P.M. with Maintenance Coordinator #37 and Executive Director #89 confirmed the fire drills were not completed on each shift at least every three months and the drills were not completed at varied times. Further interview with Maintenance Coordinator #37 stated that fire drills are conducted at the times that are automatically generated by the computer system the facility utilized to conduct, track, and monitor fire drills.

Based on observation and staff interview, the facility failed to maintain carbon monoxide detectors in working order. This had the potential to affect 64 of 64 residents residing in the facility. The census was 64.

Findings include:

During a facility tour on 01/22/24 at 10:32 A.M., the carbon monoxide detector in the laundry room was tested and failed to alarm when initiated. On 01/22/24 at 10:34 A.M., the carbon monoxide detector in the dining services area was tested and failed to activate when initiated.

Interview on 01/22/24 at 10: 33 A.M., Maintenance Director #37 stated when the carbon monoxide detector button was pressed it should sound an alarm indicating it was in working condition. Maintenance Director #37 verified the two carbon monoxide detectors were not working and he would replace them immediately.