Traditions at North Bend

Based on observation and staff interview, the facility failed to secure medications in a manner to protect residents on the memory care unit. This had the potential to affect 26 of 26 residents residing on the memory care unit. The census was 111.

Findings include:

Observation on 4/21/25 at 9:58 A.M. while touring the memory care unit with the Executive Director (ED), revealed an unlocked medication cart sitting in the nurse's station behind a swinging door that was unsecured. Drawers of the medication cart were easily opened without resistance.

Interview at the time of observation with the ED confirmed the medication cart was unlocked and not in a secure location.

Based on observation and staff interview, the facility failed to properly store food to protect against contamination and spoilage. This had the potential to affect all residents residing in the facility. The facility census was 111.

Findings include:

Observation on 4/21/25 at 10:37 A.M. while inspecting the dry storage area, revealed a box of dried lasagna noodles sitting in a box, open to air. Dietary Manager in Training (DMT) #72 confirmed lasagna noodles were sitting in an open box and that the contents needed to be secured in an airtight wrapping.

Observation on 4/21/25 at 10:39 A.M. revealed a box of puree mix rice was on a shelf unsecured and open to air with a scoop inside. DMT #72 confirmed the open puree rice mix was open and should have been secured in an air tight container and should not have a scoop inside. Puree rice mix removed and discarded by DMT #72.

Observation on 4/21/25 at 10:44 A.M. revealed a sheet cake in the stand-up refrigerator was only partially covered with a lid, leaving the cake open to air. DMT #72 confirmed cake was not covered appropriately for storage in the refrigerator.

Based on facility meeting minute review, staff interview, and resident interview, the facility failed to timely address resident grievances/concerns. This had the potential to affect 111 of 111 residents in the facility.

Findings Include:

Review of Resident Council Meeting Minutes, dated September 2024, October 2024, November 2024, February 2025, and March 2025, revealed concerns with staff wearing their name badges and/or wearing name badges so the residents could see them and know who they were speaking with.

Interview with Health and Wellness Director #124 and Executive Director #131 on 04/11/25 at 1:30 P.M. and 2:40 P.M. confirmed there have been numerous concerns voiced in resident council about staff wearing their name badges and/or where their name badges were placed so residents could know who their staff were. Executive Director #131 confirmed they have implemented a system that the receptionist will provide temporary name badges to all staff who do not come to work with them. He confirmed the receptionist is in the facility from 8:00 A.M. to 8:00 P.M.. When asked how the receptionist would capture the first shift staff, who arrive at 7:00 A.M., both stated that the nurses and managers would be responsible for getting the temporary name badges from the receptionist.

Interview with Resident #5 on 04/11/25 at 3:10 P.M. confirmed it is an on-going issue that staff are not wearing their name badges. They bring it up in resident council, but according to her, she doesn't feel as though the management have put an effective plan in place to resolve this. She is the resident council president, and it's been a constant issue that residents bring up in their council meetings for the last few months.

This violation represented non-compliance with complaint number OH00162477.

Based on medical record review, review of hospital records, staff interview, and review of the facility policy, the facility failed to provide adequate supervision and a safe environment to prevent Resident #106, who had a diagnosis of dementia and recent increase in confusion and wandering, from eloping from the locked memory care unit at the facility. This resulted in Real and Present Danger and the potential for serious life-threatening harm, injury and/or death on 05/26/24 when Resident #106 exited the building through an alarmed outside door, unsupervised and without staff knowledge. On 05/26/24 at approximately 5:55 A.M., Licensed Practical Nurse (LPN) #176 received a notification on the iPod of a door being opened on the secured unit. LPN #176 conducted an immediate head count and found Resident #106 was not on the unit. Staff searched the secured unit and then extended the search to the rest of the building and the grounds. At approximately 6:10 A.M., staff found Resident #106 on the front lawn of the building lying in the grass on his right side with swelling and bruising noted to his right eye and complaints of leg pain. Staff called nine-one-one (911), and emergency services arrived at approximately 6:18 A.M. to transport Resident #106 to the hospital for evaluation and treatment. Resident #106 returned to the facility on 05/26/24 at 11:50 A.M. with a diagnosis of fracture of the maxillary sinus. This affected one (Resident #106) of three residents reviewed for elopement risk. The facility identified three (#33, #36 and #106) residents from the secured memory care unit as being at risk for elopement. The facility census was 110.

On 06/06/24 at 9:45 A.M., the Executive Director (ED) and Unit Coordinator (UC) #161 were notified Real and Present Danger began on 05/26/24 at 1:45 A.M. when Resident #106 who had a diagnosis of dementia, exited through a malfunctioning alarmed door of the secured memory care unit to the outside of the building without staff knowledge. On 05/26/24 at approximately 5:55 A.M., an alarm sounded on the door and an immediate search for Resident #106 began. Resident #106 was located at approximately 6:10 A.M. lying on the ground in front of the building on his right side, with swelling and bruising noted to his right eye and complaints of leg pain. Staff called nine-one-one (911), and emergency services arrived at approximately 6:18 A.M. to transport Resident #106 to the hospital for evaluation and treatment. The facility conducted an investigation following Resident #106's elopement and found the door alarm was not functioning correctly when the resident exited the building and the time stamp on the camera was incorrect. After the facility updated the time to the door alarm report, it revealed the door had alarmed on 05/26/24 at 1:45 A.M. and again at 5:55 A.M. Review of the camera footage revealed Resident #106 was in the front of the building at 1:52 A.M. which indicated the resident had been outside for approximately four and a half hours before staff found him. The weather on 05/26/24 was clear without precipitation with temperatures as low as 60 degrees Fahrenheit (F). Resident #106 was wearing boxer shorts, a t-shirt, and one sock when staff found him outside the building. Resident #106 returned to the facility from the hospital on 05/26/24 at 11:50 A.M. with a diagnosis of fracture of the maxillary sinus.

The Real and Present Danger was removed on 05/28/24 when the facility implemented the following corrective actions:

On 05/26/24, the facility completed a search and found Resident #106 at approximately 6:10 A.M.

On 05/26/24 at approximately 6:10 A.M., the facility contacted emergency personnel.

On 05/26/24 at approximately 6:18 A.M., emergency personnel arrived to transport Resident #106 to the hospital.

On 05/26/24 at approximately 10:45 A.M., Memory Care Director (MCD) #150 completed reeducation of the staff regarding the elopement policy.

On 05/26/24 at approximately 10:48 A.M., MCD #150 conducted an elopement drill.

On 05/26/24 at 10:48 A.M. during the elopement drill, MCD #150 identified the alarm was not working properly on the exit door and a staff member was immediately assigned to monitor the door. Elopement drills will be held three times per week for four weeks.

On 05/26/24 at approximately 11:50 A.M., Resident #106 returned from the hospital. Resident #106 and two additional facility-identified residents (Residents #33 and #36) at risk for elopement were placed on 15-minutes checks until 06/03/24 when Resident #106 was discharged from the facility. There had been no further elopement incidents.

On 05/26/24, the frequency of exit door checks completed by the maintenance staff was increased from a weekly check to a daily check. Daily checks of the exit doors will continue on an ongoing basis.

On 05/27/24, Health and Wellness Director #117 completed the reeducation of all staff on the elopement policy.

On 05/27/24, the floor nurses reassessed all residents on the secured unit for elopement risk and updated their care plans as needed.

On 05/28/24, the alarm to the exit door was repaired with additional audio features added and a pull tab was installed.

Interviews on 06/06/24, between the hours of 2:10 P.M. and 2:48 P.M., with Dietary Manager (DM) #192, Activity Aide (AA) #182, LPN #143, Resident Assistant (RA) #181, State Tested Nurse Aide (STNA) #132 and Receptionist #170 confirmed they had been reeducated regarding the elopement policy following Resident #106's elopement on 05/26/24.

Although the Real and Present Danger was abated on 05/28/24, 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:

Review of the medical record for Resident #106 revealed an admission date of 12/18/23 with diagnoses including dementia, hypertensive heart disease, osteoarthritis, hearing loss, basal cell carcinoma, gastro-esophageal reflux disease, irritable bowel syndrome, prediabetes and right parietal cortical infarction.

Review of the change of condition assessment for Resident #106 dated 05/24/24 revealed the resident had severe orientation deficits with a past history of poor judgment creating potential for unsafe behaviors to self or others. Resident #106 was able to ambulate independently without the use of a device and he wandered intrusively and became disruptive or aggressive upon redirection.

Review of the individual service plan for Resident #106 dated 05/24/24 revealed the resident was to remain in the secured unit of the building and have 12 safety checks per day.

Review of a progress note for Resident #106 dated 05/26/24 revealed the nurse received notification there was an exit alarm sounding, and staff checked each resident room and noticed the resident was not on the unit. Resident #106 was found in front of the building lying in the grass with swelling and bruising to his right eye and complaints of leg pain. Nine-one-one (911) was called and transported the resident to the hospital.

Review of the hospital records for Resident #106 dated 05/26/24 revealed he arrived at the hospital at 6:38 A.M. The diagnosis at the hospital was a fall with a closed fracture of the maxillary sinus and swelling to the right eye. X-ray reports showed Resident #106 sustained a displaced fracture involving the anterior and posterior right maxillary sinus walls, while outside of the facility.

Interview on 06/05/24 at 10:18 A.M. with the Executive Director (ED) confirmed the alarm to the exit door to the secured unit did not activate on 05/26/24 at 1:45 A.M. when Resident #106 eloped from the facility. The door alarmed again on 05/26/24 at 5:50 A.M. and at that time staff identified Resident #106 was missing from the unit. Staff found the resident lying in the grass outside the facility at approximately 6:10 A.M. The ED further confirmed Resident #106 was outside the facility for approximately four and a half hours before staff found him. The ED confirmed Resident #106 sustained a fall with a fracture to the maxillary sinus while he was outside the building. The ED confirmed prior to the elopement incident, the exit doors on the secured unit were checked weekly but the checks of the doors had increased to daily checks moving forward.

Interview on 06/05/24 at 4:24 P.M. with Unit Coordinator (UC) #161 confirmed Resident #106 had become more confused and had been wandering both day and night around the main assisted living part of the facility where he resided and had also wandered into other residents' rooms. Staff determined Resident #106 should be moved to the secured unit due to increased elopement risk, and the resident was moved to the secured unit on 05/24/24.

Interview on 06/06/24 at 2:50 P.M. with RA #191 confirmed she was not assigned to Resident #106 on 05/26/24 but had assisted in locating him. RA #191 confirmed Resident #106 was found around 6:00 A.M. in front of the building with swelling to his face.

Interview on 06/06/24 at 5:21 P.M. with LPN #176 who had been on duty the day of the elopement confirmed she reported when she received notification on 05/26/24 at 5:47 A.M. of a door being open, staff completed a head count, found Resident #106 missing from the unit, and completed a wider search. LPN #176 confirmed Resident #106 was found on the ground lying on a rock in front of the building wearing only his underwear and a t-shirt, and the ground was wet. LPN #176 confirmed Resident #106 complained of pain to his leg and the nurse called 911 to take the resident to the hospital for an evaluation.

Review of the facility policy titled Elopement/Missing Resident dated 08/19/22 revealed the facility would maintain the safety of all residents by preventing elopements from occurring and door alarms were to be activated at all times.

This violation represents noncompliance investigated under Complaint Number OH00154479.