Majestic Care of Cedar Village

Based on record reviews, staff interviews, and policy review, the facility failed to ensure that authorizations to manage resident funds were signed by residents and witnessed by a witness who is not connected in any manner whatsoever with the Residential Care Facility or its Administrator. This affected four (#18, #24, #26 and #28) of the five residents reviewed for funds management. The facility identified 15 residents for whom they manage funds. The facility census was 103.

Findings Include:

Review of Resident #18's record revealed the resident was admitted 03/06/25. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; major depressive disorder, single episode, unspecified; and mild cognitive impairment of uncertain or unknown etiology.

Review of Resident #18's record revealed Resident #18 signed a document titled Cedar Village Senior Living Personal Needs Account Authorization with an effective date of 07/16/25. This financial management authorization form also was signed by two witnesses with the same/similar signatures as witnesses signing on three additional resident financial management authorization forms.

Interview with Business Office Manager (BOM) #101 verified the witness signatures on Resident #18's Account Authorization Form were the same witness signatures as on three additional resident financial management authorization forms. BOM #101 stated the witnesses who signed Resident #18's Account Authorization Form were employees of the facility.

Review of Resident #24's record revealed the resident was admitted 08/19/23. Diagnoses included unspecified dementia, unspecified severity, behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety

Review of Resident #24's record revealed Resident #24 and the resident's Power of Attorney (POA) signed a document titled Cedar Village Senior Living Personal Needs Account Authorization with an effective date of 09/08/23. This Account Authorization Form was signed by two witnesses with the same/similar signatures as witnesses signing on three additional resident financial management authorization forms.

Interview with BOM #101 verified the witness signatures on Resident #24's Account Authorization Form were the same witness signatures as on three additional resident financial management authorization forms. BOM #101 stated the witnesses who signed Resident #24's Account Authorization Form were employees of the facility.

Review of Resident #26's record revealed the resident was admitted 06/19/25. Diagnoses included vascular dementia, unspecified severity, with other behavioral disturbance; psychotic disorder with hallucinations due to known physiological condition; major depressive disorder, recurrent, unspecified; and generalized anxiety disorder.

Review of Resident #26's record revealed the resident signed a document titled Cedar Village Senior Living Personal Needs Account Authorization with an effective date of 09/15/25. This Account Authorization Form also was signed by two witnesses with the same/similar signatures as witnesses signing on three additional resident financial management authorization forms.

Interview with BOM #101 verified the witness signatures on Resident #26's Account Authorization Form were the same witness signatures as on three additional resident financial management authorization forms. BOM #101 stated the witnesses who signed Resident #26's authorization form were employees of the facility.

Review of Resident #28's record revealed the resident was admitted 05/28/24. Diagnoses included anxiety and depression.

Review of Resident #28's record revealed the resident signed a document titled Cedar Village Senior Living Personal Needs Account Authorization form with an effective date of 06/07/24. This Account Authorization Form also was signed by two witnesses with the same/similar signatures as witnesses signing on three additional resident financial management authorization forms.

Interview with BOM #101 verified the witness signatures on Resident #28's Account Authorization Form were the same witness signatures as on three additional resident financial management authorization forms. BOM #101 stated the witnesses who signed Resident #28's authorization form were employees of the facility.

Review of agency policy titled Resident/Patient Account Funds with effective date 11/01/24 revealed no instructions concerning obtaining witness signature(s) on the Cedar Village Senior Living Personal Needs Account Authorization form.

Based on observation, staff interviews, and facility failed to procure, store, prepare, distribute, and serve all food in a manner that protects it against contamination and spoilage. This affected all 103 residents residing in the facility as the facility identified all residents received food from the kitchen. The facility census was 103.

Findings Include:

Observation of the kitchen on 10/16/25 at 2:34 P.M. with Kitchen Manager (KM) #103, revealed the Non-Kosher kitchen walk-in cooler contained the following: An open container of BBQ sauce labeled with an opened date of 09/18/25 and no use by date on the label; an open container of maraschino cherries labeled with an opened date of 06/29/25 and no use by date on the label; an opened container of raspberry vinaigrette labeled with an opened date of 05/28/25 and no use by date on the label; an opened container of salsa labeled with an opened date of 08/28/25 and no use by date on the label; and an opened container of Italian dressing with no label indicating an opened date or a use by date. Interview with KM #013 at the same time, verified the observations.

KM #103 stated all opened food items should be labeled with an open date and a use by date by the dietary staff when containers were opened.

Continued observation of the kitchen on 10/16/25 at 2:51 P.M. with KM #103 revealed the walk-in cooler located in the Kosher kitchen revealed the following: An opened container of Worcestershire sauce labeled with an opened date of 06/02/25 and no use by date on the label; an opened container of salsa labeled with an opened date of 06/28/25 and no use by date on the label; an opened container of Creole mustard with no label indicating an opened date or a use by date, however, the container came with a manufacturer best by date of 09/02/24; an opened container of sweet pickle relish labeled with a use by date of 10/07/25; and an opened container of Grey Poupon mustard with no label indicating an opened date or use by date and the container lacked a manufacturer label indicating either expiration date or best by date on the container. Interview with KM #13 at the same time verified the observations and stated all opened food items should be labeled with an open date and a use by date by the dietary staff when containers were opened. Interview with KM #013 at the same time, verified the observations. KM #103 stated all opened food items should be labeled with an open date and a use by date by the dietary staff when containers were opened.

Continued observation of the kitchen on 10/16/25 at 3:03 P.M. with KM #103, revealed the salad prep cooler in the Kosher kitchen contained an opened container of dill pickle chips labeled with an opened date of 10/01/25 and a use by date of 10/06/25 and an opened container of ketchup labeled with an opened date of 10/01/2025 and a use by date of 10/06/25. Interview with KM #013 at the same time verified the observations.

Review of facility policy titled Labeling & Dating Guidelines with an original date of 01/02/24 revealed that all opened and leftover items will be labeled with the date of opening/date stored and a discard/use-by date. The policy also stated the date the product must be consumed or discarded may not exceed the manufacturer's use-by-date.

Based on record review, staff interview, and policy review, the facility failed to evacuate residents during two fire drills conducted on each of three shifts over the past 12 months. This had the potential to affect all the residents in the facility. The facility census was 103.

Findings include:

Review of fire drill documentation dated 10/01/24, 12/20/24, 02/11/25, 03/13/25, 04/14/25, 05/16/25, 06/28/25, 08/26/25, and 09/04/25 did not indicate that resident evacuations were performed on each of these fire drill dates.

Interview on 10/20/2025 at 1:48 P.M. with Director of Maintenance (DM) #205 confirmed that documentation provided does not indicate resident evacuations were completed when fire drills were conducted on 10/01/24, 12/20/24, 02/11/25, 03/13/25, 04/14/25, 05/16/25, 06/28/25, 08/26/25, and 09/04/25.

Review of agency policy titled Fire Safety with an effective date of 03/01/2025 stated facility would follow all federal and state laws, regulations and codes. Review of agency policy and procedure titled Fire Response Plan with an effective date of 12/01/24 revealed that evacuate means Move residents/patients and guests out of the fire zone in which the fire has been identified beyond the fire/smoke doors in the corridor. This normally means moving from the area of the fire beyond fire/smoke doors to a safe non-compromised compartment on the floor.

Based on observation, staff interview, and policy review, the facility failed to ensure confidentiality of medical records during medication administration with residents. This affected one (#18) of the three residents reviewed for medication administration. The facility census was 103.

Findings Include:

Review of Resident #18's record revealed the resident was admitted 03/06/25. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; major depressive disorder, single episode, unspecified; and mild cognitive impairment of uncertain or unknown etiology.

Observation on 10/16/025 at 12:40 P.M. of medication pass for Resident #18 revealed Licensed Practical Nurse (LPN) #207 stationed the mobile medication cart at the turn in the Sapphire Hallway near the end of the hall, but with resident rooms located ahead of the medication cart and behind the medication cart. After preparing medications for Resident #18, LPN #207 walked down the hall and into Resident #18's apartment to administer medications without closing, shutting down or otherwise locking or obscuring the computer screen on the medication cart, which displayed medical information for Resident #18. While administering medications to Resident #18 in the resident's apartment the medication cart was out of view of LPN #207.

Interview on 10/16/2025 at 12:40 P.M. with LPN #207 the computer screen on the medication cart was left open to Resident #18's medical information while administering medications to Resident #18 in her apartment.

Review of a policy titled Privacy Confidentiality Policy with a revised date of 09/16/2025 reveals that Screens on unattended computers must be returned to a password protected screen saver or login screen.

Based on closed medical record review, staff interviews, review of an emergency medical services (EMS) report, review of facility incident reports, review of the online weather information at www.wunderground.com, review of witness statements, review of telecommunications (nine-one-one [911]) recordings, review of hospital records, and policy review, the facility failed to maintain a safe environment and provide adequate supervision to prevent Resident #500, who had a diagnosis of dementia with severe cognitive impairment and wandering behaviors, from eloping from the facility. This resulted in Real and Present Danger and the potential for serious life-threatening harm, injuries and/or death on 03/21/25 at approximately 3:15 A.M. when Resident #500 exited the facility unsupervised and without staff knowledge. Resident #500 was found by the staff in a dark, grassy area of the large campus and lying in a puddle of water approximately 10 feet from the roadway yelling out for help. Resident #500 was found cold, shivering, with wet clothes on which were insufficient for exposure to the outdoor temperature of 24 degrees Fahrenheit (F). Resident #500 was transported by EMS to a local hospital Emergency Room (ER) for evaluation and emergency treatment of hypothermia (condition in which the body's core temperature drops below 95 degrees F due to exposure to cold temperatures or immersion in cold water). Resident #500 was assessed with a temperature of 86.7 (severe hypothermia) degrees F by EMS and assessed with a body temperature of 89.9 degrees F in the ER. Subsequently, Resident #500 was admitted to the hospital for hypothermia related to an environmental exposure. This affected one (#500) of one resident identified by the facility as being at risk for elopement. The facility census was 116.

On 05/20/25 at 9:52 A.M., the Executive Director (ED), Regional Nurse Consultant (RNC) #803 and Clinical Director Licensed Practical Nurse (LPN) #14 were notified Real and Present Danger began on 03/21/25 at approximately 3:15 A.M. when Resident #500, who was cognitively impaired and displayed wandering exit seeking behaviors, exited the facility without staff knowledge or supervision and was found lying in a dark, grassy area in a puddle of water approximately 10 feet from a roadway with a 35 Miles per hour (MPH) speed limit. The ambient air temperature was 24 degrees F at the time when Resident #500 eloped from the facility. Resident #500 was transported to the ER where Resident #500 was found to have a body temperature of 89.9 degrees F and was admitted for hypothermia.

The Real and Present Danger was abated on 05/21/25, when the facility implemented the following corrective action:

On 03/21/25 at 3:15 A.M., Resident #500 was reported missing by her husband (Resident #111) who resided in the same room. The staff were unable to locate the resident initially and a Code Walker (the facility's elopement code) was called, followed by calling 911. Resident #500 was found outside the facility in a wet, grassy area before EMS arrived. Notifications were made to the Clinical Director LPN #14, Physician #801, and the resident's responsible party. Resident #500 was transported and admitted to a local hospital and never returned to the Assisted Living (AL). The resident was admitted to the Skilled Nursing Facility (SNF) portion of the campus.

On 05/20/25, all residents were evaluated for elopement risk by Clinical Director LPN #14 and LPN Unit Manager #804. No other residents were identified as being at risk.

On 05/20/25, the Elopement Policy was reviewed and revised by Chief Nursing Officer (CNO) #805, Quality Assurance Officer (QAO) #806 and RNC #803.

On 05/20/25, RNC #803 educated the ED and Clinical Director LPN #14 on the Elopement Policy.

On 05/20/25, the facility's Quality Assurance and Assessment (QAA) and Quality Assurance and Performance Improvement (QAPI) committees reviewed the admission protocols for assessing the residents for elopement risk and determining if the facility can accommodate the admissions. QAA and QAPI includes the ED, Clinical Director LPN #14, Director of Marketing #802, and LPN Unit Manager #804, and while corporate members are not part of the core committee, they may attend or serve in meetings as appropriate.

On 05/20/25, education on the Elopement Policy and Risk for Elopement Assessments was completed for all the AL staff. The staff not educated by this date will receive the education/training prior to their next scheduled shift.

On 05/20/25, Clinical Director LPN #14 revised the 72-hour Admission Checklist to include the Elopement Risk Evaluation on day one of an admission.

On 05/20/25, Clinical Director LPN #14 educated all nursing staff on the revised 72-hour Admission Checklist.

On 05/20/25, all licensed nurses received in-service training from Clinical Director LPN #14 on proper documentation of a resident's conditions upon admission, and accurate and timely completion of the elopement risk assessment. The staff not educated by this date will receive training prior to their next scheduled shift and new hires will receive this training during orientation.

On 05/20/25, the QAA committee reviewed the abatement plan in an Ad Hoc QAA/QAPI meeting. The QAA committee will evaluate the audit findings and staff compliance, will recommend further corrective action as needed, monitor trends in elopement risks, and documentation quality, monthly for three months, and then quarterly. Ongoing monitoring will be monitored through the QAA/QAPI committee.

Beginning on 05/20/25, Clinical Director LPN #14 and/or LPN Unit Manager #804 will audit the Elopement Evaluation scores of five random residents three times per week for three weeks, then two times per week for three weeks, then monthly for three months. Any residents identified as being at risk will receive enhanced supervision.

Beginning on 05/21/25, the Clinical Director LPN #14/designee will conduct weekly audits of all new admissions to ensure the completion of the 72-hour checklist, timely Elopement Risk Evaluations and accurate documentation of skin and safety assessments are completed. Audits will be completed weekly for four weeks, then monthly for three months. RNC #803/designee will oversee compliance with the Elopement Risk Evaluations and 72-hour checklist weekly for four weeks. The findings will be submitted to the QAA/QAPI committee for review.

Review of medical records for three additional Residents (#56, #60 and #62) revealed all residents were assessed for elopement risk upon admission and on 05/20/25.

Interviews on 05/23/25 from 1:27 P.M. to 1:36 P.M. with LPN #10, LPN #07, Nurse Aide (NA) #24 and NA #21, revealed all staff reported they were educated on the 72- hour checklist and on elopements, and staff were knowledgeable regarding preventing an elopement and implementing the facility policy/system regarding an elopement.

Although the Real and Present Danger was abated on 05/21/25, the violation continues as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.

Findings include:

Review of Resident #500's closed medical record revealed the resident was admitted to the facility on 03/20/25 at approximately 5:00 P.M. Diagnoses included unspecified dementia moderate. Resident #500 was transferred to the hospital on 03/21/25 and discharged from the facility on 03/25/25.

Review of Resident #500's Service Assessment and Service Plan dated 02/17/25, completed in the resident's home by Clinical Director LPN #14, revealed the resident had trouble recalling the day, date, time and where she was located. Resident #500 did not wander into any inappropriate places due to inability to locate her room. Resident #500 required assistance with bathing, and toileting and Resident #500 was independent with dressing, grooming, mobility, transfers, and eating.

Review of Resident #500's physician's progress note dated 02/28/25, revealed Resident #500 was seen by Physician #801 for an annual physical. Resident #500 had a significant history of moderate dementia and was dependent on her daughter and husband for activities of daily living (ADLs). Resident #500's daughter was in the process of moving Resident #500 and her husband to an AL. The plan for the resident's diagnosis of moderate dementia was to provide supportive care and the resident required assistance with ADLs.

Review of Resident #500's medical record from 03/20/25 to 03/25/25, revealed no documented evidence of any assessments, physician orders or progress notes being completed for the resident.

Review of the facility's Self-Reported Incidents (SRIs) from 03/20/25 to 05/19/25, revealed the facility did not report any SRIs related to Resident #500 eloping from the facility.

Review of the staff schedule dated 03/20/25 revealed there were two nurses and one Nurse's Aide (NA) working in the AL facility from 7:00 P.M. to 7:00 A.M. on 03/20/25 to 03/21/25.

Review of an incident report dated 03/21/25 at 3:20 A.M., revealed the front desk called and stated Resident #500 had wandered into another resident's room around 9:30 P.M. on 03/20/25. Resident #500's husband (Resident #111 who resided in the same room as the resident) stated he was looking for her. Once Resident #500 was found, she and Resident #111 were escorted back to their room. Resident #111 stated he would lock the apartment door, and they went to bed. Resident #500 was okay and expressed no complaints at that time. The nurse checked on Resident #500 every two to three hours and Resident #500 and Resident #111 were okay. Resident #111 approached the nurse as the nurse was coming out of another resident's room around 3:15 A.M. and stated he could not find Resident #500 and she must have wandered out of the room. The nurse looked for Resident #500 in the surrounding area and rooms nearby and was unable to locate Resident #500. The nurse called the nursing supervisor and explained she was not able to locate Resident #500. The nursing supervisor came and searched a few rooms and hallways and still did not see Resident #500. The nurse supervisor called a code walker or elopement code followed by calling 911. The nurse supervisor called and stated she located Resident #500 outside while EMS was on the way. Resident #500 was alive and breathing and the resident was taken to the hospital. The nurse informed the Clinical Director LPN #14 and Resident #111. Clinical Director LPN #14 contacted Resident #500's daughter. The incident report documented Resident #500 was oriented to person and wandering was listed as a predisposing situation factor to the incident.

Review of a 911 recording dated 03/21/25 at 3:29.18 A.M., revealed LPN #08 called 911 and reported there was a resident that walked out of the facility, and they just found her. LPN #08 stated the resident had been at the facility for one day and the resident's husband stated she left the room and wandered off. LPN #08 stated apparently she wandered off outside. LPN #08 stated she was not next to the resident because the other nurses were outside with the resident, and she was told to go in and get the resident's information off the computer. LPN #08 stated they found the resident because she was screaming, so she was alive and breathing. LPN #08 reported she did not know the resident's condition. LPN #08 stated the resident's husband came down and noticed she was missing out of the room probably about 30 minutes ago. LPN #08 reported they were still outside in the front of the building near the main entrance by the street.

Review of a 911 recording dated 03/21/25 at 3:29.25 A.M., revealed an unknown person called 911 and reported we need an ambulance. The unknown person stated we found a resident outside in a puddle. The unknown person reported She went missing and we found her outside in a puddle on the side of the road.

Review of a 911 recording dated 03/21/25 at 3:29.33 A.M., revealed Registered Nurse (RN) Supervisor #800 called 911 and reported that they found a resident on the side of the road, and she was a code walker. RN Supervisor #800 stated she was at the facility and the resident was missing. RN Supervisor #800 reported the resident was shivering and stated to the dispatcher, I'm afraid this is hypothermia. When the dispatcher was trying to obtain information about the resident, RN Supervisor #800 stated she didn't know anything about the resident and stated they had just found the resident and they were outside by the street. RN Supervisor #800 reported the resident was conscious and breathing. RN Supervisor #800 stated the resident was by the main road into the facility. The dispatcher noted multiple people are calling about this resident.

Review of the EMS report dated 03/21/25, revealed EMS was called at 3:29 A.M. and arrived on the scene at 3:34 A.M. for a chief complainant of a resident found lying on the ground outside and in a puddle of water and was hypothermic. Upon arrival, the facility staff stated Resident #500's husband last saw Resident #500 around midnight and Resident #500 left to go for a walk outside. The staff found Resident #500 outside of the facility and called 911. Prior to EMS arrival, the staff covered Resident #500 with blankets. EMS staff asked the facility staff if they knew any information about Resident #500, all the staff replied they did not know anything about the resident. The facility staff gave EMS a face sheet with Resident #500's basic information and without any medical history on it. EMS noted they were unable to obtain any information from Resident #500 because of a language barrier but the resident did follow some basic commands. Resident #500 was alert, shivering, her skin was pale and cold to the touch, pulse was regular but weak and the resident's clothing was wet from laying in water. Resident #500 was moved to the ambulance and started to be warmed. Resident #500's clothing was removed because the clothing was soaked and EMS placed numerous blankets on the resident and the heat was increased in the back of the ambulance. Resident #500 was shivering so much the cardiac monitor was unreadable and the vital signs were hard to obtain. Resident #500's oral temperature was 86.7 degrees F. EMS secured an intravenous (IV) line and administered warm IV fluids. Resident #500 was transported to the emergency room (ER) without incident. Resident #500's shoes and hat were left with Resident #500 at the ER.

Review of Resident #500's hospital records dated 03/21/25, revealed Resident #500 was admitted to the ER on 03/21/25 at 4:00 A.M. for cold exposure. EMS reported Resident #500 had been missing from a nursing home for several hours and was found outside in a cold puddle of water. Upon admission to the ER, Resident #500's body temperature was 89.9 degrees F, heart rate was 138 beats a minute, respirations were 20 breathes a minute, oxygen saturation was 98 percent, and a blood pressure was 155 over 98 millimeters of mercury (mm/Hg). The ER was able to get ahold of the facility staff and talked with LPN #15 regarding the resident's medical history. Resident #500 was recently admitted to the AL with her husband, became confused and eloped this evening. Resident #500 was admitted for hypothermia, lactic acidosis, urinary tract infection (UTI) and confusion secondary to dementia. Resident #500 was discharged on 03/24/25 to a Memory Care Unit (MCU).

Review of the ED's witness statement signed and dated 03/21/25, revealed Resident #500 and her husband (Resident #111) were admitted to the facility on 03/20/25 at approximately 5:00 P.M. Resident #500 was reported wandering into another resident's room at 9:30 P.M. Resident #500's husband was aware and stated he would look after her. Resident #500 was placed on three-hour checks. Resident #500 and her husband went to bed at approximately 12:00 A.M. as confirmed by LPN #08 who checked on them in their apartment. Resident #500's husband informed LPN #08 at approximately 3:15 A.M. that Resident #500 was missing. RN Supervisor #800 initiated a code for a missing resident. Resident #500 was located at approximately 3:25 A.M. on the side of the facility's property in the grassy area which was damp. RN Supervisor #800 called 911 and Resident #500 was taken to the hospital with hypothermic conditions. The hospital called the ED and LPN Clinical Director #14 at 5:30 A.M. to inform them Resident #500 was stable, but the hospital was going to hold Resident #500 for a little longer for observation. The ED and LPN Clinical Director #14 interviewed staff members for details on the incident. The initial assessment including safety and risk assessment of Resident #500 was completed by Clinical Director LPN #14 and Marketing Director #802 indicating that Resident #500 was appropriate for the AL environment. The physician signed Resident #500's assessment as Resident #500 was suitable for the AL. The initial assessment interview portion noted there were no warning signs or flags of safety concerns as it related to unsafe wandering behavior or elopement as reported by Resident #500's daughter. Prior to moving into the facility, Resident #500 and her husband were living together in an Independent Living (IL) apartment with no additional care services. Follow-up conversations with Resident #500's daughter in the presence of Clinical Director LPN #14, Marketing Director #802 and the ED, revealed Resident #500's daughter was not completely forthcoming upon initial assessment but stated Resident #500 had exhibited wandering behaviors that had a potential safety concern on a couple of occasions. Resident #500's daughter apologized for not being transparent and she continued to state she did not say anything because she thought Resident #500's husband would be able to look after Resident #500. Resident #500's daughter agreed to transferring Resident #500 to the secured MCU in the SNF for her safety.

Review of Clinical Director LPN #14's signed but undated witness statement, revealed Clinical Director LPN #14 was notified Resident #500 was missing on 03/21/25 around 3:00 A.M. The nurse stated Resident #500 was found wandering in the facility around 9:00 P.M. Resident #500's husband (Resident #111) took Resident #500 back to their apartment and stated he would take care of her. Resident #111 approached the nurse around 3:00 A.M. and stated he could not find Resident #500. The nurse began to search the unit without success. The nurse then called for assistance from another unit and RN supervisor #800. An elopement code (Code Walker) was called, and 911 was called. Resident #500 was found outside in the grass in a puddle. EMS transported Resident #500 to the hospital. NA #23 noted she looked but couldn't find Resident #500. LPN #04 was interviewed and stated she and RN Supervisor #800 began walking the campus after 911 was called. LPN #04 stated they found Resident #500 in the grass laying in a puddle. EMS arrived at the same time and took Resident #500 to the hospital.

Review of the facility's Meeting Summary dated 04/15/25, revealed all nursing staff were educated on new admission protocol including residents being placed on two-hour checks for two days upon their admission. Further review of the facility's Meeting Summary revealed no documentation that staff were educated on elopements.

Observation of the facility completed with the ED on 05/19/25 at 8:50 A.M. revealed Resident #500 resided on the third floor of the Oakview AL unit with her husband when they were admitted on 03/20/25. The ED reported Resident #500 eloped from the facility on 03/21/25 and was found in a grassy area outside of the facility. The ED stated the facility had multiple exits that were not locked because the AL portion of the campus did not accommodate residents that required secured units. The ED stated he was not sure how Resident #500 exited the facility. The ED also reported that all exits, except for the ambulance entrance, automatically locked from the outside from 10:00 P.M. to 6:00 A.M. and if a resident walked out the door, they couldn't get back in. The ED noted the facility did not have cameras.

Interview with RNC #803 on 05/19/25 at 9:52 A.M., verified Resident #500 did not have any admission assessments, physician's orders or nurse progress notes completed when Resident #500 was admitted on 03/20/25.

Attempted to call LPN #04 on 05/19/25 at 11:20 A.M. with no response and no return call received.

Attempted to call NA #23 on 05/19/25 at 11:21 A.M. with no response and no return call received.

Attempted to call LPN #08 on 05/19/25 at 11:22 A.M. with no response and no return call received.

Interview with Clinical Director LPN #14 on 05/19/25 at 12:36 P.M., revealed she received a call from LPN #08 on 03/21/25 at approximately 3:00 A.M. and stated Resident #500 was missing, and she was about to call 911. Clinical Director LPN #14 stated she responded to the facility but by the time she arrived, Resident #500 had already been found and taken to the hospital. Clinical Director LPN #14 stated Resident #500 was admitted to the facility on 03/20/25 at 4:55 P.M. and she was found wandering in another resident's room around 9:00 P.M. Clinical Director LPN #14 stated she was not aware that Resident #500 had wandered into another resident's room until the time she learned of Resident #500's elopement. Clinical Director LPN #14 stated LPN #08 told her that she was checking on Resident #500 every couple of hours and Resident #500's husband said he would keep an eye on her and had control of it. Clinical Director LPN #14 stated she was not sure what time Resident #500 was last checked on prior to her elopement and there was no documentation of when Resident #500 was last seen in the record. Clinical Director LPN #14 reported Resident #500's husband informed LPN #08 that he could not find Resident #500 around 3:00 A.M. and LPN #08 looked for Resident #500 prior to calling the other AL staff for help. Clinical Director LPN #14 stated the staff could not find the resident and RN Supervisor #800 called the elopement code. Clinical Director LPN #14 stated 911 was called, and the staff started searching outdoors. Clinical Director LPN #14 reported Resident #500 was found lying down in the grass by the back parking lot in a puddle. Clinical Director LPN #14 stated Resident #500 was assessed by the nurses, and she was cold and shivering with a pulse. Clinical Director LPN #14 reported the staff also put a jacket on Resident #500, but Clinical Director LPN #14 did not know what Resident #500 was wearing or if she had shoes on when she was found. Clinical Director LPN #14 stated it was too dark, and she couldn't see. Clinical Director LPN #14 verified the facility had no documentation on what Resident #500 was wearing or if she had shoes on when she was found. Clinical Director LPN #14 stated EMS arrived and took Resident #500 to the hospital. Clinical Director LPN #14 stated she talked to Resident #500's daughter after the incident and she stated Resident #500 told her she was trying to go home when she left the facility. Clinical Director LPN #14 reported that when Resident #500 returned from the hospital, she was admitted to the MCU on the SNF side of the campus.

Interview with RN Supervisor #800 on 05/19/25 at 12:53 P.M., revealed LPN #08 called her on 03/21/25 around 3:00 A.M. and reported Resident #500's husband stated Resident #500 was missing. RN Supervisor #800 stated the staff searched the third floor where Resident #500 resided. RN Supervisor #800 reported Resident #500 was admitted to the facility on 03/20/25 around 5:00 P.M. RN Supervisor #800 stated she received a phone call from an unknown resident around 9:00 P.M. who stated Resident #500 was wandering in their room. RN Supervisor #800 stated she had LPN #08 check on Resident #500 at 9:00 P.M. when she was wandering in another resident's room. RN Supervisor #800 reported that they were doing every two-hour checks on Resident #500 and Resident #111 was caring for Resident #500 in their room. RN Supervisor #800 stated LPN #08 checked on Resident #500 on 03/21/25 at approximately 12:00 A.M. and Resident #500 went to bed around 12:00 A.M. RN Supervisor #800 reported Resident #500 was reported missing by her husband around 3:00 A.M. RN Supervisor #800 stated she called an elopement code when the staff could not find Resident #500 and the resident was found within eight minutes of her calling an elopement code. RN Supervisor #800 reported Resident #500 was found in a grass area approximately 10 feet from the main road in a puddle of water. RN Supervisor #800 stated it was very dark, and she did not think passing cars could see Resident #500. RN Supervisor #800 stated when Resident #500 was found, she was moaning, shivering and could not be understood. RN Supervisor #800 reported she was not able to assess Resident #500's skin because it was dark and she did not take Resident #500's temperature. RN Supervisor #800 reported 911 was called but she did not know the name of the resident, so she was not able to provide 911 with that information by phone. RN Supervisor #800 stated EMS arrived and took Resident #500 to the hospital. RN Supervisor #800 reported Resident #500 was wearing a bathrobe when she was found but unsure if the resident was wearing shoes. RN Supervisor #800 stated she gave Resident #500 her coat and something to wrap around her neck. RN Supervisor #800 reported it was cold and had rained early at the time of the resident's elopement.

Follow-up interview with Clinical Director LPN #14 on 05/19/25 at 1:40 P.M., revealed the facility did not complete elopement assessments on all other residents following Resident #500's elopement from the facility.

Interview with the ED on 05/19/25 at 4:30 P.M., revealed he was called by RN Supervisor #800 on 03/21/25 at approximately 3:45 A.M. and informed him that Resident #500 was found cold, wet and shivering outside on the grassy side of the property. RN Supervisor #800 also informed the ED that 911 was called, and the resident was taken to the hospital. The ED stated he arrived at the facility on 03/21/25 between 4:45 A.M. and 5:00 A.M. and met with Clinical Director LPN #14 and talked with staff. The ED reported they spoke with RN Supervisor #800, LPN #08 and NA #23. The ED stated the facility received a call from the hospital at 5:30 A.M. and informed that Resident #500 was stable, and they would be keeping her for hypothermia, and a UTI. The ED verified it was very cold on the morning when Resident #500 eloped. The ED reported he was never notified when Resident #500 was observed wandering around the facility on 03/20/25 approximately 9:00 P.M. until Resident #500 eloped from the facility. The ED stated it is a resident's right to wander. The ED stated LPN #08 informed him Resident #500 was last seen on 03/21/25 at 12:00 A.M. The ED verified the facility did not have any documentation regarding Resident #500 being seen by LPN #08 on 03/21/25 at 12:00 A.M., 3:00 A.M. or any documentation on what Resident #500 was wearing at the time of the elopement. The ED verified the facility did not complete any education on elopements or complete any initial or ongoing elopement audits after Resident #500 eloped from the facility on 03/21/25. The ED stated Resident #500 was admitted to the secured unit in the SNF following her discharge from the hospital on 03/24/25.

Review of local weather conditions located at Weather Underground (https://www.wunderground.com/history/daily/us/oh/mason/KOHMASON56/date/2025-3-3), revealed the ambient air temperature near the location of the facility on 03/21/25 was a low temperature of 21 degrees Fahrenheit and a high of 48 degrees Fahrenheit. The temperature at the time of Resident #500's elopement was 24 degrees Fahrenheit.

Review of the facility's Elopement and Wandering policy dated 01/02/24, revealed the facility would ensure residents who exhibited wandering behavior and who were at risk for elopement, received adequate supervision to prevent accidents. The residents would be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. Adequate supervision would be provided to help prevent accidents or elopements. Any staff member becoming aware of a missing resident would alert personnel using facility approved protocols. The designated facility staff would look for the resident and the ED or designee will notify the police department if the resident was not located in the building or on the grounds.

This violation represents non-compliance investigated under Complaint Number OH00165673.

Based on personnel file review, staff interview, and policy review, the facility failed to ensure newly hired staff received first-aid training within 60 days of hire date. This affected two employees (Nurse Aides #195 and #150) out of the four employees reviewed. This had the potential to affect all residents at the tacitly. The facility census was 106.

Findings include:

Review of personnel file for Nurse Aide NA #195, revealed a hire date of 10/02/24. There was no documented evidence that NA #195 had first-aid training.

Review of the personnel file for Nurse Aide #150 revealed a hire date of 08/02/23. There was no documented evidence that Nurse Aide #150 had first-aid training.

Interview with Clinical Operations Nurse (CON) #135 on 03/06/25 at 12:55 P.M., verified Nurse Aids #195 and #150 did not have documentation to support they received first-aid training.

Review of the facility document titled Care Team Member Personnel File and On and Off Boarding Checklist dated 03/2020, revealed personnel files that included confidential and medical files should have the following items included in the file, that included first aid training.

Based on observation, staff interview, facility policy review, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.. This had the potential to affect all the residents who resided in the facility. The facility census was 106.

Findings include:

Observation of the small serving kitchen on 03/05/25 at 10:20 A.M. with Dietary Manager (DM) #200, revealed several gnats swarming at the entrance to the kitchen. Interview at the same with DM #200 verified the flying gnats.

Observation of the lunch service tray line on 03/05/25 at 11:46 A.M. to 12:19 P.M., revealed Dietary Cook (DC) #201 used his gloved hand to pick up the hot dogs and place them in buns. DC #201 used his gloved to pick up shredded cheese and place on the chili dog then use his same gloved hand to pick up sweet potato fries and place them on a tray. DC #201 plated several trays then changed gloves. DC #201 adjusted his hat with the gloved hands then reached into the pan of hot dogs and continued to use his glove hands to retrieve and place the hot dogs in buns, along with putting cheese on the chili dog, and placing the sweet potato fries on the tray. DC #201 picked up a stack of paper orders and shuffled through the papers with his gloved hands. DC #201 adjusted his shirt, picked up hamburger with his same gloved hand and placed it on the open hamburger bun. Interview with DC #201 verified he plated food with the same gloved hands after he touched his hat, his clothing, and the paper meal tickets. DC #201 stated he should have utilized serving tongs and completed hand hygiene.

Observation of delivery of lunch trays on 03/05/25 at 12:20 P.M. through 12:37 P.M., revealed the lunch trays were delivered to the floor in folding Styrofoam trays and on an utility cart . Dietary Aid (DA) #202 delivered meal trays to a total of 16 Residents (#02, #06, #07, #11, #12, #15, #19, #22, #29, #32, #37, #42, #43, #45, #46, and #49). DA #202 knocked on resident doors, opened the resident doors, touched items inside the resident's room with her ungloved hands and never completed any hand hygiene while delivering trays. Interview with DA #202 immediately afterwards, verified she touched numerous objects while delivering the trays and never completed any hand hygiene. The last resident tray was delivered at 03/05/25 at 12:37 P.M.

Observation of the test tray on 03/05/25 at 12:38 P.M., revealed as DM #200 sat the test trays down on a dining room table, there were gnats flying around the test trays. DM #200 tested the temperature of the food trays and the chili cheese dog 103 degrees Fahrenheit (F), the milk was 53 degrees F, the cold bean salad was 64 degrees F. DM #200 verified the food was not held and served at a proper temperature. DM #200 stated the chili dog tasted cold and chewy, the sweet potato fries were cold and unappealing. DM #200 verified the facility served the residents' food in folding Styrofoam trays and used an open utility cart. DM #200 also verified the gnats flying around the test trays.

Observation of the Kosher kitchen on 03/06/25 at 11:20 A.M. with DC #190, revealed a large walk-in refrigerator that contained a large metal container with what appeared to be spinach only labeled with the date. (what was the date) The walk-in refrigerator led into a walk-in freezer that contained an opened bag of breaded chicken, potato wedges and breaded chicken fingers with no label and/or date. A large cardboard box of sausage patties opened to air with no label and/or date. The dairy sink had a broken shelf lying on the floor beneath sink. There were gnats flying around the dishwasher and the dishwasher had food splattered debris all over it. The floor around the three-compartment sink was soiled with a black substance and had food debris underneath the sink. The air vents were heavily soiled, and the ceiling was spotted with food and debris. Interview at the same time, verified the condition of the condition.

Observation of the main kitchen on 03/06/25 at 11:25 A.M., with DA #191, revealed the walk-in refrigerator contained a large, opened box of green beans exposed to the air with no label and/or date. A large, opened box of sliced sweet potatoes opened to air and not labeled and/or dated. Two long silver pans with white substances which were not labeled or dated. The sink next to the dishwasher was heavily soiled with an unknown black substance and the black substance ran up the wall to the sink. The sink had a pipe dripping and there was a puddle of water below the sink The dishwasher and pipes were heavily soiled with food debris and splatters and the top of the dishwasher had a large amount of dust, debris, and food splatter. DA #191 stated the residents of the AL received from the Kosher kitchen as well as the main kitchen. DA #191 verified the conditions of the main kitchen and stated he had no idea what the white item in the silver pans was.

Review of the report titled, Food Inspection Report , dated 02/05/25, from the local Health Department revealed a buildup of dust, food debris, and grease on the sides, and handles of cooking equipment. Further review of the report revealed live insects in both kitchen areas that included the dish wash areas. The floors were not smooth and easily cleanable. The facility was not maintained clean and had a buildup of dust on the ceiling vents in both kitchens.

Review of the facility policy titled, Dietary Department, undated, confirmed proper hand hygiene is the fundamental practice to prevent the spread of illness. All dietary team members must strictly adhere to the policy. Further review of the policy stated the dietary team will wash their hands after touching, face, hair, clothes, or body and before serving meals.

Review of the facility policy titled, Food Production, dated March 2019, confirmed the kitchen will be kept clean, neat, and orderly. Food will be served and prepared with clean tongs, scoops, forks, and spoons.

Review of the facility policy titled, Food Storage, dated October 2018, confirmed food will be stored and protected from contamination. The policy stated that opened containers of food will be resealed in a manner that products the remaining food and will be dated. All opened food will be labeled with the date of opening/date stored.

This violation represents non-compliance investigated under Complaint Number OH00162480.