Valley View Health Care Center, Inc

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

noted to have a strong smell of alcohol. Resident #1 returned to the facility at 10:45 p.m. A skin check was done and the resident was placed on one-to-one supervision. A psychosocial services note, dated 9/8/25 at 11:01 a.m., documented that the social services director (SSD) met with Resident #1 post elopement on 9/5/25. Resident #1 continued to report his desire to relocate to his home country and his belief he did not need placement in the facility. Resident #1 reported his mother told him she was coming for him because

he did not belong there. He reported it was coming soon when he was asked when this was going to happen.III. Facility investigation of Resident #1's elopement on 9/5/25On 9/10/25 at 2:54 p.m. the NHA provided the facility's investigation of Resident #1's elopement from the facility on 9/5/25. The investigation revealed Resident #1 was last seen on 9/5/25 at 9:30 p.m. during routine building rounds. During routine building rounds at 9:45 p.m., Resident #1 was not able to be found. The facility staff commenced a full building and perimeter search immediately after identifying Resident #1 was missing. The facility staff notified the NHA, the director of nursing (DON), the attending physician and the local police department. At 10:30 p.m. Resident #1 was located by facility staff a couple blocks away from the facility. Resident #1 was noted to have a strong odor of alcohol. Resident #1 willingly re-entered the facility at 10:45 p.m. with staff assistance. Resident #1 reported he got disoriented and did not know how to get back to the facility. Upon Resident #1's return, he was assessed by the nurse and placed on one-to-one monitoring by facility staff.The DON interviewed Resident #1 on 9/8/25 and Resident #1 reported he left the facility grounds by climbing the corner section of the perimeter fence. Resident #1 explained the tension wires were installed

on the interior side of the fence and served as foot holds, allowing him to climb and propel himself over the fence. Resident #1 indicated that climbing the fence was easy for him to accomplish due to his physical fitness. The investigation documented there were no staff or other resident witnesses. The facility's security cameras did not capture the elopement, identifying a blind spot in coverage. Resident #1 was placed on one-to-one monitoring from staff and monitored for alcohol intoxication. IV. Staff interviewsLicensed practical nurse (LPN #2) was interviewed on 9/10/25 at 5:25 p.m. LPN #2 said she was assigned to be Resident #1's one-on-one for monitoring his whereabouts for elopement concerns. LPN #2 said Resident #1 had voiced in the past his desire to leave the facility to go to his home country. LPN #2 said she normally worked night shift and was on shift the night Resident #1 eloped from the facility. LPN #2 said Resident #1 had seemed baseline, completing normal routines with smoking and spending time outside, taking his medications and conversing with her. LPN #2 said the resident became agitated after a call from his mother

on the day of the elopement. LPN #2 said the facility completed 15-minute checks on residents to ensure all residents were accounted for. She said Resident #1 was last seen outside in the front courtyard, prior to him eloping. LPN #2 said that once he was not located in the facility, the staff started a building and grounds search then began notifying appropriate parties. The SSD, the DON, the NHA and the regional nurse consultant were interviewed on 9/11/25 at 9:03 a.m. The SSD said Resident #1 had been a resident at the facility prior to his admission on [DATE REDACTED]. The SSD said when the resident was previously admitted to

the facility, Resident #1 was independent and appropriate on outings. The SSD said the resident had always expressed the want to go to his home country. The SSD said Resident #1's mother no longer had guardianship of Resident #1 and the facility was contacted by the appointed guardian to see if Resident #1 could return to the facility. The SSD said the facility received a call from the resident's mother with questions about the fence being electrified, which the fence was not electrified. The SSD said she reviewed the security cameras one to two times a week or more if needed. She said she reviewed them to observe for behaviors or as part of an investigation to reveal what occurred.

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