Apple Rehab Rocky Hill

(Resident #1 would ask to have things reheated or NA #1 would get something fresh if needed). NA #1 stated Resident #1 was usually back on the unit by 8:00 PM and if he/she ate a meal in the dining room, Resident #1 would let NA #1 know that - she stated the NA in the dining room does not share that information with the unit.

When she was notified at around 8:15 PM that Resident #1 had left the unit, she checked the tray, and it was still in the room untouched.

Interview with LPN #1 on 12/31/2025 at 2:52 PM identified he was the regular charge nurse for Resident #1 and was assigned to care for Resident #1 on 12/27/2025 during the 3:00 to 11:00 PM shift. LPN #1 stated Resident #1 ambulated independently around the facility, like to wear his/her coat when inside the facility, and he administered Resident #1's 5:00 PM medications and recalled seeing Resident #1 in his/her room between about 5:30 PM in bed wearing a jacket and the dinner tray was on the bedside table. Resident #1 had no complaints or reported concerns, and attended smoke breaks. LPN #1 stated NAs were responsible to pick up the dinner trays and document meal consumption, but stated Resident #1 ate when he/she wanted to and would bring his/her meal trays out of the room when finished because it was usually later in the shift. LPN #1 stated he was notified about 8:15 by the supervisor that Resident #1 was not in the building, and he was not aware prior to that time.

Interview and review of facility documentation with the DON on 12/31/2025 at 2:17 PM identified she was notified at 8:15 PM that RN #1 had received a call from the local police that Resident #1 had been found outside of the facility and had been transported to the hospital for evaluation. NA #3 had last seen Resident #1 in the lobby, fully dressed with shoes and a jacket at 5:40 PM.

The DON stated although Resident #1 had dementia and was confused at times, she did not expect staff to be aware of Resident #1's location as he/she was not considered an elopement risk and he/she ambulated independently; she expected staff to monitor those as risk for elopement not someone who was independent. Resident #1's dining habits were such that he/she ate when he/she wanted to, often around 6:30 or 7:00 PM. RN #1 was busy after the 7:00 PM smoke break and the DON stated she did not expect RN #1 to check to see why Resident #1 did not attend the 7:00 PM smoke break as per his/her usual routine since he/she ambulated independently. NAs are expected to monitor food consumed at each meal and notify the nurse if the resident fails to eat a meal or has had a change in consumption.

Interview failed to identify why the NA in the dining room did not communicate with the staff on the unit, and why Resident #1's whereabouts were not verified at least every two (2) hours as the video recorded Resident #1 left the facility at 5:36 PM and the facility was not aware of Resident #1's where abouts until the local police notified them at 8:15 PM (2 hours and 39 minutes). Resident #1 was not monitored for meal consumption, was reported last seen in the lobby wearing a coat about 5:40 PM, and location was not monitored after video stamp recorded left the facility at 5:36 PM.

Staff were unaware he/she had left the facility for 2 hours and 39 minutes until notified by police at 8:15 PM.

Although requested, the facility was unable to provide a policy in regard to routine monitoring of residents for safety.

Facility ID: