The Villages Of Orleans Health And Rehab Center

monitoring.

Review of the physician orders 08/01/2025 - 08/30/2025 did not include the order Resident #1 may go out on pass with responsible party.The facility Nursing Home Facility Incident Report dated 08/29/2025 documented on 08/29/205 at approximately 5:00 PM Resident #1 left the facility with Housekeeper #1.

Housekeeper #1 drove the resident to the resident's hometown and arrived at the responsible party's house approximately 45 minutes away from the facility.During an observation on 11/13/2025 at 9:49 AM, Resident #1 was observed well kempt, self-propelling their wheelchair in a common area.

The resident asked if the surveyor knew there a particular street was and if they could give them a ride there later.During telephone interview on 11/13/2025 at 10:25 AM, Resident #1's responsible party stated Resident #1 came to their home unexpectedly on 08/29/2025 at approximately 5:45 PM accompanied by a person unknown to the responsible party.

The responsible party contacted an acquaintance that worked at the facility to come get Resident #1.

During an interview on 11/13/2025 at 10:45 AM, Licensed Practical Nurse #2 stated they received a telephone call from Resident #1's responsible party on 08/29/2025 at approximately 6:00 PM.

Licensed Practical Nurse #2 went to the responsible parties home and encouraged Resident #1 to return to the facility.

During an interview on 11/13/2025 at 11:48 AM, the Director of Nursing stated Licensed Practical Nurse #2 called them on 08/29/2025 at approximately 6:15 PM- 6:30 PM to report Housekeeper #1 had driven Resident #1 to their responsible party's house.

The Director of Nursing stated they immediately sent out a facility wide alert at 6:27 PM that Resident #1 had eloped from the facility.

Additionally, they stated no care plan interventions were initiated when the wander guard bracelet was discontinued on 08/20/2525.

During an interview on 11/14/25 at 8:05 AM, Licensed Practical Nurse #3 stated Resident #1 spoke daily of wanting to leave the facility to see the tall buildings, often stating they were leaving later in the week or being discharged .

They stated the resident would have to be redirected.

Licensed Practical Nurse #3 stated there was no increase monitoring of Resident #1's whereabouts after the wander guard was removed and prior to their elopement.During a telephone interview on 11/14/2025 at 8:57 AM, with interpreter #473966, Housekeeper #1 stated Resident #1 had requested a ride to their hometown and they picked Resident #1 up at the facility and transported the resident approximately 45 minutes away.

Housekeeper #1 stated that Resident #1 had told them their daughter would give them money for gas.

Housekeeper #1 stated they were unaware that they should not have taken Resident #1 out of the facility.During telephone interview on 11/17/2025 at 9:30 AM, the Medical Provider stated Resident #1 had variable mental status with poor judgement and at times could be manipulative.

The Medical Provider stated facility staff should not be transporting residents unless trained to do so and must follow the procedures in place for signing residents out to ensure the facility knows if a resident leaves the facility.Based on observation, interview, and record review the facility implemented the following corrective actions as of 09/23/2025.Resident #1's care plan was reviewed on 08/29/2025. A wander guard was replaced, and every 15-minute checks were initiated.The facility reeducated all staff regarding elopement policy and not to take residents out on pass.All residents at risk for elopement were reevaluated.

Then were reviewed daily for one week, weekly for a month, and monthly for three months.Facility policies regarding elopement/wandering residents and out on pass were reviewed.10 NYCRR 415.12(h)(2)

Facility ID: