Olimpia's Home Care LLC.

“Based on record review, documentation review, and interview, the governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to the physical health and safety of a resident. Finding include: 1. A record review of an incident report dated October 23, 2025 revealed that R3 was discovered missing from the facility at 06:30 am. The resident was found by a neighbor and returned to the facility at 7:10 am. R3 suffered minor injuries to the left upper front of the resident's forehead. R3's resident representative, physician, and the Department were notified. 2. A documentation review of the facility's Policies and Procedures titled, "Quality Management Program, including Incident Reports" stated, "All home employees will be trained using basis common sense to observe constantly the residents and their behaviors." 3. In an interview, O1 revealed, no one was sure when R3 left the facility but it was believed that it occurred when E2 was coming into the facility to start the work shift. O1 revealed, the facility installed a new keypad on the front door and it was not there the previous Thursday. 4. In an interview, E1 acknowledged the manager failed to ensure the health, safety and welfare of R3.”

“Based on documentation review and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.   Findings include:   1. A review of Department documentation revealed the facility was authorized to provide Directed care services. 2. A record review of an incident report dated October 23, 2025 revealed that R3 was discovered missing from the facility at 06:30 am. The resident was found by a neighbor and returned to the facility at 7:10 am. R3 suffered minor injuries to the left upper front of the resident's forehead. R3's resident representative, physician, and the Department were notified." 3. Review of the facility's Policies and Procedures titled "Safety of Wandering Residents" states: "1. Caregivers on duty will verify the presence of confused residents in the home every 2 hours or less." and "4. Caregivers will maintain securely locks on the front door, yards, and hazardous areas at all times." 4. In an interview, E1 revealed, the manager installed a new keypad but it had a delayed exit lock. R3 may have exited the facility before the keypad locked back. E1 acknowledged that there were no controls or alerts to notify employees of the egress of a resident from the facility. This is a repeated deficiency from the on-site Complaint inspection conducted on May 29, 2025.”

“Based on documentation review and interview, the manager failed to ensure that policies and procedures established, documented, and implemented to protect the health and safety of a resident were followed. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.   Findings include: 1. A review of Department documentation revealed a complaint intake report which included sworn testimony which stated "Oa be56 found pt sitting on ground in street in an altered state only stating [the pt] name. While on scene staff from a nearby care home approached us looking for lost pt. Pt was witnessed by neighbors fell down and hit [the pt] head. Pt has a abrasion to r forehead. Neighbors believe [R1] was unconscious for a little while. Pt transferred to go in r48 to go for evaluation. Pt on is normal per staff now on scene. Pt denies any pain. Transport Narrative: R48 dispatched and responded code 2 to stated address. Upon arrival found [R1] sitting on asphalt in neighborhood under care and assessment of BE56. Pt wandered away from care home in neighborhood and fell, and was found by bystanders and caregivers looking for [the pt] and are on scene." 2. Review of the facility's Policies and Procedures titled "Safety of Wandering Residents" states: "1. Caregivers on duty will verify the presence of confused residents in the home every 2 hours or less." and "4. Caregivers will maintain securely locks on the front door, yards, and hazardous areas at all times." 3. In an interview, E1 revealed that a contractor left the door ajar and that although staff were in the facility, there were no staff in the area to notice that the resident had left the facility. E1 acknowledged that policies and procedures for ensuring the safety and general whereabouts of residents, were not followed.”

“Based on record review, documentation review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident’s date of occupancy. The deficient practice posed a potential TB exposure risk to residents.   Findings include:   1. A review of R2’s medical record revealed no documentation indicating that R2 was free from TB. Based on R2's admission date, this documentation was required.   2. In an interview, E1 acknowledged that the TB requirements were not met for R2 before or within seven days of admission into the facility.”

“Based on documentation review and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.   Findings include:   1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. A review of Department documentation revealed a complaint intake report which included sworn testimony which stated "Oa be56 found pt sitting on ground in street in an altered state only stating his name. While on scene staff from a nearby care home approached us looking for lost pt. Pt was witnessed by neighbors fell down and hit his head. Pt has a abrasion to r forehead. Neighbors believe he was unconscious for a little while. Pt transferred to go in r48 to go for evaluation. Pt on is normal per staff now on scene. Pt denies any pain. Transport Narrative: R48 dispatched and responded code 2 to stated address. Upon arrival found [R1] sitting on asphalt in neighborhood under care and assessment of BE56. Pt wandered away from care home in neighborhood and fell, and was found by bystanders and caregivers looking for him and are on scene." 3. Review of the facility's Policies and Procedures titled "Safety of Wandering Residents" states: "1. Caregivers on duty will verify the presence of confused residents in the home every 2 hours or less." and "4. Caregivers will maintain securely locks on the front door, yards, and hazardous areas at all times." 4. In an interview, E1 revealed that a contractor left the door ajar and that although staff were in the facility, there were no staff in the area to notice that the resident had left the facility. E1 acknowledged that there were no controls or alerts to notify employees of the egress of a resident from the facility.”

“Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two current residents sampled. Findings include: 1. A review of R2's medical record revealed a signed medication order for Donepezil HCL 5 milligram (MG) oral tablet once a day at bedtime dated November 1, 2024. 2. The Compliance Officers inspected a container of medication for R2. The Compliance Officers observed a medication bottle for R2 for Donepezil HCL 10 MG tablet once a day in the morning. 3. A review or R2's medical record revealed a Medication Administration Record. Donepezil HCL 5 MG was documented as administered to R2 from November 1, 2024 to November 12, 2024. 4. In an interview, E1 reported there was an error with the medication and R2's primary care physician was working to clear up the miscommunication. E1 reported R2 had received Donepezil HCL 10 MG from November 1, 2024 to November 12, 2024. 5. In an interview, E1 acknowledged medication had not been administered in compliance with the medication order.”

“Based on observation and interview, the manager failed to ensure medication stored by the facility was stored in a locked area. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a medication lock box in the lower door of the refrigerator in the kitchen. The Compliance Officers removed the medication lock box from the refrigerator and tried the lock. The medication lock box opened without modifying the code. Inside the medication lock box was Rhopressa OP solution and a box of Lorazepam 0.5 milligram oral concentrate. 2. In an interview, E1 acknowledged medication stored by the facility was not stored in a locked area.”

“Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. Findings include: 1. During an environmental inspection of the facility the Compliance Officers observed a bottle of "Liquid-Plumr" clog destroyer gel, a bottle of Windex, a bottle of "Smart Way" Bleach, a can of "Sprayway" glass cleaner, and a can of "Endust" multi-surface cleaner in an unlocked cabinet below the sink in the kitchen. 2. In an interview, E1 acknowledged the toxic materials were not stored in a locked area and inaccessible to residents.”