Starfish Care Homes, LLC.

“Based on document review, interview, and observation the manager failed to ensure there was a means of exiting the facility for a resident that allowed the resident to exit to a location at least 30 feet away from the facility, that is secure. 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 facility documentation revealed an incident report documenting the elopement of R1 on February 25, 2026.   2. A tour of the facility revealed an exit gate, locked with a keypad.   3. In an interview, E2 reported that, on the day of the elopement, the lock in the exit gate malfunctioned and became jammed, which allowed R1 to elope from the facility.   4. In an exit interview, the findings were discussed with E1 and E2 and no additional information was provided.”