1. Autumn Leaves of Lee’s Summit, Lee’s Summit, MO: Facility staff failed to provide protective oversight and supervision for residents with histories of elopements and exit-seeking behavior for two residents. Facility staff failed to accurately assess the residents for elopement risk, develop and implement interventions to prevent elopements, and update individual service plans to direct the staff on the care of residents. This resulted in Resident #1 eloping from the facility for the third time. This resident was found several blocks from the facility. Further, Resident #2 eloped from the facility without staff knowledge for the third and fourth time.
  2. Cottages of Lake St. Louis, Lake St. Louis, MO: The facility failed to provide protective oversight for one resident when the surveyor observed the resident exit the facility in his/her wheelchair. No staff responded to the alarm and the resident continued to propel him/herself towards a busy street. As no staff responded, the surveyor redirected the resident away from the street and back into the facility. One staff member was on duty at the time providing care to another resident and was unable to hear the alarm.