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Elmcroft of Sagamore Hills
Elmcroft of Sagamore Hills.
(Adam Ferrise, Northeast Ohio Media Group)
SAGAMORE HILLS, Ohio — The assisted living facility where a 94-year-old woman was found dead Monday of hypothermia was cited in 2011 after a resident escaped from the building twice in a two-week span.
The state cited Elmcroft of Sagamore Hills for failing to implement a plan to ensure the patient never wandered away from the building again, according to a review of state records.
More than three years later, Sagamore Hills police are investigating the death of 94-year-old resident Martha Jendrix, whose body was found outside the facility.
Sagamore Hills police said she was outside more than an hour and are trying to understand how she managed to escape the building. The state health department is also investigating.
Elmcroft executive director Greg Kaminski did not return calls seeking comment on Tuesday. On Monday, he told the Northeast Ohio Media Group that they are fully cooperating with the police investigation.
The resident who wandered away from the facility twice in 2011 was diagnosed with mental health disorders, dementia, disorientation, vertigo and was known to occasionally wander.
He was stopped on a major highway near the facility the morning of Aug. 12, 2011 after wandering away from the building, state records say.
A car pulled over, stopping traffic on the highway. An employee ran after the resident and brought him back to the building. Two weeks later, he escaped his room, walked down a staircase and out of the building.
The man was found sitting outside the building. State health inspectors found staff never documented the resident's new supervision plan after the first escape.
"The facility had not implemented interventions to ensure Resident #1 would not attempt another elopement, nor did the facility have interventions in place regarding Resident #1 going outside unsupervised," state records say.
Elmcroft was cited during seven other state inspections since 2011.
A residential assistant was fired after a March 18, 2012 incident in which she grabbed a patient by the throat and threatened the patient with jail after being attacked.
The patient, who suffered from dementia and Alzheimer's, grabbed the woman's breast and twisted it, then grabbed the employee's hair. The employee was at the end of a back-to-back shift, state records noted.
Another state inspection in March 2012 showed the facility was understaffed for 17 nightshifts inspectors reviewed between Jan. 30, 2012 and March 11, 2012. No one on the staff during those shifts was licensed to be able to administer certain medication, oxygen and insulin.
The inspection found that 42 patients at the time could have needed care in one of those areas.
A medical technician during that time frame gave insulin to a patient despite not having a license to do so. Inspectors found the technician signed the paperwork using the initials of a nurse licensed to administer insulin.
The nurse told inspectors she was not at work during that time and didn't administer the insulin. The technician was previously warned about providing unlicensed treatment the previous month, state records say.
Elmcroft was also cited in March 2012 for failing to properly monitor a 93-year-old hospice care patient with dementia after she fell twice in the same month and fractured her ankle.
A nurse failed to properly document an injury a patient suffered on July 12, 2011. Physicians never checked the bruising on the inside the patient's left upper-arm area.
Elmcroft was most recently cited after a June 26, 2014 inspection for having dirty blankets, pillows, sheets and towels on the floor of two linen closets inside the facility.
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