WARRENSVILLE HEIGHTS, Ohio — An Ohio Department of Health survey found the Avenue at Warrensville Care and Rehabilitation Center failed to provide "adequate supervision" to prevent Alvera Meuti, 84, from leaving the facility, which resulted in "Immediate Jeopardy" and "actually harm leading to death."
According to the 27-page state report, no one realized Meuti was outside the building until it was too late.
"The facility failed to have adequate and effective systems in place to ensure the resident's safety and supervisory needs were met," even though an assessment determined she was at risk of elopement, the report said.
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It also revealed one of two doors Meuti pushed open to get outside was equipped with an alarm, but staff said "no staff members... recalled or admitted de-activating the alarm" or "hearing any door alarm."
The report also found two staff members failed to report that Meuit was missing.
A nursing assistant said "he did not see" Meuti in her room at 4:00 a.m. on Christmas Eve but "forgot to tell his nurse."
News 5 Investigators previously reported that the nurse assigned to Meuti's room, Amber Henderson, waited nine hours to report her missing.
Henderson told police she assumed Meuti was with her brother for the holiday, but admitted there was no record of anyone signing her out of the facility.
Henderson was charged with one felony count of involuntary manslaughter and two misdemeanors in Bedford Municipal Court last month.
Her case was bound over to Cuyahoga County, where it remains under investigation, according to the Cuyahoga County Prosecutor's Office.
News 5 reached out to the Avenue at Warrensville Heights Care and Rehabilitation Center and its parent company, Progressive Quality Care, about the state's survey Tuesday afternoon, but have yet to receive a response.
