Health inspection·September 21, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #5's elopement events were submitted as self-reported incidents to the Ohio Department of Health incident tracking website. This affected one (Resident #5) of three residents reviewed for elopement. The total census was 99. Findings include: Record review of Resident #5 revealed he was admitted to the facility 07/13/21 and had diagnoses including dementia, alcohol abuse, and major depressive disorder. A probate physician assessment dated [DATE] revealed he had severe cognitive, judgement, insight, and memory deficits which rendered him incapable of self-management of person and estate. He had a court-ordered guardian in place as of 12/23/21. Review of his minimum data set assessment on 06/20/23 revealed he refused to complete a mental status assessment and required supervision assistance for transfers and locomotion. He was assessed as having verbal behaviors four to six of seven days and rejection of care one to three of seven days. His elopement risk assessment dated [DATE] revealed he was at risk for elopement due to being cognitively impaired, ambulated independently, and had a history of elopement and substance use disorder. Review of his care plan revealed he was at risk for elopement and was to be only allowed on the back patio when he wished to be outside. Additional care plan interventions were added from 09/08/23 to 09/19/23 including moving him to the secured unit for safety, 1-1 supervision in evening hours when awake, observing him for signs of intoxication, and referrals to psychiatric hospitals. Review of Resident #5's progress notes and elopement incident reports revealed the front door camera detected him leaving the facility at 8:11 P.M. on 09/07/23 and he was found at the front door waiting to return inside at 9:50 P.M. the same day. He refused to identify how and why he exited. He was assessed as oriented to place, person, and situation (not time) and to not have any injuries. The facility placed him on 15 minute checks and inserviced staff on his elopement risk. On 09/11/23, Resident #5 was identified missing from the facility at roughly 7:55 P.M. The facility contacted the police, who found and returned him at 9:30 P.M. the same day. He had a case of beer in his possession, and when the facility removed it he threw a can at the wall. He was brought to the secured unit and had behaviors including hitting the glass door, screaming profanities, and banging on other resident doors. He was sent to the emergency room at 10:35 P.M. and was returned to the facility the following day at 11:49 A.M. on 09/13/23 he was returned to his original room (in the 500 hall) off the Page 1 of 4 365048 365048 09/21/2023 Life Care Center of Westlake 26520 Center Ridge Rd Westlake, OH 44145

F 0609 secured unit. Level of Harm - Minimal harm or potential for actual harm Review of the facility incident log revealed elopement incidents for Resident #5 were documented on 09/07/23 and 09/11/23. Residents Affected - Few Review of the Ohio Certification and Licensure website revealed no evidence either of the above-noted events were submitted as self-reported incidents (SRIs) to the Ohio Department of Health. Interview with the Administrator on 09/19/23 at 12:05 P.M. confirmed the above findings. He said he did not make SRI reports because the facility identified the events as being unauthorized leaves rather than elopements. This deficiency represents noncompliance investigated under OH00146250. 365048 Page 2 of 4 365048 09/21/2023 Life Care Center of Westlake 26520 Center Ridge Rd Westlake, OH 44145

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to prevent two elopement events by Resident #5. This affected one (Resident #5) of three residents reviewed for elopement. The total census was 99. Findings include: Record review of Resident #5 revealed he was admitted to the facility 07/13/21 and had diagnoses including dementia, alcohol abuse, and major depressive disorder. A probate physician assessment dated [DATE] revealed he had severe cognitive, judgement, insight, and memory deficits which rendered him incapable of self-management of person and estate. He had a court-ordered guardian in place as of 12/23/21. Review of his minimum data set assessment on 06/20/23 revealed he refused to complete a mental status assessment and required supervision assistance for transfers and locomotion. He was assessed as having verbal behaviors four to six of seven days and rejection of care one to three of seven days. His elopement risk assessment dated [DATE] revealed he was at risk for elopement due to being cognitively impaired, ambulated independently, and had a history of elopement and substance use disorder. Review of his care plan revealed he was at risk for elopement and was to be only allowed on the back patio when he wished to be outside. Additional care plan interventions were added from 09/08/23 to 09/19/23 including moving him to the secured unit for safety, 1-1 supervision in evening hours when awake, observing him for signs of intoxication, and referrals to psychiatric hospitals. Review of Resident #5's progress notes and elopement incident reports revealed the facility camera detected him leaving the facility at 8:11 P.M. on 09/07/23 and he was found at the front door waiting to return inside at 9:50 P.M. the same day. He refused to identify how and why he exited. He was assessed as oriented to place, person, and situation (not time) and to not have any injuries. The facility placed him on 15 minute checks and inserviced staff on his elopement risk. On 09/11/23, Resident #5 was identified missing from the facility at roughly 7:55 P.M. The facility contacted the police, who found and returned him at 9:30 P.M. the same day. He had a case of beer in his possession, and when the facility removed it he threw a can at the wall. He was brought to the secured unit and had behaviors including hitting the glass door, screaming profanities, and banging on other resident doors. He was sent to the emergency room at 10:35 P.M. and was returned to the facility the following day at 11:49 A.M. on 09/13/23 he was returned to his original room (in the 500 hall) off the secured unit. Review of witness statements from the 09/11/23 elopement revealed State-Tested Nursing Aide (STNA) #600 documented when she learned Resident #5 was missing at 7:55 P.M., she informed the charge nurse on the 200 hall who said she had a med pass to do. STNA #600 called the 600 unit and informed that nurse, and the nurse said it was not her issue, she would continue her medication pass, and the resident would probably be back soon. Review of police report #23-23051 revealed on 09/11/23 at 8:21 A.M. the police were dispatched to search for Resident #5 as a missing person. They found him on what appeared to be a return route to 365048 Page 3 of 4 365048 09/21/2023 Life Care Center of Westlake 26520 Center Ridge Rd Westlake, OH 44145

F 0689 Level of Harm - Minimal harm or potential for actual harm the facility with a 12-pack of beer. The police escorted him back to the facility. The report made no mention of him having any injury or other adverse effect. Review of the facility incident log revealed elopement incidents for Resident #5 were documented on 09/07/23 and 09/11/23. Residents Affected - Few Observation of camera footage from the facility's secured front door on 09/18/23 at 10:51 A.M. revealed Resident #5 exited the facility at 8:10 P.M. on 09/07/23 by following what appeared to be a visitor out the door after they punched in a code, with two other apparent visitors following behind him. Resident #5 exited out the front door at 7:45 P.M. on 09/11/23 when a staff member punched in a code for what appeared to be two visitors, then turned away. As the visitors were entering, Resident #5 approached from the opposite direction as the staff member and exited behind the visitors. Interview with the Director of Nursing on 09/18/23 at 11:00 A.M. revealed the facility put Resident #5 on 15 minute checks following the first elopement. Following the second elopement, the facility noted he left in the evening hours after the secretary was gone (who typically is in the facility from 7:00 A.M. to 7:00 P.M.). The facility then removed 15 minute checks and placed him on 1-1 care when he was awake from 7:00 P.M. to 7:00 A.M. Interview with Resident #5 on 09/19/23 at 9:46 A.M. revealed he left the facility without notifying staff on multiple occasions. He did so by waiting until people came in to unlock the door for him. During these events he went to local stores roughly a mile away via wheelchair and then returned under his own power. He said he dressed appropriately for the weather and suffered no injuries during these events. He felt he did not need a guardian and was taking action to try to get it removed. Interview with the Administrator on 09/19/23 at 12:05 P.M. confirmed the above findings. Review of the facility's elopement policy dated 11/23/22 revealed that elopement occured when a resident left the premises without authorization or necessary supervision. It did not indicate specific protocols to take when a resident eloped. The surveyor made two attempts to contact Resident #5's guardian during the survey, including a message left requesting a return call. No response was received before the end of the survey. This deficiency represents noncompliance investigated under OH00146250. 365048 Page 4 of 4