Health inspection·November 20, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on medical record review, review of a self-reported incident, review of an investigation, staff interview, and review of facility initiated corrective action, the facility failed to ensure care and services were provided to prevent a resident elopement. This affected one (#100) of three residents reviewed for elopement. The facility census was 120. Findings include: Review of the medical record for Resident #100 revealed an admission date of 02/09/23. Diagnoses included Alzheimer's disease, psychosis, and paranoid schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/01/23, revealed Resident #100 had severely impaired cognition, and was independent for ambulation with the assistance of a wheeled walker. Review of the elopement risk assessments dated 02/09/23, 05/09/23, 08/09/23, and 11/11/23 revealed Resident #100 was at a high risk for elopement. Review of the plan of care dated 02/09/23 revealed Resident #100 was at risk for elopement. Interventions included to document wandering behaviors and report to a physician, provided diversional activities when exit seeking, and provide an overall secure and safe environment. Review of a self reported incident (SRI) and investigation dated 11/10/23 revealed during the evening medication administration, it was observed that Resident #100 was absent from her room at approximately 8:30 P.M. A thorough search of the resident's room, bathroom, and closet yielded no results. The investigation revealed that an outside window was open approximately 15 inches and was missing the screen which was previously in place. In an effort to locate Resident #100 an external search was conducted, and other staff members were notified, and a comprehensive search was extended throughout the building and outside surroundings. Resident #100 was located at approximately 8:50 P.M., just within the tree line on the facility property and concealed in a pile of leaves. A detailed assessment of Resident #100's range of motion (ROM) and injuries indicated no abnormalities. Resident #100 was safely transported back into the facility, and upon returning to her room, Resident #100 was dressed in slacks, a long-sleeve shirt, and an outside jacket, but was without shoes or socks. The resident's hands and feet were cold to the touch while her face and trunk exhibited warmth. Resident #100's temperature was obtained and found to be a normal temperature of 98 degrees Fahrenheit (F). (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 365085 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365085 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Medina 2400 Columbia Rd Medina, OH 44256 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)