Health inspection·November 13, 2025

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, staff interview, and policy review, the facility failed to ensure a resident elopement was reported to the State Agency as required. This affected one resident (Resident #129) of three residents reviewed for elopement. The facility census was 76.Findings include: Review of the medical record for Resident #129 revealed an admission date of 05/13/22. Diagnoses included but were not limited to chronic obstructive pulmonary disease, alcohol dependence with alcohol induced persisting dementia, alcohol dependence with alcohol induced psychotic disorder with hallucinations, moderate dementia with psychotic disturbance and age-related bilateral cataracts. Review of Resident #129's care plan last reviewed on 08/21/25 indicated Resident #129 was at risk for elopement due to being disoriented to place, have impaired safety awareness and dementia with wandering behaviors. Interventions listed were to distract resident from wandering and intervene as appropriate. Offer various activities throughout the day and provide structured activities. Resident #129 was also noted to have impaired cognitive function and thought processes related to alcoholic dementia with a history of hallucination, long and short-term memory loss and poor decision making. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #129 revealed a Brief Interview of Mental Status (BIMS) score of 09 which indicated moderate cognitive impairment. Review of activities of daily living (ADLs) revealed Resident #129 required supervision for toileting, bathing, dressing and hygiene. Resident #129 was noted to be independent for walking 150 feet. No alarms or wander guards were noted on the assessment Review of the elopement assessment dated [DATE] for Resident #129 revealed a score of 8 which indicated he was low risk for elopement. Review of the endangered missing adult alert dated 11/09/25 timed at 9:19 P.M. revealed a missing adult alert was issued for Resident #129. Review of the nursing progress notes for Resident #129 revealed no notes related to Resident #129 being missing from or returning to the facility. Interview on 11/12/25 at 12:18 P.M. with the Administrator confirmed the facility did not notify the State Agency following being notified Resident was missing from the facility via email nor did the facility open a self-reported incident through the Ohio Department of Health's Certification and Licensure System. The Administrator confirmed she was investigating the incident and the investigation remained in progress. Review of the December 2007 revised facility policy titled Elopements revealed staff shall investigate and report all cases of missing residents. If an employee discovers that a resident is missing from the facility, he/she shall determine if the resident is out on an authorized leave or pass. If the resident was not authorized to leave, initiate a search of the building and premises. If the resident is not located, notify the Administrator and Director of Nursing Service, the resident's legal representative, physician, law enforcement officials and voluntary agencies. Upon return of the resident, the Director of Nursing Services shall complete and file an incident report and document relevant information in the resident's medical record. The policy was vague did not mention reporting elopements to the state agency. Page 1 of 8 365310 365310 11/13/2025 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the 11/01/2019 revised facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed neglect is the failure of the facility, its employees or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress. The Administrator or his/her designee will notify Ohio Department of Health (ODH) of all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident or Misappropriation of Resident Property and Injuries of Unknown Source as soon as possible but not later than twenty-four hours (24) hours from the allegations was made known to the staff member. This deficiency represents non-compliance investigated under Complaint Number 2664258. 365310 Page 2 of 8 365310 11/13/2025 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

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 review of the medical record, staff and resident interviews, review of the in-progress facility investigation, review of a local police report, review of local weather reports, and facility policy review, the facility failed to prevent an elopement for one resident (Resident #129) of three residents reviewed for elopement. The facility census was 76. Findings include: Review of the medical record for Resident #129 revealed an admission date of 05/13/22. Diagnoses included but were not limited to chronic obstructive pulmonary disease, alcohol dependence with alcohol induced persisting dementia, alcohol dependence with alcohol induced psychotic disorder with hallucinations, moderate dementia with psychotic disturbance and age-related bilateral cataracts. Review of Resident #129's care plan last reviewed on 08/21/25 indicated Resident #129 was at risk for elopement due to being disoriented to place, have impaired safety awareness and dementia with wandering behaviors. Interventions listed were to distract resident from wandering and intervene as appropriate. Offer various activities throughout the day and provide structured activities. Resident #129 was also noted to have impaired cognitive function and thought processes related to alcoholic dementia with a history of hallucination, long and short-term memory loss and poor decision making. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #129 revealed a Brief Interview of Mental Status (BIMS) score of 09 which indicated moderate cognitive impairment. Review of activities of daily living (ADLs) revealed Resident #129 required supervision for toileting, bathing, dressing and hygiene. Resident #129 was noted to be independent for walking 150 feet. No alarms or wander guards were noted on the assessment Review of the elopement assessment dated [DATE] for Resident #129 revealed a score of 8 which indicated he was low risk for elopement. Review of physician orders for November 2025 did not reveal any physician orders related to requiring a secured unit or safety monitoring devices.Review of the endangered missing adult alert dated 11/09/25 timed at 9:19 P.M. revealed a missing adult alert was issued for Resident #129.Review of the hospital after visit summary dated 11/10/25 printed at 4:11 P.M. for Resident #129 revealed a diagnosis of moderate dementia associated with alcoholism with mood disturbance, right hip pain, and confusion. The resident received an intravenous infusion for electrolyte replacement. Laboratory testing and a urinalysis were completed. Imaging tests including a computed tomography (CT) scan of his brain, a chest x-ray, electrocardiogram, and an x-ray of his right femur and leg were completed. The after visit summary noted there were no medication changes or follow up appointments needed and he was released from the emergency room. Review of the nursing progress notes for Resident #129 did not reveal any evidence of documentation related to the resident being observed missing, notifications being made, the resident being found and taken to the hospital, or returning to the facility. The last entered progress note was on 10/26/25 related to a pharmacy review and the following note was dated 11/12/25 timed at 3:08 A.M. indicating Resident #129 was alert times one to two (indicating to person and place), was easily redirected, and showed some confusion. Review of a local police report dated 11/09/25 timed at 6:50 P.M. revealed the officer was dispatched to the facility at 6:56 P.M. and arrived at the facility at 7:07 P.M. The officer was dispatched to the facility for a missing resident who was last seen at approximately 2:00 P.M. Upon arrival at the facility, the officer spoke to the receptionist and then to the nurse. According to multiple nurses, Resident #129 was last seen around 12:00 P.M. A nurse went to check on Resident #129 around 6:00 P.M. and discovered he was missing. Resident #129 was last seen wearing a blue, black and white flannel shirt, a baseball cap and light-colored jeans. The report noted the nurse mentioned it was the first time Resident #129 had left the facility. Nearby businesses were checked. 365310 Page 3 of 8 365310 11/13/2025 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Additional information was added to the report on 11/10/25 at approximately 9:30 A.M. when an officer was dispatched to a local hospital for a report of a missing person having been found. The officer met with Resident #129 and Social Services Designee (SSD) #316. SSD #316 stated she left the faciity on [DATE] around 8:30 A.M. to search for Resident #129. SSD #316 went to his last known address and upon turning onto the road, SSD #316 saw Resident #129 walking down a driveway and immediately made contact with him. SSD #316 stated she made contact with Resident #129 around 9:20 A.M. SSD #316 stated once Resident #129 was in her car, she took him to the hospital. Resident #129 told SSD #316 he had walked to his house and slept in his car in the garage. Resident #129 stated someone began yelling at him, so Resident #129 started to leave the area. SSD #316 stated Resident #129 did not appear injured but did state his hip was hurting him. Resident #129 was noted speaking to a nurse at the hospital and did not know what month it was. SSD #316 stated once Resident #129 was cleared she would take him back to the facility. Review of the elopement investigation dated 11/10/25 revealed Resident #129 was last seen by an alert and oriented resident around 3:30 P.M. exiting the building through the front exit doors. Around 5:40 P.M., the clinical on-call nurse was notified staff were unable to locate Resident #129 following attempting to administer his medications to him. At 5:42 P.M., a search party was initiated within the building. At 5:45 P.M., the regional management team was notified. At 6:00 P.M., the police and family were notified. Searches continued inside the facility and around the grounds and staff were driving around the surrounding areas looking for Resident #129. A second search was conducted inside and around the facility around 10:00 P.M. At 8:15 A.M. on 11/10/25, SSD #316 drove the surrounding area and to Resident #129's last known address. SSD #316 found Resident #129 walking back towards the facility and escorted Resident #129 to a local hospital for evaluation. Resident #129 returned to the facility with SSD #316 on 11/10/25 at 4:40 P.M. Review of the witness statement from Licensed Practical Nurse (LPN) #376 revealed the nurse went to administer the resident's evening medications on 11/09/25 and noticed Resident #129 was not in his room. LPN #376 asked the aides where the resident was and was told he was downstairs. The nurse went downstairs to locate the resident and could not find him. The search immediately began. LPN #376 reported Resident #129 was last seen between 2:00 P.M. and 3:00 P.M. Review of the witness statement from Certified Nursing Assistant (CNA) #346 revealed Resident #129 was here when she started her shift on 11/09/25 at 7:00 A.M. After eating breakfast, Resident #129 went down to the secured unit to visit his friend. Resident #129 came back upstairs at lunch time. At 2:45 P.M., Resident #129 stated he wanted to go visit his friends downstairs and it was the last time CNA #346 saw him. CNA #359 asked the dietary aide to tell the secured unit staff to tell Resident #129 to come back upstairs for dinner. LPN #371 from the secured unit came upstairs and told staff Resident #129 was not downstairs and she had not seen him since lunch. Review of the witness statement from CNA #359 revealed Resident #129 ate breakfast in his room then said he was going downstair to visit his friends before he came back up and ate his lunch. Around 2:45 P.M., Resident #129 said he was going downstairs to see his friend. When dinner trays were delivered, CNA #359 asked a dietary staff member to tell Resident #129 to come upstairs for dinner. LPN #371 came upstairs and said she hadn't seen Resident #129 since lunch. Review of the witness statement from LPN #371 stated she had last seen Resident #129 on 11/09/25 at approximately 12:30 P.M. as he was going upstairs for lunch and did not see him after that. Review of the witness statement from STNA #353 revealed she last saw Resident #129 going to the secured unit on 11/09/25 around 3:05 P.M. Review of the undated witness statement from Administrator #300 revealed Resident #100 reported to the Administrator she had seen Resident #129 leaving the building on 11/09/25 at approximately 3:30 P.M.Review of historical weather using the website weather underground 365310 Page 4 of 8 365310 11/13/2025 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (https://www.wunderground.com/history/daily/us/oh/cleveland/KCLE/date/2025-11-9) revealed the weather conditions on 11/09/25 were a high of 44 degrees Fahrenheit (F) and a low of 31 with a wind speed of 10-21 miles per hour (mph). Review of google maps website revealed Resident #129 walked 6.7 miles from the facility to his previous address. It was estimated to take two hours and 30 minutes to walk from the facility to Resident #129's previous address.Review of the facility incident/accident log for 11/01/25 to 11/12/25 revealed Resident #129's elopement was not recorded on the incident log.Observation and interview on 11/12/25 at 8:46 A.M. revealed on 11/09/25 he stated he left the facility, was unsure what time it was, and walked to his house. Resident #129 stated he was cold and slept overnight in the car in the garage and did not know anyone else was living there. Resident #129 stated when he woke up the next morning, he was cold and walked to an unnamed convenience store to get a cup of coffee and began walking back to the facility and went back to his room. Resident #129 did not recall if he talked to the police or who he talked to when he got back to the facility.Interview on 11/12/25 at 10:11 A.M. with SSD #316 revealed she received a call from the Administrator on 11/09/25 at 8:42 P.M. stating Resident #129 was missing. When SSD #316came to work on 11/10/25 at 8:00 A.M., she went back out to look for Resident #129 in her car and headed to his last known address. SSD #316 stated she observed Resident #129 walking on the sidewalk around 9:15 A.M. and yelled at him from her car. Resident #129 approached and got into SSD #316's car to warm up. SSD #316 stated Resident #129 was observed to be wearing a black jacket with a flannel shirt with a t-shirt underneath with jeans and a baseball cap with socks and shoes. Resident #129 told SSD #316 he was cold and hungry and his hip hurt. After speaking with the Administrator, SSD #316 took Resident #129 to the local emergency room for evaluation. SSD #316 stayed with Resident #129 while at the hospital and upon his release at 4:20 P.M., she drove Resident #129 back to the facility.Interview on 11/12/25 at 10:57 A.M. with Administrator #300 and Regional Administrator #379 stated Resident #129 was his own person and left the facility without staff knowledge and walked to his last known address, stayed there overnight, and came back the next morning. Administrator #300 stated she became aware Resident #129 was missing on 11/09/25 around 5:40 P.M. Resident #100 stated Resident #129 had walked out the front door of the facility between 3:30 P.M. and 3:45 P.M. Following being made aware of Resident #129 being missing without staff knowledge, they began searching inside and outside the facility and several staff began searching the nearby areas. Administrator #300 told SSD #316 to search the nearby area on 11/10/25 shortly after 8:00 A.M. SSD #316 located Resident #129 walking on the sidewalk near his prior residence. SSD #316 took Resident #129 to the emergency room for evaluation and following his release he was brought back to the facility.Telephone interview on 11/13/25 at 10:24 A.M. with LPN #376 revealed while working on 11/09/25, she last saw Resident #129 downstairs around 3:15 P.M. around shift change and he appeared to be going to the secured unit, and she went back to her unit upstairs. Around 5:30 P.M., she went to pass medications to Resident #129, and he was not in his room. She asked the aides working where he was and they said he was downstairs visiting friends in the memory care unit. LPN #367 went downstairs to the secured unit and LPN #371 stated Resident #129 was not there. LPN #76 began searching all the units and asking staff and residents if they had seen Resident #129, but no staff had knowledge of Resident #129's whereabouts. LPN #376 went back upstairs and notified the Administrator, police, and the resident's family. Review of the December 2007 revised facility policy titled Elopements revealed staff shall investigate and report all cases of missing residents. If an employee discovers that a resident is missing from the facility, he/she shall determine if the resident is out on an authorized leave or pass. If the resident was not authorized to leave, initiate a search of the building and premises. If the resident is not located, notify the 365310 Page 5 of 8 365310 11/13/2025 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0689 Level of Harm - Minimal harm or potential for actual harm Administrator and Director of Nursing Service, the resident's legal representative, physician, law enforcement officials and voluntary agencies. Upon return of the resident, the Director of Nursing Services shall complete and file an incident report and document relevant information in the resident's medical record. This deficiency represents non-compliance investigated under Complaint Number 2664258. Residents Affected - Few 365310 Page 6 of 8 365310 11/13/2025 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to ensure complete medical records were maintained for one resident (Resident #129) of three records reviewed for accurate and complete medical records. The facility census was 76. Findings include:Review of the medical record for Resident #129 revealed an admission date of 05/13/22. Diagnoses included but were not limited to chronic obstructive pulmonary disease, alcohol dependence with alcohol induced persisting dementia, alcohol dependence with alcohol induced psychotic disorder with hallucinations, moderate dementia with psychotic disturbance and age-related bilateral cataracts. Review of Resident #129's care plan last reviewed on 08/21/25 indicated Resident #129 was at risk for elopement due to being disoriented to place, have impaired safety awareness and dementia with wandering behaviors. Interventions listed were to distract resident from wandering and intervene as appropriate. Offer various activities throughout the day and provide structured activities. Resident #129 was also noted to have impaired cognitive function and thought processes related to alcoholic dementia with a history of hallucination, long and short-term memory loss and poor decision making. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #129 revealed a Brief Interview of Mental Status (BIMS) score of 09 which indicated moderate cognitive impairment. Review of activities of daily living (ADLs) revealed Resident #129 required supervision for toileting, bathing, dressing and hygiene. Resident #129 was noted to be independent for walking 150 feet. No alarms or wander guards were noted on the assessment Review of the elopement assessment dated [DATE] for Resident #129 revealed a score of 8 which indicated he was low risk for elopement. Review of the endangered missing adult alert dated 11/09/25 timed at 9:19 P.M. revealed a missing adult alert was issued for Resident #129. Review of a local police report dated 11/09/25 timed at 6:50 P.M. revealed the officer was dispatched to the facility at 6:56 P.M. and arrived at the facility at 7:07 P.M. The officer was dispatched to the facility for a missing resident who was last seen at approximately 2:00 P.M. Upon arrival at the facility, the officer spoke to the receptionist and then to the nurse. According to multiple nurses, Resident #129 was last seen around 12:00 P.M. A nurse went to check on Resident #129 around 6:00 P.M. and discovered he was missing. Resident #129 was last seen wearing a blue, black and white flannel shirt, a baseball cap and light-colored jeans. The report noted the nurse mentioned it was the first time Resident #129 had left the facility. Nearby businesses were checked. Additional information was added to the report on 11/10/25 at approximately 9:30 A.M. when an officer was dispatched to a local hospital for a report of a missing person having been found. The officer met with Resident #129 and Social Services Designee (SSD) #316. SSD #316 stated she left the faciity on [DATE] around 8:30 A.M. to search for Resident #129. SSD #316 went to his last known address and upon turning onto the road, SSD #316 saw Resident #129 walking down a driveway and immediately made contact with him. SSD #316 stated she made contact with Resident #129 around 9:20 A.M. SSD #316 stated once Resident #129 was in her car, she took him to the hospital. Resident #129 told SSD #316 he had walked to his house and slept in his car in the garage. Resident #129 stated someone began yelling at him, so Resident #129 started to leave the area. SSD #316 stated Resident #129 did not appear injured but did state his hip was hurting him. Resident #129 was noted speaking to a nurse at the hospital and did not know what month it was. SSD #316 stated once Resident #129 was cleared she would take him back to the facility. Review of the nursing progress notes for Resident #129 did not reveal any evidence of documentation related to the resident being observed missing, notifications being made, the resident being found, being taken to the hospital, or returning to the facility. 365310 Page 7 of 8 365310 11/13/2025 Gardens of North Olmsted 23225 Lorain Rd North Olmsted, OH 44070

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The last entered progress note was on 10/26/25 related to a pharmacy review and the following note was dated 11/12/25 timed at 3:08 A.M. indicating Resident #129 was alert and oriented times one to two (indicating to person and place), was easily redirected, and showed some confusion. Interview on 11/13/25 at 9:02 A.M. with Assistant Director of Nursing (ADON) #339 confirmed she did not feel it was necessary to write a progress note for a resident being identified as missing from the facility or document notifications to the family, physician, or police. Interview on 11/13/25 at 9:20 A.M. with the Director of Nursing (DON) #326 confirmed documentation should be done at least every couple of days for a wellness note to ensure resident is at baseline or if there have been any noted changes. DON #326 confirmed no progress notes were documented for Resident #129 related to the resident's elopement on 11/09/25. Interview on 11/13/25 at 9:48 A.M. with the Administrator confirmed following Resident #129 being identified as missing from the facility on 11/09/25, staff should have documented the events, updates, and notifications in the resident's progress notes. Review of the July 2017 revised facility policy called; Charting and Documentation revealed the following information is to be documented in the resident medical record: objective observation, medications administered, treatments or services provided, changes in resident's condition, events, incidents or accidents involving the resident and progress toward or changes in the care plan goals and objectives. This deficiency represents non-compliance investigated under Complaint Number 2664258. 365310 Page 8 of 8