Inspection·July 6, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Social Service note dated 06/25/23 at 2:42 P.M. revealed Resident #10 exhibits behaviors, stating untruths to get her own way. She tends to exhibit confusion with medication regiment and would not listen to education or redirection. The resident could be verbally and physically aggressive with staff and had a history of both with other residents. The resident tends to exhibit delusional behavior regarding staff. Resident can be confrontational towards others and would then state she was a victim. The resident scored an 11 out of 15 on her Brief Interview for Mental Status. She had diagnoses of anxiety, dementia, depressive disorder, and personality disorder. Review of the Brief Interview for Memory Status (BIMS) score dated 06/25/23 revealed Resident #10 had scored an 11 for moderately impaired cognition. Review of the plan of care revealed no documentation of Resident #10 having an elopement or wandering plan of care. Review of physician orders for June 2023 identified no orders for devices to prevent elopement. Further review of the orders revealed Resident #10 had an active order indicating she may go Leave of Absence (LOA) overnight with her daughter, may take medications however no narcotics were to go with her dated 08/22/22. Resident #10 had an order for a wander guard on 07/14/22 and it was discontinued on 08/07/23. Review of the June 2023 Medication Administration record revealed Resident #10 had an order to obtain a blood sugar before meals and at bedtime. She was to receive sliding scale Humalog insulin based on those blood sugar readings. She did not receive a blood sugar reading or insulin on 06/27/23 at 4:00 P.M. and 9:00 P.M. Review of the right shoulder x-ray dated 06/27/23 at 5:11 P.M. revealed Resident #10 had a mildly comminuted fracture in the distal third of the right clavicle. Review of the progress note dated 06/28/23 at 7:23 A.M. revealed Resident #10 had left the building without telling anyone or signing out in the LOA book. She had gone to Starbucks and then from there she was sent to [NAME] Emergency Department. LOA policy was reviewed and the staff needed to be notified every time she was leaving the building. Resident acknowledges teaching. Review of Google Maps revealed the corner of [NAME] road and [NAME] Village road was approximately 0.4 miles from the facility. On 06/29/23 at 12:15 P.M. an interview with Resident #10 revealed she had left the building on Tuesday 06/27/23 because she had to go to the bank. She stated she had been asking for over a month for someone to take her to the bank and they have refused. She stated she left through the front door around 3:30 P.M. She stated she was walking two blocks over to First Commonwealth bank on [NAME] Avenue. She stated but she tripped and fell on the corner of [NAME] and [NAME] Village Avenue. She stated about 10 people stopped and called 911. She stated she did not sign herself out and she did not have a telephone with her. On 06/29/23 at 1:44 P.M. an interview with Licensed Practical Nurse #202 revealed on 06/27/23 she had just come on shift at 3:00 P.M. and was getting report and counting narcotics when Resident #10 came up the hallway in her wheelchair but she then went back to her room. She stated a few minutes later Resident #10 came down the hallway walking with her walker. She stated she did not think anything of it because Resident #10 would sometime go into the dining room or go outside and sit on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365324 If continuation sheet Page 2 of 4 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 365324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Belden Village 5005 Higbee Avenue NW Canton, OH 44718 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few patio. She stated at around 4:30 P.M. she went to get Resident #10's blood sugar level but could not find her. She stated she never went to find her to do her blood sugar at that time. She stated she did not know why but she just did not go find her to get her blood sugar but looking back now she should have. She stated at around 8:30 P.M. she was going to get Resident #10's bedtime blood sugars and she noticed Resident #10 was not in her room and her purse was gone. She stated he notified the other nurse working and they began looking for her. She stated Social Worker #207 was still working so she helped look for the resident too. She stated they searched inside and outside of the building. She stated Social Worker #207 called the police around 10:30 P.M. and as she was on the phone with the police, the hospital called and stated Resident #10 had fallen in front of Starbucks and was taken to the hospital by squad. On 06/29/23 at 2:55 P.M. an interview with Social Worker #207 revealed she had been getting ready to leave around 10:00 P.M. and the nurse working came and told her Resident #10 could not be located. She stated she called the Director of Nursing (DON) to see what she was to do in case she did not come back until after midnight because everyone needed to be in the building at midnight. She stated she was just concerned because if Resident #10 was out over the midnight hour that affected the bed hold and payment. She stated the DON instructed her to search the building and do a head count. She stated she started to panic when they could not find her so she called the police and while she was on the phone with the police the hospital called to state Resident #10 was in the emergency room (ER) because she had fallen in front of Starbucks and was sent to the ER. On 06/29/23 at 3:40 P.M. with the DON revealed the nurses working the floor contacted her around 10:00 P.M. on 06/27/23 to report Resident #10 was missing. She stated as she was on the phone with the nurse the facility's Social worker called her. She stated it all happened really fast. She stated she told them to do a head count and search for her. They could not find her so the Social Worker was going to report it to the police but as she was on the phone with the police the hospital called to state they had her in the ER. She stated she called the ER and spoke to someone, she did not get her name, to ask if they could keep her at the hospital and find alternate placement for her because they had issued her several 30-day notice for her behaviors and non-payment. However, the person she spoke to stated they did not do that and they were sending her back to the facility. She stated they did not treat her leaving as an elopement because she comes and goes all the time. She stated however they did in-service the whole staff on elopement because of the nurse not searching for her at 4:30 P.M. when she seen she was not in the building. She verified the nurse should have been more thorough in looking for her. On 06/29/23 at 5:10 P.M. an interview with Human Resource Director (HRD) #208 stated she had seen Resident #10 going out the front door with her walker, two bags and a purse. She stated she asked her where she was going and she told her to the bank and to get some hair products. She stated she asked her if she had signed out and she had stated no. She stated she went up to the unit to look in the sign out book to see if Resident #10 had signed out and she had not so she signed her out. Observation of the sign out sheet at this time with HRD #208 revealed HRD #208 had written 02/27/23 at 3:45 P.M. resident refused to sign out instead of the correct date of 06/27/23. She verified she put the wrong date down. She stated she had not told anyone she had left because she was late for an appointment and needed to leave. On 07/06/23 at 10:30 A.M. an interview with Physician #210 revealed he was aware she had left the facility and he believed she had the LOA prior to leaving the facility. He stated but he did not have any of her information in front of him and was only going by memory. He stated she was an extremely difficult resident. He stated he thought she used a walker for ambulation but most of the time she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365324 If continuation sheet Page 3 of 4 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 365324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Belden Village 5005 Higbee Avenue NW Canton, OH 44718 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not use anything for ambulation and he was not sure of her mobility status off the top of his head. He stated in regard to her leaving the facility by herself she tested out high enough on her BIMS score to make her own decision but that does not mean she made appropriate decisions but she had her rights. He stated he wished she would not leave the facility but she was permitted to leave. Review of the facility policy titled, Routine Resident Checks, dated 07/13 revealed the staff should make routine resident checks to help maintain resident safety and well-being. To ensure the safety and well-being of the residents, the nursing staff should make a routine check on each resident at least once per each eight-hour shift. Routine resident checks involve entering the resident's room, identifying the resident elsewhere on the unit to determine if the resident needs were being met, identify a change in the resident's condition, identify whether the resident has a concern, and see of the resident was sleeping or needed toileting assistance. This deficiency represents non-compliance investigated under Complaint Number OH00144115. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365324 If continuation sheet Page 4 of 4