Health inspection·July 13, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of a facility investigation, and review of a self-reported incident, the facility failed to ensure care plans were developed and implemented for residents with wandering and eloping behaviors. This affected two (#53 and #20) of five residents reviewed for behaviors. The current census was 68. Findings include: 1. Review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #53 include dementia, aphasia, heart failure, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has impaired cognition and was not coded as having wandering behaviors. Review of Resident #53's care plans dated April 2023 revealed there was no focus for behaviors including elopement and wandering. Review of a self-reported incident (SRI) dated 05/15/23 revealed on 05/15/23 Resident #53 walked out of the locked dementia unit, but did not leave the building. Per the report, the resident was observed on the hallway outside of the locked unit knocking on the door to get back into the dementia unit. Further review of the report revealed the resident's wife had visited and the resident may have followed her out of the unit and then attempted to return to the locked unit. Review of a facility investigation on 05/15/23 revealed the resident's wife had been to visit the resident and was leaving the locked unit, and the resident followed her out of the unit. Resident #53 then knocked on the door to return to the unit. Resident #53's Wandergaurd (alerting device worn by individuals at risk for elopement) was checked, and the Wanderguard locked all doors leading outside of the facility. A code alert bracelet was added as an intervention to lock the dementia unit doors. Review of the Resident #53's progress notes dated 05/24/23 at 8:51 A.M. revealed the resident continued to have wandering behaviors of attempting to enter other resident's rooms and trying to exit the unit causing alarms to sound. Interview on 07/12/23 at 3:30 P.M. with State Tested Nurse Aide (STNA) #108 and Hospitality Aide (HA) #216 stated Resident #53 had wandering behaviors and needed to be checked on frequently. STNA Page 1 of 2 365362 365362 07/13/2023 Green Hills Center 6557 US 68 South West Liberty, OH 43357

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #108 was unsure if the resident had a Wanderguard and code alert bracelet or just a Wanderguard. HA #216 stated Resident #53 had wandering behaviors to the point of trying to exit the doors of the unit. Neither STNA #108 nor HA #216 were able to see the behaviors and interventions for such behaviors in the resident's care plans. Interview on 07/13/23 at 11:20 A.M., with the Administrator verified there was no behavior or elopement care plan for Resident #53 to address his wandering and elopement behaviors. 2. Review of Resident #20's medical record revealed the resident was admitted to the facility 05/23/23. Diagnoses for Resident #20 include dementia, heart disease, diabetes type two, and encephalopathy. Review of the MDS assessment dated [DATE] revealed the resident had impaired cognition and was coded with the behavior of wandering. Review of Resident #20's care plans dated May 2023 revealed there was no focus for behaviors or elopement. Review of Resident #20's progress notes dated 07/02/23 at 8:51 A.M. revealed the resident was observed outside of the unit on the secured courtyard when the door alarm sounded. Staff returned the resident inside the dementia unit and the staff continued to monitor the resident. Interview on 07/13/23 at 11:20 A.M. with the Administrator verified there was no focus for behaviors including elopement in Resident #20's care plans prior to 07/12/23. 365362 Page 2 of 2