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 (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 2 Event ID: 365362 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 365362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Hills Center 6557 US 68 South West Liberty, OH 43357 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)