Inspection·January 4, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and she would call his sister. Resident #10 walked away from LPN #100 towards an emergency exit door and tried to leave. LPN #100 was able to persuade Resident #10 to walk back to his room. LPN #100 assigned a State Tested Nursing Assistant (STNA) to provide one-to-one supervision for Resident #10 until he calmed down. On 12/26/23 at 5:00 P.M. the one-to one supervision was discontinued. Review of the elopement investigation dated 12/27/23 revealed Resident #10 had refused medications on 12/26/23 and 12/27/23 and was last seen in the facility in his bed on 12/27/23 at 2:00 A.M. by LPN #130. At approximately 3:00 A.M. on 12/27/23 LPN #130 was making rounds and noticed the Resident #10 was not in his bed or his bathroom. LPN #130 notified other staff that Resident #10 was missing, and the staff began to search for him. LPN #130 noted the window to the room across from Resident #10's room (Resident #12's room) faced the parking lot and was wide open. The facility notified local police on 12/27/23 at 3:50 A.M. that Resident #10 was missing. Local police found the resident at a bus stop near the facility on 12/27/23 and took the resident to the hospital for an evaluation. Review of the preliminary police investigation report dated 12/27/23 revealed the facility called the police on 12/27/23 at 3:58 A.M. and notified them Resident #10 was missing from the facility and they suspected he exited the building via a bedroom window. Review of the written statements from Registered Nurse (RN) #135, LPN #130 and STNA #140 who worked from 7:00 P. M. on 12/26/23 to 7:00 A. M. on 12/27/23 revealed they began to search for Resident #10 on 12/27/23 at 3:00 A.M. once they were advised he was missing. Each staff member participated in the search and all residents were accounted for except for Resident #10 Review of the hospital emergency report for Resident #10 dated 12/27/23 timed at 9:59 A. M. revealed the resident was found outside the facility wandering and unable to answer questions and had been transported to the emergency room by ambulance. Police confirmed Resident #10 was a missing person who had escaped from the facility. Resident #10 was alert and oriented to person only and was examined by the hospital physician with no injuries. Resident #10's vital signs were stable, and all lab tests and x-rays were within normal limits. Interview on 01/02/24 at 1:00 P. M. with LPN #100 confirmed she worked from 7:00 A.M. to 7:00 P.M. on 12/26/23. LPN #100 confirmed Resident #10 told her early in the shift that he wanted to leave, and she requested he stay with her while she finished passing the medications and then she would call his sister. Resident #10 then walked away towards an emergency exit door and tried to go out the door. LPN #100 followed him towards the door and was able to redirect him back to his room. LPN #100 confirmed she notified the nurse practitioner (NP) of Resident #10's exit seeking behavior and the NP gave an order for a Wanderguard bracelet. LPN #100 confirmed she attempted to place the Wanderguard bracelet on Resident #10 without success. She then assigned STNA #150 to provide one-to-one supervision to the resident until he calmed down. LPN #100 confirmed the one-to-one supervision was discontinued on 12/26/23 at 5:00 P.M. because the resident was no longer displaying agitation and restlessness. LPN #100 confirmed Resident #10 was in his room on 12/26/23 at 7:00 P.M. when she ended her shift. Interview on 1/02/24 at 1:15 P. M. with STNA #150 confirmed she sat with Resident #10 on 12/26/23 from 9:00 A. M. until 5:00 P. M. until he was calm. Interview on 01/04/24 at 9:10 A. M. with Occupational Therapist (OT) #114 and OT #116 confirmed they worked with Resident #10 when he was admitted to the facility from 12/20/23 to 12/25/23. They described Resident #10 as very confused and unable to comprehend simple requests. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365379 If continuation sheet Page 2 of 3 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 365379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Walden Park 5700 Karl Road Columbus, OH 43229 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 Interview on 01/02/23 at 2:59 P. M. with the Director of Nursing (DON) confirmed the facility had a secured unit, but Resident #10 was not placed in the unit because he did not have a diagnosis of dementia. The DON further confirmed Resident #10 had an exit-seeking attempt on 12/26/23 and the facility completed a new elopement risk assessment which indicated he was at risk for elopement. The DON confirmed the order for the Wanderguard bracelet for Resident #10 was not implemented because the resident refused. The DON confirmed the facility did not develop an elopement risk care plan for Resident #10, and the resident eloped from the facility on 12/27/23. Review of facility policy titled Elopement Policy dated 04/26/22 revealed the facility would attempt to prevent resident elopements to the extent possible. Elopement occurred when a guest/resident who needed supervision left a safe area without authorization and/or any necessary supervision to do so. This deficiency represents non-compliance investigated under Complaint Number OH00149516. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365379 If continuation sheet Page 3 of 3