Health inspection·June 30, 2022

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) assessments were accurate. This affected four residents (#40, #6, #37, and #4) of four reviewed for accuracy of MDS assessments. The facility census was 62. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 02/10/22 with diagnoses including dementia with behavioral disturbance, anxiety disorder, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. The assessment indicated a wander/elopement alarm was not used and wandering was not exhibited. Review of the progress notes 05/13/22 at 2:04 P.M., 05/16/22 at 3:58 P.M., 05/17/22 at 3:40 P.M., 05/17/22 at 4:09 P.M., 05/18/22 at 4:13 P.M., and 05/18/22 at 9:42 P.M. revealed the resident exhibited wandering and exit seeking behaviors. Review of the physician's orders for June 2022 identified orders for a Wander Guard device (ordered 02/10/22). On 06/27/22 at 9:35 A.M., observation of Resident #40 revealed she was walking up and down the memory care hallway and attempted to exit the unit. The door alarm sounded and the resident did not open the door. On 06/27/22 at 9:47 A.M., interview with Licensed Practical Nurse (LPN) #359 revealed Resident #40 exhibited wandering and exit seeking behaviors. LPN #359 stated Resident #40 had attempted to exit the unit and the door alarms sounded because she was wearing a Wander Guard. On 06/29/22 at 10:02 A.M., observation of Resident #40 revealed she walked out the doors of the memory care unit and the door alarms sounded. On 06/29/22 at 10:06 A.M., observation of Resident #40 revealed she attempted to open the exterior door of the memory care unit and was unsuccessful. On 06/29/22 at 10:09 A.M., interview with LPN #392 confirmed Resident #40 exhibited wandering and exit seeking behaviors. LPN #392 stated Resident #40 had a Wander Guard and the door alarms would sound if she attempted to exit the unit. (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 5 Event ID: 365429 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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)