Health inspection·March 6, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on observation, interview, record review, and facility investigation review the facility failed to prevent Resident #18 from exiting the facility unsupervised. This affected one resident (Resident #18) of three residents reviewed for accidents. The facility census was 102. Finding include: Review of the medical record for Resident #18 revealed an admission date on 12/05/23. Diagnoses included dementia severe with other behavioral disturbance, Alzheimer's Disease, anxiety disorder, and a need for assistance with personal care. Review of Resident #18's admission Minimum Data Set (MDS) Assessment, dated 12/11/23, revealed the resident had severe cognitive impairment, did not have any behaviors and had no impairments to his upper and lower extremities. The assessment indicated the resident was independently able to sit, stand, and use the restroom. The resident required supervision or touch assistance for walking 10 feet in a room, corridor, or smaller space. Review of Resident #18's progress note dated 01/06/24 revealed the resident had increased exit seeking behaviors at doors. He was redirectable mostly. The resident was having slight agitation towards staff when attempting to redirect but he calmed down quickly. The resident believes he is going home. The facility offered one on one conversation, increased monitoring and offered snacks. No other further concerns currently. Review of Resident #18's elopement evaluation dated 01/08/24 revealed the resident was high risk for elopement due to capability of leaving the facility, the resident is not oriented times three, the resident wanders in the facility, the resident exhibits exit seeking behavior, and the resident has a previous history of attempted elopements. Review of Resident #18's Care plan dated 01/09/24 revealed the resident was a risk for elopement related to exit seeking behavior. Interventions included to calmly redirect and divert the resident's attention, distract resident when wandering and is insistent on leaving the facility by offering pleasant diversion, structured activities, food, conversation, television, books, promptly check when alarm systems goes off to ensure the resident is safe and remains in the facility, and refer to psychiatrist or behavior specialist as needed. Page 1 of 4 365604 365604 03/06/2024 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility investigation dated 02/03/24 revealed on 02/03/24 door alarms started going off on the locked memory care unit (Unit E) and Licensed Practical Nurse (LPN) #100 started checking the doors and windows, the State Tested Nursing Assistants (STNA) came out of a room and started checking the doors and looking out the doors and windows. STNA #101 went outside while LPN #100 and the STNA #103 started checking all the resident rooms. The immediate action taken was that the resident was brought back in by the midnight nurse (LPN #102). The resident was assessed without injury, vitals were stable, notifications were made, and a new elopement evaluation was completed on the resident. The resident stayed close by the STNAs or nurse until shift change. The investigation revealed while conducting the door audits it was found a bad Maglock (an electrified locking device that uses low-voltage power to keep an entrance secure) power supply on the right-hand breezeway door on the memory care unit. The power supply was replaced, and all other doors were tested. The investigation indicated the resident was missing for approximately five to ten minutes. Review of the Maintenance record revealed the memory care Maglock were assessed on 02/02/24 and passed the inspection. Review of State Tested Nursing Assistant (STNA) #101 witness statement dated 02/03/24 revealed she last saw Resident #18 on 02/03/24 at 10:15 P.M. near the nurse's station, She and another STNA were both in resident rooms providing peri-care when the alarm sounded. STNA #101 reported she responded to the door first and did not see anyone outside. She reported she notified the nurse and went outside while the other two staff members completed a head count. She stated she went as far as the side road and did not see anyone. She came back inside to get a flashlight to go back outside when LPN #102 (midnight nurse) came inside with the Resident #18. The STNA indicated from the time the alarm went off to the time the Resident #18 returned was about five to ten minutes. She stated that the nurse did call another wing for assistance. The other units completed a head count. The STNA reported that when the resident returned, he was smiling and was in no distress. STNA #101 stated he may have thought he was going to work due to the fact when he returned, he was talking about selling things which was his previous occupation. Review of LPN #100 witness statement revealed Resident #18 was last seen in the hallway with both STNAs (that were) working on the unit. She heard the alarms go off and the door was checked. One STNA went outside to search. She and the other STNA completed a head count and started searching on the unit for the resident. She reported everyone responded right away. The nurse notified another unit of the situation, as this was happening. The oncoming nurse (LPN #102) came walking onto the unit with the resident. She reported the resident was missing from around 10:15 P.M./10:20 P.M. to 10:25 P.M./10:30 P.M. An assessment was completed on the resident, the Power of Attorney and physician on call were also notified. Review of LPN #102's witness statement revealed she saw Resident #18 in the back parking lot when driving in for her oncoming shift. The resident was not in any distress or harm. She immediately took the resident back to his unit and then went to clock in. Her clock in time was 10:38 P.M. Review of STNA #103's witness statement revealed the alarm went off around 10:25 P.M. and LPN #102 brought Resident #18 back to the unit at 10:30 P. M. The last time she saw the resident was prior to her going to care for another resident. The resident was walking up the hallway and then the alarms in the breezeway were going off. STNA #101 responded first, from another resident's room and she went outside to search. She and the nurse started a head count and were searching from room to room when Resident #18 was returned to the unit by LPN #102. 365604 Page 2 of 4 365604 03/06/2024 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 03//06/24 throughout the day revealed the resident walked independently with staff standing close by. Facility staff encouraged him to participate in activities and frequently interacted with him. The resident appeared confused and was unable to complete an interview. Phone interview on 03/06/24 at 3:53 P.M. Maintenance Director #104 revealed the doors in the memory care unit have a Maglock power supply that powers into the facility. He reported he tests the door weekly and just tested them on 02/02/24. He reported the power supply must have gone out at some point after his test on 02/02/24. This left the Maglock not working but did not affect the alarm. The next morning (02/04/24), he came in and replaced a new power supply on the Maglock and he has been checking them three times a week since then. No other issues with any of the other doors had been identified. Further interview revealed they (the Maglock) don't go bad for a year or two but that one just happened to go bad. He stated the doors are checked regularly and when they find they are bad, they replace them. Interview on 03/06/24 at 10:30 A.M. with Interim Administrator #105 revealed on 02/03/24 at around 10:20 P.M. the side front door started alarming on the facility's locked memory care unit. The unit was staffed with two STNAs and one nurse. STNA #101 responded to the alarm first, went outside, but could not see anyone. The nurse (LPN #100) was notified and began completing a head count and room search with STNA #103. STNA #101 came back inside to find a flashlight and, at this time, LPN #102 walked back onto the unit with Resident #18. This was around 10:25 P.M. or 10:30 P.M. LPN #102 stated the resident was found in the employee parking lot. He is independent, had shoes on, pants on, and a shirt. The resident was assessed, and no injuries were noted. The residents' wife and physician were notified. The resident's Psychiatrist was notified the next morning; The resident was placed on a one on one until he was assessed by this psychiatrist. The facility assessed the doors and found that the power supply to the Maglock was not functioning, and it was replaced right away on 02/04/24. Review of the facility's Elopement Protocol and Procedures revised 09/13/22 revealed, upon determining a resident cannot be located a headcount will be conducted, the clinical supervisor or designee will notify the Administrator, the highest ranking staff member becomes the Team Leader and coordinates the search. If the resident is not located on premises the team leader will direct with staff to conduct and external search. The deficient practice was corrected on 02/25/24 when the facility implemented the following corrective actions: 1. All facility employees received Elopement education. 2. All staff working the memory care were interviewed and witness statements were collected on 02/03/24. 3. Facility staff conducted audits three times a day of the facility's doors which had Maglocks to ensure they were functioning properly starting 02/04/24. 4. Resident #18's elopement evaluation was updated (remained a high risk) on 02/03/24. 5. The Maintenance Director was educated to ensure all exterior alarms with Maglocks are checked weekly for function per manufacturers guidelines on 02/04/24. 6. Resident #18 was assessed by the psychiatrist on 02/04/23. 365604 Page 3 of 4 365604 03/06/2024 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0689 7. On 02/25/34 the facility conducted Elopement Drills on all units for all shifts. Level of Harm - Minimal harm or potential for actual harm This violation represents non-compliance investigated under Complaint Number OH00151693. Residents Affected - Few 365604 Page 4 of 4