Inspection·November 21, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on medical record review, observation, resident interview, staff interview, review of the facility's Self-Reported Incident (SRI) and investigation, review the National Weather Forecast, and review of facility policy, the facility failed to provide adequate supervision to ensure a cognitively impaired resident, assessed to be at moderate risk for elopement from the facility and had previous attempts to elope, did not elope from the facility. This resulted in Immediate Jeopardy when Resident #26 was placed at risk for potential serious harm and/or injury when the resident eloped from the facility without staff knowledge and exited through the front door. The resident was missing for approximately six hours before being found approximately 3.9 miles from the facility, after accepting a ride from a neighbor of the facility, riding public transportation, accessing funds from the bank, and located walking along a main downtown street with variances of two to four lanes. This affected one (#26) of six residents (#26, #45, #66, #84, #91 and #96) reviewed for elopement. The facility identified four residents (#26, #45, #84, and #91) to be at risk for elopement. The facility census was 71. On 11/08/23 at 3:34 P.M., the Administrator was notified Immediate Jeopardy began on 10/20/23 at 7:00 A.M. when State Tested Nurse Aide (STNA) #556, assigned to provide one-to-one supervision for Resident #26, left at the end of her shift without ensuring another staff member assumed supervision of the resident. Subsequently, Resident #26 cut off his wander guard bracelet from his left ankle with a pair of nail clippers and exited from the facility through the front door without staff knowledge. Resident #26 was located approximately six hours later by facility staff as the resident was walking down a main downtown street, approximately 3.9 miles away from the facility. The ambient air temperature outside on 10/20/23 was a low of 50 degrees Fahrenheit (F) to a high of 54 F. Resident #26 was placed at potential risk of being hit by a car while walking through areas that had two to four lane roads of traffic, traveled by city bus, procured a ride from a facility neighbor, withdrew funds from the bank, and gave money to a friend. At the time of discovery, Resident #26 was transported to the hospital for evaluation and found to have no injuries. The Immediate Jeopardy was removed, and the deficient practice corrected on 10/21/23 when the facility implemented the following corrective actions: · On 10/20/23 at approximately 8:10 A.M., Registered Nurse (RN) #521 discovered Resident #26 was not in his room and initiated a head count of facility residents. All residents were accounted for, except Resident #26. (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 7 Event ID: 365684 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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)