Health inspection·September 3, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 09/03/24 at 10:30 A.M. revealed Resident #1 in his room in bed. Resident #1's room door was closed and could not be seen from the hallway. There was not a staff member observed in Resident #1's room. Interview with State Tested Nursing Assistant (STNA) #180 and STNA #190 on 09/03/24 at 10:30 A.M. confirmed Resident #1 was ordered to be 1:1 supervision. STNA #180 and STNA #190 confirmed a staff member should be with Resident #1 at all times and there was a brief time that he was not being provided with 1:1 supervision. Interview with the Administrator on 09/03/24 at 10:38 A.M. confirmed Resident #1 had eloped from the facility on 08/30/24. Resident #1 was just admitted the prior evening. Resident #1 was found near a local park. The Administrator was unsure how Resident #1 had eloped. The Administrator confirmed Resident #1 was ordered to be 1:1. The Administrator confirmed the facility conducted an investigation but was unable to determine how Resident #1 eloped so Resident #1 was placed on 1:1 supervision. Interview with the Director of Nursing (DON) on 09/03/24 at 11:24 A.M. confirmed Resident #1 eloped from the building on 08/30/24. Resident #1 was last seen by staff on 08/30/24 approximately 7:30 A.M. Resident #1 was found by Nurse Practitioner (NP) #100 near a local park and returned to the facility on [DATE] at 8:25 A.M. Resident #1 was assessed and had no injuries. The DON confirmed Resident #1 was ordered to be 1:1 and that a staff member was not in his room when observed 09/03/24 at 10:25 and 10:30 A.M. Interview with Business Office Manager (BOM) #120 on 09/03/24 at 2:00 P.M. revealed she searched for Resident #1 when he eloped on 08/30/24. BOM #120 arrived to the location where Resident #1 was located at about the same time as NP #100. BOM #120 transported Resident #1 back to the facility. Resident #1 came back the facility willingly. Phone interview with Licensed Practical Nurse (LPN) #200 on 09/03/24 at 2:24 P.M. revealed she was the dayshift nurse on 08/30/24. LPN #200 was unable to find Resident #1 when she went to his room to get medications on 08/30/24 at approximately 7:30 A.M. LPN #200 informed STNA's who helped search the unit. Resident #1 was unable to be found so an elopement code was called and staff began searching the facility and surrounding areas. Resident #1 was found outside of the facility and returned on 08/30/24 at approximately 8:30 A.M. LPN #200 assessed Resident #1 upon his return and he did not have any injuries. LPN #200 denied hearing any exit alarms, seeing any windows open, or having any family members in the unit the morning on 08/30/24. Phone interview with LPN #150 on 09/03/24 at 2:32 P.M. revealed she was the night shift nurse on 08/29/24 to 08/30/24. LPN #120 reported last seeing Resident #1 on 08/30/24 at approximately 7:00 A.M. when reporting off to the day shift nurse. Resident #1 stuck his head out of his room. Resident #1 was a little restless during the night and walked around. LPN #120 denied seeing Resident #1 push on any doors or attempt to elope. LPN #120 did not hear any exit alarms on 08/29/24 or 08/30/24. LPN #120 was informed Resident #1 was missing form the facility while at a tanning salon and questioned when the last time she had seen him. Interview with NP #100 on 09/03/24 at 2:38 P.M. revealed she found Resident #1 near a local park on 08/30/24. Resident #1 was very pleasant, but confused. NP #100 had not yet seen Resident #1 at the facility before 08/30/24 and did not know him. NP #100 identified Resident #1 by a picture that was sent out by the facility. Resident #1 did not have any injuries. Resident #1 has been assessed and some medication have been adjusted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365722 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 365722 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Glen Alzheimer's Community 3800 Summit Glen Drive Dayton, OH 45449 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 Review of the facility's undated policy Elopement Prevention and Management Overview revealed elopement is defined as when a resident/patient leaves the premises or a safe area without authorization and/or any necessary supervision and places the resident at risk for harm or injury. Post elopement procedures included complete and document a physical assessment of the resident/patient upon return to the facility to determine if further treatment is required, notify all parties of resident's return to the facility, review and revise the interventions related to prevention of elopement/missing resident, and communicate the modification of interventions to the caregiving staff, resident and/or resident representative. This deficiency represents non-compliance investigated under Complaint Number OH00157403. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365722 If continuation sheet Page 3 of 3