Health inspection·February 7, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on interview and record review, the facility failed to ensure the safety and well being of Resident #51 when they did not return from a leave of absence. This affected one (Resident #51) of one resident reviewed for a leave of absence from the facility. The facility census was 49. Findings include: Review of the medical record for Resident #51 revealed an admission date of 12/13/23 with diagnoses including malignant neoplasm of the bone (cancer), multiple myeloma (cancer of the blood) and repeated falls. He was discharged from the facility on 01/14/24. Review of the Resident Sign Out form dated 01/06/24 revealed Resident #51 signed out for a leave of absence on 01/06/24 at 7:10 A.M. Review of the nursing progress note dated 01/06/24 at 6:53 A.M. revealed Director of Nursing (DON) #211 documented Resident #51 went out on leave of absence from the facility and stated he would be back later. The medical record did not contain evidence the resident returned on this date or efforts to ensure Resident #51 was safe when he did not return to the facility later that day. Review of the nursing progress note dated 01/07/24 at 4:19 P.M. revealed DON #211 had called Resident #51's sister for a status update as he had went with family on a leave of absence. Resident #51's sister stated he had gone to water therapy and when self-transferring he fell and broke his femur. She stated he was at the hospital for surgery. Interview on 02/07/24 at 9:22 A.M. with DON #211 verified facility staff had not reached out to Resident #51 or his family as to why he had not returned to the facility on [DATE]. She stated she had asked staff on 01/07/24 if Resident #51 had returned and staff had told her he had not. She stated she immediately called Resident #51's sister for an update. She verified staff should have attempted to locate the resident on 01/06/24 when he did not return to the facility. Review of the facility policy titled, Leave of Absence, undated, revealed residents were to notify the nurse of the date, time and length of the leave of absence. If a resident did not return in 24 hours from the expected date and time and did not communicate with the facility, the physician would be notified to determine if a discharge order would be given. The policy also stated if the resident did not return from the leave of absence or communicate with staff, that reasonable attempts would be made to notify them of their discharge. Page 1 of 2 365825 365825 02/07/2024 Grande Oaks 24579 Broadway Ave Oakwood Village, OH 44146

F 0689 This deficiency represents non-compliance investigated under Complaint Number OH00150245. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365825 Page 2 of 2