Health inspection·August 28, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Review of the care plan, closed 08/26/23, revealed there was no care plan indicating Resident #1 was at-risk for elopement, which was consistent with the elopement risk screen completed on 07/05/23. Review of the progress notes for January 2023 to August 2023 revealed no documentation of Resident #1 exit seeking or stating he wanted to leave prior to his elopement. Residents Affected - Few Review of the facility's investigative timeline of events related to Resident #1 eloping from the facility revealed Resident #1 was last seen on 08/23/23 at 12:40 P.M. when the Director of Nursing opened the door to allow Resident #1 into the courtyard. On 08/23/23 at 1:30 P.M., approximately 50 minutes later, Resident #8 returned from her leave of absence with family and stated she saw Resident #1 at the local flea market. On 08/23/23 at 1:35 P.M., facility staff began to search the facility and grounds for Resident #1. On 08/23/23 at 1:40 P.M., facility staff drove to the flea market and around the surrounding area to search for Resident #1. On 08/23/23 at 2:20 P.M., the Director of Nursing contacted the local police department to report a missing person. On 08/23/23 at 2:30 P.M., all facility staff returned to the facility after being unable to locate Resident #1. At that time, the Director of Nursing attempted to contact Resident #1's emergency contacts to notify them of the elopement and they notified facility staff of potential locations where Resident #1 might go. On 08/23/23 at 2:40 P.M., facility staff drove to the locations provided by Resident #1's sister to search for him and also searched local restaurants, bars, and gas stations in the surrounding areas. On 08/23/23 at 3:30 P.M., facility staff went to all the local hospitals and bus stations. On 08/23/23 at 5:00 P.M., the Director of Nursing spoke with Resident #1's sister again and she provided additional locations he might have gone to. On 08/23/23 at 5:40 P.M., facility staff searched the additional locations provided by Resident #1's sister with no luck. On 08/23/23 at 9:30 P.M., all facility staff returned to the facility and the search was called off at that time. On 08/24/23 at 8:30 A.M., the facility Administrator followed up with the local police department and bus stations. On 08/24/23 at 9:00 A.M., the facility department heads met to strategize a game plan for the continued search. On 08/24/23 at 10:00 A.M., the facility department heads began searching again. On 08/24/23 at 10:15 A.M., Resident #1's sister provided another potential location for staff to search. On 08/24/23 at 10:40 A.M., facility staff went to the local police department and spoke with deputies about Resident #1's potential whereabouts and officers provided facility staff with Resident #1's last known address. On 08/24/23 at 11:25 A.M., facility staff stopped at a local gas station and employees there indicated Resident #1 had been there approximately 25 minutes prior. On 08/24/23 at 11:30 A.M., all facility department heads drove to the area around the gas station to assist in the search. On 08/24/23 at 12:30 P.M., Resident #1 was located at his previous residence. On 08/24/23 at 1:00 P.M., Resident #1 returned to the facility with facility staff, a head to toe assessment was completed, his mood and behavior was evaluated, and Resident #1 said he wanted to go back to his apartment. On 08/24/23 at 2:00 P.M., the facility's Medical Director arrived at the facility, assessed Resident #1, and wrote the discharge order. Resident #1 was discharged with family at that time. Interview on 08/28/23 at 9:12 A.M. with the Administrator stated Resident #1 failed to sign himself out of the facility or notify any staff that he was leaving on 08/23/23, which prompted the facility to begin their elopement protocols. Observations on 08/28/23 from 9:25 A.M. to 4:58 P.M. revealed multiple residents were using the keypad to go out to the courtyard unassisted by facility staff. Interview on 08/28/23 at 10:05 A.M. with the Administrator stated the courtyard was enclosed with a fence. She also stated the gate in the courtyard, which lead to the parking lot, had no lock on it for fire safety reasons. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365831 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 365831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505 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 Observation on 08/28/23 at 12:44 P.M. of the courtyard revealed the gate leading to the parking lot had no lock on it. Interview on 08/28/23 at 3:10 P.M. with the Administrator stated facility staff had tasks to complete and could not keep every resident in sight at all times. Residents Affected - Few Interview on 08/28/23 at 3:36 P.M. with the Director of Nursing (DON) stated she let Resident #1 into the courtyard on 08/23/23 and then walked away. She stated another resident informed her that Resident #1 was seen at the local flea market and when she went to check the courtyard Resident #1 was not there. The DON verified Resident #1 exited the courtyard through the unlocked gate. She said Resident #1 did not require around the clock supervision and he went out to the courtyard all the time to sit in the sun. Interview on 08/28/23 at 4:48 P.M. with Transportation Staff #102 stated Resident #1 had opened the unlocked courtyard gate on a previous occasion and looked around before closing the gate back. Review of facility policy titled Missing Resident, dated 09/03/19, revealed if it was discovered a resident was missing, a facility wide search would be conducted. If the resident was not located in the facility, the Administrator and Director of Nursing would be notified. If the resident still was not located after a thorough sweep of the facility, perimeter, and immediate surrounding area, the local police department would be notified and the police would take over the investigation. When the resident returned to the facility, they would be assessed for injury. A timeline of events would be maintained to use for QAPI investigation to include the root cause of the incident and corrective actions. Review of facility policy titled, Elopement Prevention, not dated, revealed residents would be assessed for elopement risk on admission, routinely, and upon a significant change in condition. If a resident was identified as at-risk for elopement, an individualized care plan would be implemented to prevent elopement. The resident's picture and pertinent information would be placed in the elopement binder. Wandering or exit seeking behaviors would be documented in the medical record. When a departing resident returned to the facility, they would be assessed for injury and the incident would be documented in their medical record. Staff would follow the protocols outlined in the missing persons policy for any resident discovered to be missing from the facility. This deficiency represents non-compliance investigated under Complaint Number OH00145848. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365831 If continuation sheet Page 3 of 3