Health inspection·December 4, 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 NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Residents Affected - Few Based on observations, closed medical record review, review of the facility investigation and witness statements, staff interviews, review of the police incident report, review of the hospital report, review of the local weather report, and review of the facility policy addressing elopement, the facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping from the facility. This resulted in Immediate Jeopardy and subsequent serious harm and/or injuries when one resident (Resident #115) eloped from the facility without staff knowledge, was missing approximately one hour and thirty minutes and was found approximately 0.3 miles from the facility by a police officer and was taken to the hospital and admitted with a right hip fracture and hypothermia. This affected one (#115) of three residents reviewed for risk of elopement. The facility identified 35 residents at risk for elopement. The facility census was 111. On 11/20/23 at 3:53 P.M., the Administrator, Director of Nursing (DON), Corporate Director of Clinical Services (CDCS) #200, and Corporate Clinical Support Registered Nurse (CCSRN) #201 were notified Immediate Jeopardy began on 11/01/23 at 5:30 A.M. when State Tested Nursing Assistant (STNA) #305, during her morning rounds, discovered Resident #115 was missing and notified the Nurse Supervisor Licensed Practical Nurse (LPN) #279. Staff searched the facility and the facility grounds and could not locate Resident #115 and notified the local police. The resident was found in a parking lot across the street from the facility approximately 0.3 miles by a police officer. The resident was taken to the hospital for evaluation and was diagnosed with a fractured right hip and hypothermia. According to the police report the outside temperature in the area on 11/01/23 at 7:00 A.M. was 30 degrees Fahrenheit (F). The Immediate Jeopardy was removed on 11/03/23 and the deficient practice was corrected on 11/14/23 when the facility implemented the following corrective actions: On 11/01/23 at 7:03 A.M., Former Resident #115 was found by the local police approximately 0.3 miles from the facility and was transported to the hospital for evaluation and treatment by emergency medical personnel. On 11/01/23, the facility initiated a Quality Assurance Performance Improvement (QAPI) review with initial measures taken including initiating an investigation of the incident and cooperation with local law enforcement. On 11/01/23, CCSRN #201 completed an audit to confirm all resident wandering risk assessments Page 1 of 5 365889 365889 12/04/2023 Lodge Nursing & Rehab Center 9370 Union Cemetery Road Loveland, OH 45140

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few actively reflected residents' care needs for wandering risk and placement in the facility. One resident (#09) was identified with a new increased onset of wandering behaviors. Resident #09 was placed on one-to-one supervision. Resident #09's family was contacted regarding the resident's increased behaviors and initial monitoring. The Interdisciplinary Team (IDT) recommended Resident #09 be moved to the facility's secured unit. Resident #09's physician was notified, and the resident was moved to the secured unit on 11/02/23. There were no other residents identified with an increased risk for elopement. Resident #115 did not return to the facility. On 11/01/23, Maintenance Director #312 completed an audit and confirmed all doors and alarms in the facility were functioning properly. On 11/01/23, new alarms for all entrance/exit doors to the facility and doors exiting to the courtyard on the 200 and 300 units with audible and sensory lights were ordered. The nursing staff completed resident head counts every two hours until the new alarms were installed on 11/03/23. The Administrator and DON provided education to all team members including nursing, dietary, maintenance, housekeeping, activities, social services, and leadership regarding the policy for missing residents. The education was initiated on 11/01/23 at 8:00 A.M. and was completed for all staff on 11/01/23 by 5:02 P.M. The DON/Designee will continue monitoring two times a week for three additional weeks with visual observation of missing resident drills. Monitoring and any issues identified will be addressed and reviewed in the following QAPI committee. The initial QAPI review was completed on 11/01/23. The DON is responsible for ongoing compliance. Review of the audit reports revealed elopement drills were conducted on 11/03/23 at 1:20 P.M., 11/06/23 at 3:30 P.M., 11/13/23 at 3:23 P.M., 11/14/23 at 12:45 P.M. and 11/21/23 at 2:30 P.M. There were no negative findings with any of the drills. The facility will continue with monthly elopement drills. Observations on 11/20/23 between 11:50 A.M. and 12:30 P.M. revealed the alarms on the exit doors for the front and back entrance and the doors exiting to the courtyard of the 200 and 300 units of the facility were functioning properly. When activated the alarms had to be turned off by staff manually by using a key to the alarm. On 11/21/23, review of the medical records for two additional residents (#05 and #15), reviewed for elopement, revealed no concerns. Observation of Residents #05 and #15 on 11/21/23, revealed elopement interventions were in place. On 11/21/23 between 1:30 P.M. and 2:15 P.M., staff interviews were conducted with Receptionist #307, RN #302, STNA #203, Occupational Therapist #311, Director of Rehabilitation #310, Medical Records Assistant #308, and Dietary Aide #309, confirmed staff were knowledgeable about the procedures to follow if a resident eloped from the facility and the need to reassess residents for elopement risk if they had a change in condition such as increased wandering behaviors and/or exit-seeking behaviors. Findings include: Closed medical review revealed Resident #115 was admitted to the facility on [DATE] and discharged home with his daughter on 10/13/23 and was readmitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, urinary tract infection, Alzheimer's disease, wedge compression 365889 Page 2 of 5 365889 12/04/2023 Lodge Nursing & Rehab Center 9370 Union Cemetery Road Loveland, OH 45140

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few fracture of T11-T12, wedge compression fracture of the fourth lumbar vertebra, occlusion and stenosis of bilateral vertebral arteries, and chronic kidney disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #115 was cognitively impaired and required partial to moderate assistance with toileting, dressing, and transfers and locomotion and used a wheelchair and walker for mobility. Resident #115's MDS was coded for the presence of wandering behaviors. Review of the elopement risk evaluation dated 10/13/23 revealed Resident #115 propelled himself with some assistance, was alert and oriented to person, place, and time, was happy with placement, had no attempts of elopement and was a low risk for elopement. Review of the medical record for Resident #115 revealed the resident was discharged to home with family in the community on 10/13/23. Further review revealed Resident #115 was taken to the hospital by his family on 10/19/23 and was admitted and treated for a urinary tract infection and confusion and then was readmitted to the facility on [DATE]. Resident #115 was not reassessed for elopement risk upon readmission to the facility on [DATE] and no subsequent elopement risk assessments were completed for the resident. Review of the readmission physician orders for Resident #115 dated 10/21/23 revealed the orders did not include any orders for elopement prevention interventions. Review of the care plan dated 10/24/23 revealed Resident #115 was an elopement risk/wanderer as evidenced by impaired safety awareness and was noted to wander. Interventions included the following: distract resident from wandering by offering pleasant diversions, offer structured activities, food, conversation, television, document and keep family and physician aware of resident's wandering and attempts to redirect resident. Review of the nurse progress notes dated 10/25/23 at 7:14 P.M. revealed staff observed Resident #115 wandering outside in the fenced courtyard. Staff had not seen the resident exit the facility. Resident #115 was escorted back into the facility and placed back in his wheelchair and assisted back to his room. Review of the nurse progress note dated 10/26/23 at 1:34 A.M. revealed staff observed Resident #115 pushing the back door open and attempting to exit the facility. Staff provided reorientation to the resident regarding staying at the facility and seated the resident at the nurse's station for close monitoring and prevention of elopement. Review of the nurse progress note dated 11/01/23 at 5:30 A.M. per Licensed Practical Nurse (LPN) #279 revealed Resident #115 was noted to be missing at 5:30 A.M. when STNA #305 was doing rounds. Nursing staff searched the unit three times and were unable to locate Resident #115. Next all staff in the building were notified and searched the entire building and grounds and were unable to locate Resident #115. Nursing staff notified nine-one-one (911) on 11/01/23 at approximately 6:30 A.M. regarding the missing resident. Resident #115 was last seen by staff on 11/01/23 between 3:00 A.M. and 3:30 A.M. in his bed. At approximately 7:00 A.M., the police found Resident #115 across the street on the ground in a parking lot with multiple abrasions covering his body. Resident #115 was alert and answered all questions appropriately. Resident #115 was transferred to the hospital for evaluation. Resident #115's daughter was notified of the incident and verbalized understanding. 365889 Page 3 of 5 365889 12/04/2023 Lodge Nursing & Rehab Center 9370 Union Cemetery Road Loveland, OH 45140

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the police report dated 11/01/23 at 7:03 A.M. revealed Resident #115 was located by police officers lying on the ground behind a building across the street from the facility. The outside temperature was approximately 30 degrees F. Resident #115 appeared to be in distress and was not wearing shoes and was covered with cuts as if he had been going through the brush. He was transported by emergency personnel to the hospital for evaluation. Review of the hospital notes report dated 11/01/23 revealed Resident #115 arrived at the hospital at 7:29 A.M., with his active problem list and diagnoses listed as hypothermia, intertrochanteric fracture of the right hip, and multiple abrasions. Resident's body temperature upon admission to the hospital was 89 degrees F. Further review of the hospital records revealed Resident #115 required surgical intervention, a total right hip arthroplasty to repair the right hip fracture sustained during the elopement incident. Interview on 11/20/23 at 10:24 A.M. by telephone with STNA #305 confirmed she was Resident #115's assigned aide on the morning of 11/01/23 and between 3:00 A.M. and 3:30 A.M. during her rounds she observed the resident in his room sleeping. STNA #305 confirmed at approximately 5:30 A.M. during her rounds she did not see Resident #115 in his room and immediately reported the missing resident to the Nurse Supervisor, LPN #279. STNA #305 confirmed she did not hear any exit door alarms prior to or after she observed the resident was not in his room. Further interview with STNA #305 confirmed LPN #279 instructed the aide and STNA #306 to search resident rooms to include looking in closets and under beds, but they were unable to locate Resident #115. STNA #305 confirmed she then stayed on the unit to monitor the other residents in the common area while the other staff searched the facility and grounds for Resident #115. Interview on 11/20/23 at 10:40 A.M. by telephone with the night shift Nurse Supervisor LPN #279 confirmed she was Resident #115's assigned nurse on 11/01/23 when Resident #115 eloped from the facility. LPN #279 confirmed she had observed Resident #115 ambulating in the hallway of the unit the night of 10/31/23 as he normally did and was not exit seeking. LPN #279 confirmed she was alerted by STNA #305 at approximately 5:30 A.M. on the morning of 11/01/23 that Resident #115 was not in his room, and she could not locate him. LPN #279 stated she immediately instructed STNAs #305 and #306 to search the unit including closets, under the beds and residents who were still in bed because sometimes residents would go to other rooms and get in bed if the bed was empty. LPN #279 confirmed she notified other staff in the facility to search the facility and grounds. LPN #279 confirmed she did not hear any door alarms on the unit during the night of 10/31/23 or the morning of 11/01/23. Interview on 11/20/23 at 11:30 A.M. with the DON confirmed he arrived at the facility on 11/01/23 at approximately 6:40 A.M. and a police officer standing in front of the facility notified him Resident #115 had been found across the street in the parking lot. The DON confirmed he notified the Administrator, and they went to observe Resident #115 prior to his transfer to the hospital on [DATE]. The DON confirmed when they observed Resident #115, he was awake and alert and was being transferred to a stretcher. The DON stated Resident #115 was wearing anti-slip socks, a tee-shirt and sweatpants, and a gown over his tee shirt. The DON confirmed prior to 11/03/23 when the exit door alarms were changed as part of the facility's corrective action, the door alarms would chime when the door was opened and then stopped sounding immediately when the door was closed. The DON confirmed the new door alarms installed on 11/03/23 had a louder audible signal and required staff to go to the alarm with a key to silence them. All nurses were given a key to silence the alarms. The DON further confirmed all residents in the facility who have been assessed to be at risk for elopement were to be placed on the secured unit which had a separate alarm system. The DON confirmed Resident #115 had been assessed on 10/13/23 as not at risk for elopement and the facility did not complete an updated elopement 365889 Page 4 of 5 365889 12/04/2023 Lodge Nursing & Rehab Center 9370 Union Cemetery Road Loveland, OH 45140

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few risk assessment for the resident following his wandering and exit seeking behaviors on 10/25/23 and 10/26/23. Interview on 11/22/23 at 1:40 P.M. by telephone with the Administrator confirmed staff called her on 11/01/23 at 6:10 A.M. and notified her Resident #115 was missing and staff were outside looking for him. The Administrator confirmed she arrived at the facility on 11/01/23 at 6:15 A.M. and drove through the parking lot looking for Resident #115. The Administrator confirmed at 6:30 A.M. she entered the facility and instructed LPN #279 to call the police regarding missing Resident #115. The Administrator confirmed the local police notified her at 7:00 A.M. that Resident #115 had been located off the facility grounds. The Administrator confirmed she and the DON drove to see Resident #115 as emergency medical personnel were transferring resident to the ambulance and the resident was alert and responsive to questions. Further interview with the Administrator confirmed the facility was not able to determine which door Resident #115 had used when he exited the facility. Following the incident, the facility replaced all of the door chimes with louder door alarms which required a key to be silenced. The new door alarms were placed on all entrance and exit doors and doors exiting to the courtyard on the 200 and 300 units. Review of the online weather report at https://www.wunderground.com/history/daily/us/oh/[NAME]/KCVG/date/2023-11-1 revealed the air temperature on 11/01/23 at 6:00 A.M. was 32 degrees F, there was no precipitation, and the wind speed was approximately eight miles per hour. Review of the facility's policy titled, Missing Resident, reviewed 03/2021 revealed it was the facility policy to assist in alerting staff when a resident's location is unknown to enable a quick and efficient response by all staff. This deficiency represents non-compliance investigated under Complaint Number OH00148375. 365889 Page 5 of 5