Health inspection·November 14, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 medical record review, staff interview, review of the police reports, review of the facility Self-Reported Incidents (SRI), review of the website www.accuweather.com, review of the incident/accident log, review of the hospital discharge record, review of the incident report, review of the staff witness statements, and policy review, the facility failed to provide adequate interventions and/or supervision to prevent a cognitively impaired resident (Resident #10), who was assessed at risk for elopement, from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on [DATE] when Resident #10 eloped from the facility and the resident was found by the police 0.5 miles from the facility. Additionally, Resident #10 eloped from the facility a second time on [DATE] and was missing for over 17 hours and was eventually found by the police sitting in the middle of an intersection of a residential street with a speed limit of 25 miles per hour and a low overnight temperature of 46 degrees Fahrenheit (F). This affected one (Resident #10) of three (#10, #74, #85) residents reviewed of a total of six (#10, #74, #85, #88, #98, and #99) residents identified by the facility at risk for elopement. The facility census was 106. On [DATE] at 1:04 P.M., the Administrator, Regional Director of Operations (RDO) #7777, Regional Registered Nurse (RRN) #1021, and Director of Nursing (DON) #525 were notified Immediate Jeopardy began on [DATE] at 6:50 A.M. when facility staff were notified Resident #10, who was assessed at risk for wandering and elopement and had documented intermittent confusion and impaired decision-making abilities. On [DATE] at 6:50 A.M. the police were dispatched for a confused elderly man, and Resident #10 was found 0.5 miles aware from the facility. The facility was not aware Resident #10 had eloped from the facility until they were contacted by the police. Additionally, the Immediate Jeopardy continued when Resident #10 eloped from the facility a second time on [DATE] at approximately 5:59 P.M., when staff failed to complete the ordered 15-minute checks and were unaware he was missing until 8:15 P.M. Resident #10 was found on [DATE] at 11:35 A.M., when the police were dispatched for an elderly man with dementia using a walker approximately 2.6 miles from the facility. He was found 17 hours later, sitting in the intersection of two roads that had speed limits of 25 miles per hour. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was verified as corrected on [DATE] when the facility implemented the following corrective actions: -On [DATE] at approximately 7:45 P.M., Resident #10 was not in his room, and it was determined that he was last seen between 5:30 P.M. and 6:00 P.M. on [DATE]. The facility immediately initiated a search for Resident #10. -On [DATE] at approximately 8:00 P.M., the facility initiated a head count, and all residents were accounted for except for Resident #10. -On [DATE] at approximately 8:30 P.M., the facility administrator notified the Upper Arlington Police of Resident #10's absence. -On [DATE], the Upper Arlington Police requested assistance from the City of [NAME] Page 1 of 7 365950 365950 11/14/2025 Sapphire Rehabilitation and Care Center 1605 Northwest Professional Plaza Columbus, OH 43220

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Police Department who had access to a [NAME] with Thermal capabilities. -On [DATE], the Ohio Bureau of Criminal Investigations was contacted and at approximately 9:52 P.M., a silver alert was completed and sent out statewide. -On [DATE] around 10:30 P.M., the Hocking County Sheriff's Office was notified and assisted with the search for Resident #10. -On [DATE] at approximately 9:30 A.M., the facility Administrator, RDO #7777, RRN #1021, Regional Clinical Manager (RCM) #4728, Unit Manager #333 and DON #525 conducted an AD HOC Quality Assurance and Performance Improvement (QAPI) meeting. -On [DATE], Resident #10 was found at approximately 11:35 A.M. approximately 2.5 miles from the facility. The Upper Arlington Police along with the emergency medical services (EMS) responded and transported Resident #10 to Riverside Methodist Hospital for an evaluation. -On [DATE], RCM #4728 and RDO #7777 reviewed and updated the facility elopement policy. The facility updated the policy to reflect clearer definitions on elopement, more concise instructions to staff on reporting elopement, investigation procedures, and notification to appropriate agencies and medical staff. -On [DATE] at approximately 2:00 P.M., Resident #10's care plan was updated by the facility DON #525 to reflect resident now resides on the secured unit. -On [DATE] at approximately 2:00 P.M., the facility staff completed a whole house head count as part of the facility's daily audits of residents. All residents were accounted for. -On [DATE] at 2:30 P.M., Resident #10 returned to the facility and was immediately placed on the facility secured unit. -On [DATE] at approximately 3:11 P.M., Resident #10 was assessed by the facility nurse with no significant injuries. The assessment revealed two open areas on the right foot assessed as abrasions. -On [DATE], a whole house audit of all residents was completed to ensure all residents were accurately assessed for elopement risk and no new residents were identified as being high risk for elopement. All residents who were previously identified as being high risks had their care plans reviewed for accuracy and no inaccuracies were found. -On [DATE], facility Unit Manager #333 initiated education on the facility elopement policy which included one facility Registered Nurse (RN), four Licensed Practical Nurses (LPN), and two Certified Nursing Assistants (CNA). -On [DATE], the facility continued education for all staff on the facility elopement policy. Five LPNs, two CNAs were educated in person by facility Unit Manager #333. DON #525 and the Administrator were educated on the facility Elopement Policy by RDO #7777. Medical Director #23 and Certified Nurse Practitioner (CNP) #1002 were educated on the Elopement Policy via the telephone by RDO #7777. -On [DATE], 16 LPN's, 30 CNA's, three Activity Employees, eight Housekeepers, 10 Dietary Staff, four Office Staff, 21 Therapists, five Speech Therapists, and one Maintenance Director were educated on the facility Elopement Policy via the telephone by Human Resources Director #1234. -On [DATE], two RNs, 11 LPNs, 27 CNAs, three Dietary Staff, four Housekeeping Staff, two Office Staff, seven Therapists, and one Maintenance Staff were educated in person by the Administrator and Human Resources Director #1234 on the facility Elopement Policy. -On [DATE] by 12:00 P.M., RRN #1021 and DON #525 reviewed all residents (#10, #74, #85, #88, #98, and #99) who were assessed as a high risk for elopement and had their care plans reviewed for accuracy and updated as necessary. No inaccuracies were found. -On [DATE], RRN #1021 checked the facility elopement binders and verified they reflected the status of the residents in the facility. No changes were identified. -On [DATE], RRN #1021 reviewed the Brief Interview for Mental Status (BIMS) for Residents #10, #74, #85, #88, #98, and #99, who were deemed at high risk for elopement, to ensure the assessments were accurate. There were no changes made to the resident's assessments. -On [DATE], the facility Clinical Managers Unit Manger #272, Minimum Data Set (MDS) #396, DON #525 and RRN #1021 completed a second check of all Elopement Risk Assessments and Elopement Care Plans for Accuracy. -On [DATE], one LPN, one CNA and one Office Staff member were educated on the facility Elopement Policy by the Administrator. -No staff will be permitted to work at the 365950 Page 2 of 7 365950 11/14/2025 Sapphire Rehabilitation and Care Center 1605 Northwest Professional Plaza Columbus, OH 43220

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few facility who have not received and reviewed the updated facility Elopement Policy. Facility education on the Elopement Policy will be ongoing. -All new hired employees will be educated on the facility Elopement Policy as part of the general orientation. -On [DATE] through [DATE], elopement drills and head counts were completed at various times/shifts. Staff knowledge and review of the drill was completed by RDO #7777 the following day. The Administrator reviewed and verified no actual elopements occurred. -On [DATE], [DATE], [DATE], [DATE], and [DATE], the facility's Interdisciplinary Team (IDT) members which included Unit Manager #272, MDS #396, DON #525, RRN #1021, Social Service (SS) #371, and the Administrator reviewed elopement care plans to ensure interventions were in place. No identified concerns were noted. -The facility will complete weekly elopement drills for eight weeks with the drills rotating between day and night shift to ensure each shift will have at least four elopement drills. Drills will be done monthly and randomly thereafter. -The facility will conduct head counts daily as part of their midnight census procedure which ensures that all residents are accounted for daily. -All new residents will be assessed by the facility nursing staff and follow up completed to ensure proper assessments and interventions are in place for residents deemed to be high risk for elopement. -On [DATE], telephone interviews with LPN #333, LPN #3000, CNA #3020, CNA/Housekeeping/Laundry Aid #3030, RN #3010, Human Resources Director #1234, the DON #525, and the LNHA verified they all had received education on the policies/procedures for elopement. All staff had knowledge of how to respond to an elopement situation. Staff reported there had been no elopements since [DATE]. The LNHA verified he had continued on-going training/education/drills for all staff on elopement policies/procedures. -On [DATE], review of the audits dated [DATE], [DATE], and [DATE] revealed elopement drills were completed successfully and on-going monitoring continued. -The facility denied any further elopements since [DATE] up until exit on [DATE]. Findings Include: Review of the medical record revealed Resident #10 admitted to the facility on [DATE] with an immediate transfer to the emergency room due to low blood sugar. Resident #10 was readmitted to the facility on [DATE] to a non-secured room. Diagnoses included complete traumatic amputation at knee level, lower left leg, chronic systolic heart failure, chronic kidney disease, Type 2 diabetes mellitus, and cerebral infarction. Review of the discharge paperwork from Riverside Ohio Health Hospital dated [DATE] revealed Resident #10 had a nontraumatic intracranial hemorrhage, large left infarct with associated edema and mild mass effect with associated hemorrhagic transformation as well as acute metabolic encephalopathy secondary to recent stroke, hypoglycemia, and hospital-acquired delirium. It also revealed during this resident's hospital stay, he was noted to be oriented to person and year but with tangential and intermittent confusion, similar to recent hospitalization dated [DATE]. Review of Resident #10's admission elopement risk, dated [DATE], revealed a score of a 10.0 indicating a high risk of elopement. The assessment also revealed this resident to be disoriented at times, has had reported episodes of wandering, and the number of reported elopements attempted in the past six months was two. Resident #10's family/responsible party voiced concerns indicating the resident may have wandering tendencies or try to leave. Review of the plan of care initiated on [DATE] for Resident #10 revealed no interventions for elopement risk. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 09 which suggested moderate cognitive impairment. The resident required no assistance with bed mobility and transfers. Review of the physician assessment completed by Medical Doctor #694 dated [DATE] revealed Resident #10 was alert and oriented times two; documented thinks he was supposed to be teaching at a vocational school. Review of the skilled nursing assessment for day shift dated [DATE] at 5:26 P.M. revealed Resident #10 was alert and oriented to person, time and situation but not to place. Review of the skilled nursing 365950 Page 3 of 7 365950 11/14/2025 Sapphire Rehabilitation and Care Center 1605 Northwest Professional Plaza Columbus, OH 43220

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few assessment for day shift dated [DATE] at 7:06 P.M. revealed Resident #10 was alert and oriented to person, place, and time, but unable to determine situation with impaired decision-making ability, and confusion. Review of the medical record for Resident #10 revealed the cognitive awareness assessment was not completed on [DATE]. Review of the police report dated [DATE] at 6:50 A.M. revealed a caller was walking her dog near her house located approximately 0.5miles away from the facility and advised there was an elderly male who was in the cold and confused, so she brought him into her house. On [DATE] at 7:23 A.M., the police called the facility to see if he was a resident there. On [DATE] at 7:24 A.M. it was verified he was a resident at the facility. On [DATE] at 7:30 A.M. Resident #10 was returned to the facility. Review of the past weather on www.accuweather.com revealed on [DATE] and timed from 2:00 A.M. through 7:00 A.M., revealed the temperature ranged from 63 degrees Fahrenheit (F) to the low of 57 degrees F at 6:40 A.M. Review of the incident report classified as other dated [DATE] at 7:00 A.M. by former DON #400 revealed Resident #10 was assessed as confused, had impaired memory, was an active exit seeker, and wandered. At approximately 7:00 A.M., the nursing staff noted he was absent from his room. Resident #10 was last seen by staff at approximately 2:00 A.M., fully dressed with his shoes on. There was no description in the incident of what clothing the resident had on when he returned to the facility. The resident was found approximately three blocks from the building and was returned to the facility by law enforcement. The resident was assessed and found without injuries. The resident representative and the on-call physician were notified. Resident #10 was placed on one-to-one supervision. Review of a progress note dated [DATE] at 7:32 A.M., entered by former DON #400, revealed Resident #10 exited the facility to take the trash out, and was returned to his room by staff. Assessment completed with no new findings. The responsible party and the on-call provider were notified. Will continue to monitor. Review of the physician orders dated [DATE] for Resident #10 revealed no one-to-one was ordered for resident safety after his elopement on [DATE]. Review of the medical record dated [DATE] for Resident #10 revealed no cognitive awareness evaluation was completed upon his return to the facility, and the resident was returned to the non-secured unit. Review of the elopement risk assessment dated [DATE] revealed Resident #10 scored a 17.0 which indicated he was at high risk for elopement. The assessment revealed the resident was disoriented at times and had attempted to leave or had successfully eloped. Review of the Self-Reported Incidents (SRIs) revealed there was no SRI submitted related to Resident #10's elopement on [DATE]. Review of the plan of care dated from [DATE] through [DATE] revealed Resident #10 had no interventions regarding elopement risk and elopement. Review of the nursing skilled assessment for night shift dated [DATE] at 11:09 P.M. revealed Resident #10 was alert and oriented to person, time and situation, but unable to determine place with delusions. Review of the skilled nursing assessment for night shift dated [DATE] at 11:03 P.M. revealed Resident #10 was alert and oriented to person, place and situation but unable to determine time. Review of the progress note dated [DATE] at 2:03 P.M. written by SS #371 revealed Resident #10 came to her office and expressed being unhappy about not being able to go home and see his dog. SS #371 noted that it was not an appropriate time to go home and get his truck; and his dog was brought in every other day to the facility. Resident #10 was pleasantly confused and rambling from one topic to another. Review of the skilled nursing assessment for day shift dated [DATE] at 6:35 P.M. revealed Resident #10 was alert to person only. Not oriented to place, time and situation and noted to have short-term memory impairment, impaired decision-making ability, and was confused. Review of the physician order dated [DATE] at 6:39 P.M. revealed Resident #10 was started on 15-minute checks every shift. Review of the skilled nursing assessment for day shift dated [DATE] at 2:35 P.M. revealed Resident #10 was alert to person and situation only. Not alert to place and 365950 Page 4 of 7 365950 11/14/2025 Sapphire Rehabilitation and Care Center 1605 Northwest Professional Plaza Columbus, OH 43220

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few time. Review of the elopement risk assessment dated [DATE] at 9:30 P.M. revealed Resident #10 scored 14.0 which indicated he was at high risk. The resident was also assessed as disoriented at times, had attempted to leave or successfully eloped, had two reported elopement attempts in the past six months and had expressed the desire to go home , pack belongings, or lingered near exits. Review of the nursing progress note dated [DATE] at 11:25 P.M. revealed Resident #10 displayed agitation, aggression, and attempted to leave out the back door of his room numerous times. The resident was redirected back into his room. Resident #10 slammed a chair against the door on numerous occasions displaying anger and aggression. The on-call Certified Nurse Practitioner (CNP) #1111 was notified and an order for one-to-one supervision was obtained. Review of the care plan initiated [DATE] revealed Resident #10 was at high risk for elopement related to cognitive impairment. Interventions included frequent 15-minute checks and observe/record/report to medical doctor risk factors for potential elopement. Review of CNP #1002's physical assessment dated [DATE] revealed Resident #10 was becoming more agitated and aggressive towards staff. He was confused but understood what was going on around him and had poor insight into why he was at the facility. The assessment indicated the resident had moderate impaired cognition and a plan was initiated for 15-minute checks. A trial of Depakote (can be used as a mood stabilizing medication) and Haldol (an antipsychotic medication) as needed was noted and the one-to-one supervision order was discontinued. Review of the progress note dated [DATE] at 11:47 A.M. by RRN #1021 revealed the IDT reviewed the elopement/wandering episode, Resident #10 was immediately placed on one-to-one supervision following the incident. CNP #1002 was aware and reduced monitoring to 15-minute checks. Review of the skilled nursing assessment for night shift dated [DATE] at 11:31 P.M. revealed Resident #10 was alert to person and situation only. The resident was not alert to place and time, had impaired decision-making ability, confusion, and delusions. Review of the medical record from [DATE] through [DATE] revealed no documentation of 15-minute checks for Resident #10. Review of the progress note dated [DATE] at 7:45 P.M. by RRN #1021 revealed Unit Manager #333 was notified by the nursing staff that Resident #10 was not in his room at shift change when rounds were completed. Review of the Upper Arlington police report dated [DATE] at 8:41 P.M. revealed Resident #10 was reported missing from the facility by the Administrator. The police were dispatched to the area to search for the resident. The facility staff notified the responding officers Resident #10 was last seen on [DATE] at 5:20 P.M. for his medication. The resident was scheduled for 15-minute checks, but there was no documented evidence these checks were completed. The facility grounds were searched; the resident was declared missing and placed in the Law Enforcement Automated Data System (LEADS). The video surveillance was obtained and revealed Resident #10 exited the facility out of the front entrance at 5:59 P.M. and headed north bound. Resident #10's Power of Attorney (POA) was called and notified. When asked about dementia or cognitive concerns, the POA stated he is sometimes delusional, but did not have an actual diagnosis. She added Resident #10 has had a decline in his cognitive abilities lately. According to the POA, Resident #10 also expressed wanting to go back home and stated he would walk 15 hours back to Laurelville. The POA allowed the officers to come to her house and do a search for the resident with no success. The Hocking County sheriffs were notified, and the property was checked with no success. It was made known that Resident #10 had walked out of the facility before on [DATE] and was returned by the police, so thermal [NAME] were used to search for the resident. On [DATE] at 11:35 A.M., a Community Member #4444 called in to report she was drinking coffee and observed an elderly man sitting in the street. She spoke with the man and thought he had dementia and called in. When an officer arrived, Resident #10 was sitting at the intersection of Stoneygate Lane and Stonehenge Court (2.6 miles away) with his walker. The resident was transported 365950 Page 5 of 7 365950 11/14/2025 Sapphire Rehabilitation and Care Center 1605 Northwest Professional Plaza Columbus, OH 43220

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to Riverside Hospital for evaluation, and all parties were notified. Review of the past weather on www.accuweather.com revealed on [DATE] at 5:59 P.M., through [DATE] at 9:00 A.M., revealed the temperature ranged from 46 degrees F in the evening, night, and early morning hours to 64 degrees F. Review of the statement obtained by CNA #777 who cared for Resident #10 when he eloped revealed she last saw him on [DATE] around 5:45 P.M. when she brought him his dinner tray and he was sitting on his bed. Review of the statement obtained by Licensed Vocational Nurse #424 who cared for Resident #10 when he eloped revealed her last round on the resident was on [DATE] between 5:30 P.M. and 6:00 P.M. Resident #10 was sitting up in his room in his chair finishing dinner. Review of the progress note dated [DATE] at 3:06 P.M. revealed Resident #10 had open areas on the second and third digits of his right foot without noted pain or discomfort. Review of the physician order dated [DATE] by RRN #1021 revealed Resident #10 was ordered on a secured unit related to mood disorder and poor safety awareness. Review of the skin assessment completed by the wound CNP #4217 dated [DATE] revealed Resident #10 had three wound abrasions noted to the right foot: the second digit had an area that measured 0.4 centimeters (cm) by 0.4 cm by an undetermined depth, the third digit had an area that measured 1.5 cm by 1.5 cm by an undetermined depth, and the fourth digit had an area that measured 0.4 cm by 0.4 cm by an undetermined depth. Review of the facility SRIs revealed there was no SRI submitted related to Resident #10's elopement on [DATE]. Review of the facility incident/accident log from [DATE] through [DATE] revealed Resident #10's elopements on [DATE] and [DATE] were not documented. Interview on [DATE] at 12:43 P.M., RRN #1021 verified Resident #10 eloped from the facility on [DATE]. A follow-up interview on [DATE] at 11:25 A.M., RRN #1021 revealed Resident #10 had left the faciity on [DATE] as well but was not considered an elopement since he does have cognitive intact moments. An incident report was created, but no safety measures were put into place even after the event when the resident was still assessed as high risk for elopement. RRN #1021 verified on admission to the facility on [DATE] Resident #10's elopement risk was high, and no care plan and/or care interventions were in place for his safety until [DATE] and the resident had documented cognitive impairments with memory, judgement, and with his assessment which indicated he was at a high risk for elopement. A follow-up interview on [DATE] at 2:15 P.M. RRN #1021 verified Resident #10 was on 15-minute checks since [DATE], but there was no documentation of the checks in the medical record. Interview on [DATE] at 2:32 P.M., the POA revealed Resident #10 was starting to get more confused since he had been admitted to the facility and indicated to the facility, he was at risk for leaving the facility as he had a history of that. Interview on [DATE] at 1:01 P.M., CNA #777 revealed she cared for Resident #10 on the evening of [DATE]. Around 5:30 P.M., he was in bed, and she placed his tray on his bedside table and had not checked on him until rounds and shift change around 7:00 P.M. She thought the nurse on duty was checking on him every 15 minutes for the remainder of the shift and she verified she had not documented her 15-minute checks anywhere in his record. For the checks, it was a verbal exchange between the CNA and the nurse to let each other know when they checked on the resident. Interview on [DATE] at 1:43 P.M. the Administrator verified no notification and/or self-reported incident (SRI) was sent to the Ohio Department of Health for Resident #10's elopement on [DATE]. Multiple attempts to interview former DON #400 and Community Member #4444 were unsuccessful. Review of the facility policy titled Elopement and Missing Resident Policy (undated) revealed it is the policy of this facility to provide a safe and secure environment for all residents. Staff will take proactive measures to prevent elopement. Prevention includes assessment for risk of elopement and develop an individualized care plan. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 03/2024 revealed residents have the right to be free from 365950 Page 6 of 7 365950 11/14/2025 Sapphire Rehabilitation and Care Center 1605 Northwest Professional Plaza Columbus, OH 43220

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few abuse, neglect, exploitation, and misappropriation of resident property. Neglect is the failure of the facility, its employees, or facility service providers to provide good and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health in accordance with the procedures of this policy. Initial reporting involving neglect, exploitation, mistreatment, misappropriation of resident property and injuries of unknown sources will be reported to the Ohio Department of Health immediately, but in no event later than 24 hours from the time the incident/allegation was made known. This deficiency represents non-compliance investigated under Master Complaint Number OH002642701. 365950 Page 7 of 7