Health inspection·February 13, 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 record review, interview, and facility policy review the facility failed to ensure Resident #49 did not leave the facility without staff knowledge and did not ensure a safe discharge. This affected one resident (#49) of three residents reviewed for elopement. The facility census was 48. Findings include: Review of the closed medical record for Resident #49 revealed an admission date of 01/23/24 and a discharge date of 02/11/24. Diagnoses included human immunodeficiency virus (HIV), schizophrenia, depression, and dementia. He was his own responsible party. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was moderately cognitively impaired. The assessment identified the resident had no wandering behaviors. The resident required supervision for ambulation. Review of the plan of care dated 01/23/24 revealed no evidence Resident #49 was at risk for elopement. Review of the elopement risk assessment dated [DATE] revealed Resident #49 was not at risk for elopement. Review of the nurses' note dated 02/07/24 at 2:27 P.M. revealed Resident #49 was upset and wanted to go home. Review of the nurse's notes dated 02/10/24 at 5:24 P.M. revealed Resident #49 was not in his room. The facility was searched, and the resident could not be located. The residents' brother was contacted and said Resident #49 was free to leave if he chose to do so. The Director of Nursing (DON) and physician were notified. Review of the nurse's note dated 02/12/24 at 12:27 P.M. revealed Resident #49 left the facility against medical advice (AMA). Interview on 02/12/24 at 9:53 A.M. with Licensed Practical Nurse (LPN) #200 revealed the second floor was not a secured unit. She confirmed Resident #49 was ambulatory and not an elopement risk. Interview on 02/12/24 at 10:31 A.M. with Resident #49's brother confirmed he received a call from the facility on 02/10/24 at approximately 5:00 P.M. informing him the resident was missing. He (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366021 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 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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)