Health inspection·January 10, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Immediate jeopardy to resident health or safety THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on record review, staff interview, review of hospital records, review of camera footage, review of the facility's investigation, observations, review of Weather Underground computerized environmental temperatures website, review of Google Maps, and review of the facility's Guideline for Elopement/Missing Resident policy, the facility failed to follow their policy for responding to door alarms and checking residents after the sounding of a door alarm, to prevent the elopement of a cognitively impaired resident, with a history of attempted elopement and who was assessed to be at risk for elopement from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening injuries, negative health outcomes and/or death, when Resident #11 left the facility through an alarmed door, without staff knowledge, and was found by staff in the Emergency Department (ED) of a local hospital, approximately one-half mile from the facility and across a four-lane road with a speed limit of 35 miles-per-hour, after being brought to the ED by an unknown community member. This affected one (#11) of five (#11, #12, #13, #14, #15) residents reviewed for exit seeking behaviors from the facility. The facility identified five residents with a history of exit seeking, and 15 residents at risk for elopement. The facility census was 52. On 01/08/24 at 1:38 P.M., the Executive Director, the Director of Health Services (DHS), and the Clinical Campus Support Registered Nurse (CCSRN) #500 were notified Immediate Jeopardy began on 12/26/23 at approximately 12:56 P.M. when Resident #11 walked out of the north door of the secured unit causing the door alarm to activate, alerting staff a resident may have exited the building. At 12:57 P.M., Certified Resident Care Associate (CRCA) #101 responded to the door alarm and silenced the alarm without opening the door to check outside, and without conducting a headcount of residents on the secured unit; therefore, not following the facility procedure for responding to an activated door alarm. The facility was unaware Resident #11 was missing until approximately 2:44 P.M. when staff determined that the resident sleeping in Resident #11's bed was not Resident #11. Resident #11 was subsequently discovered approximately two hours and 20 minutes later, at 3:16 P.M. by facility staff at the Emergency Department of a local hospital with abrasions to his left hand, right forehead and left knee. The Immediate Jeopardy was removed, and the deficiency corrected on 12/27/23 when the facility implemented the following corrective actions: • On 12/26/23 at 3:25 P.M., the DHS began educating all staff on the facility elopement and missing (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 5 Event ID: 366221 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 366221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springview Manor 883 West Spring Street Lima, OH 45805 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)