Health inspection·July 3, 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 medical record review, staff interview, and policy review, the facility failed to prevent elopement. This affected one (Resident #24) of three reviewed for elopement. The facility census was 48. Findings include: Review of the medical record of Resident #24 revealed an admission date of 02/01/24. Diagnoses included Wernicke's encephalopathy and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively impaired and required maximal assistance with activities of daily living. Review of the Wander Risk Evaluation dated 02/02/24 revealed Resident #24 was at a risk for wandering. The form did not indicate any interventions to be care planned. Review of the admission Nursing Evaluation dated 02/02/24 revealed Resident #24 was alert, confused, and oriented to name only. The form indicated Resident #24 experienced hallucinations, delusions, and resists care. Review of the care plan revealed an entry dated 03/20/24 indicating Resident #24 was at risk for elopement related to impaired cognition, wandering, attempting to leave the facility requiring a one on one (1:1) sitter. The goal was for Resident #24 to not leave the building without a staff member, family member, or other approved person. Interventions included observe for signs that Resident #24 may be planning on leaving the facility such as wearing a coat or jacket, carrying a bag with possessions in it, or statements that he is going to leave. Intervene by asking Resident #24 if he is going somewhere, and offer alterative activities. Observe Resident #24's movements on the unit and in the facility. If resident attempts to leave the building, redirect and involve him in another activity. Review of the progress note dated 05/27/24 at 4:30 P.M., written by Registered Nurse (RN) #101, revealed Resident #24 eloped out of the facility in his wheelchair through the 100 hallway door. This occurred approximately 10 minutes after he received his evening medications. The staff were alerted because the alarm went off. Resident #24 was seen outside sitting in his wheelchair in front of the facility. He was returned to his room and education was provided. Resident #24 did not understand why he should not leave the facility. The Director of Nursing (DON) was notified and the management team was working on transferring Resident #24 to a sister facility. (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 3 Event ID: 366302 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 366302 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Shiloh Springs 3500 Shiloh Springs Road Trotwood, OH 45426 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)