Health inspection·January 9, 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 closed medical record review, staff interview and review of a fall investigation, the facility failed to provide appropriate monitoring during personal care to prevent a fall. This affected one (#114) of three residents reviewed for falls. The facility census was 161. Findings Include: Review of Resident #114's medical record revealed an admission date of [DATE]. Diagnoses included encephalopathy, chronic kidney disease, and unspecified dementia. Resident #114 was admitted to hospice on [DATE] and expired in the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #114 was severely cognitively impaired, was dependent on staff for toileting assistance, and needed substantial assistance with turning in bed. Review of a plan of care focus area, revised [DATE], revealed Resident #114 had an activities of daily living (ADLs) self-performance deficit related to impaired mobility. Interventions included extensive one to two person staff assistance with bed mobility. Review of a fall risk assessment, dated [DATE], revealed Resident #114 was at high risk for falls. Review of a progress note, dated [DATE], revealed Resident #114 fell during personal care when a nurse aide left to get a towel and came back to see the resident sliding off the bed. Resident #114 was noted to have hit his head and had a small abrasion above the eye with slight swelling and no bleeding. Hospice was notified. Follow-up vital signs and neurological assessments revealed no further injury. Review of the fall investigation revealed a written statement, dated [DATE], by State Tested Nursing Aide (STNA) #601. The statement indicated STNA #601 was changing Resident #114, left to get more towels, returned and began to wet the towels, then heard a noise and saw Resident #114 was falling. STNA #114 tried to catch the resident but he was too heavy and slid to the floor. Further review of the investigation revealed the intervention noted was to educate staff to bring all supplies before entering rooms and to lay residents flat before leaving their side. Interview on [DATE] at 11:03 A.M. with Licensed Practical Nurse (LPN) #502 revealed she was involved with the investigation and follow-up to Resident #114's fall. LPN #502 stated STNA #601 begun providing incontinence care and left Resident #114 on his side to retrieve more supplies, and when she returned he was seen sliding from the bed. She confirmed staff was not to leave residents alone on their side when giving care and the aide should have rung for assistance or returned him to a supine position before leaving. LPN #502 stated STNA #601 was reeducated following the event. Interview on [DATE] at 2:05 P.M. with STNA #601 confirmed she was the aide giving care when Resident #114 fell. STNA #601 stated she lowered the bed during care and left the room to get more towels. While wetting a towel in the sink, STNA #601 stated she hear Resident #114 shout and found him hanging on to the railing with his legs out of the bed. STNA #601 stated she tried to catch the resident's lets legs but he was too heavy and she assisted him to slide out of the bed. STNA #601 denied (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 2 of 3 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 365046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, 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)

F 0689 leaving Resident #114 on his side, but acknowledged he was close to the edge of the bed. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Master Complaint Number OH00149666. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365046 If continuation sheet Page 3 of 3