Health inspection·January 20, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few respect her wishes. Prior to the x-ray being completed, Resident #49 agreed to go to the hospital for evaluation. Her evaluation at the hospital found she had a non displaced fracture on left metacarpal (five) and closed fracture of radius and ulna in left forearm. She was sent home with pain medication and a referral to follow up with orthopedics. There was no specific information in the progress notes as to how Resident #49 fell. Review of Resident #49 Investigation Summary related to the fall, dated 01/13/24, revealed Resident #49 was being transferred from the toilet to her shower chair by one State Tested Nursing Aide (STNA), instead of two staff as required. This was a contributing factor to her fall and injury. Observation on 01/19/24 at 11:26 A.M. of Resident #49 revealed the resident was in her recliner reading. Resident #49 had a sling to left arm and a cast to her wrist being elevated on a pillow. Interview with Resident #49 at this time revealed she fell and broke her arm as well as bumped her head. She went on to explain she went to the hospital and she had broken her wrist and hand bone. Resident #49 explained she uses two people to help move her at any time. Interview with Licensed Practical Nurse (LPN) #101 on 01/19/24 at 2:30 P.M. confirmed there was only one staff person with Resident #49 at the time of the fall. She confirmed her care plan and [NAME] (document to assist staff with the care of residents) was for Resident #49 to have two persons during all transfers. She confirmed the outcome of the investigation found that the STNA did not ask for assistance with transferring Resident #49 when she should have. Review of facility Fall Management and Incident Intervention Protocol, dated July 2022, revealed it was the policy of the facility to conduct an investigation into the potential causative factors for each resident incident, including those classified as a fall. In addition, residents will be assessed as to their risk for sustaining a fall. Interventions will be implemented and evaluated in order to decrease the incidence of resident incidents, including falls, and to minimize the risk of injury. Nurse will assess for any injury sustained as a result of the fall after occurrence. Post fall physical assessment may include vital signs, range of motion, skin assessment, assessment of pain, and mental status. All assessment findings should be documented in the clinical record. Movement of the resident from the original site and position of the fall should only take place after assessment finding reveal that it will not cause further injury to do so. Documentation of the assessment findings and initiation of treatment interventions should be completed as appropriate. The physician and family will be made aware of the incident, as soon as possible, and evidence of notification should be documented in the clinical record. Documentation will be completed on the post fall status of the resident following the incident, in the clinical record. Any new interventions will be added to the resident plan of care and will be communicated to the relevant nursing staff. All falls will be reviewed by the focus group. Members will review events of the incident, and discuss possible recommendations and alterations to resident's plan of care, including the appropriateness of PT/OT/Restorative referral. The deficient practice was corrected on 01/15/24 when the facility implemented the following corrective actions: o On 01/13/24 Resident #49, who required assistance of two people for transfers, was transferred from the toilet to a shower chair by one person, resulting in a fall. o On 01/13/24 Resident #49 agreed to go to the hospital for evaluation and her evaluation found she had a non-displaced fracture on left metacarpal (five) and closed fracture of radius and ulna in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 left forearm. She was sent home with pain medication, a referral to follow up with orthopedics, and later required orthopedic surgery. Level of Harm - Actual harm Residents Affected - Few o On 01/13/24 an Investigation Summary was completed related to the fall which revealed Resident #49 was being transferred from the toilet to her shower chair by one State Tested Nursing Aide (STNA), instead of two staff as required. The facility determined this was a contributing factor to her fall and injury. o On 01/13/24, the On-Call Nurse audited 22 staff members to ensure they had gait belts and were carrying their Kardexes, reflecting required assistance for transfers. 21 out of 22 staff members audited on 01/13/24 required follow-up, which was immediately completed. o On 01/13/24, Nurse Managers educated all STNAs and Nurses on [NAME] and gait belt use. o Starting on 01/14/24, audits were completed on four staff members to ensure gait belts and Kardexes were utilized. One staff member was reeducated on 01/14/24. Audits from 01/15/24 to 01/18/24 had no issues noted. Audits will be completed for four weeks by the Director of Nursing/Designee. o Starting on 01/14/24, audits were completed on five residents to ensure all fall prevention measures were in place as ordered. All resident audits from 01/14/24 to 01/18/24 had no issues noted. Audits will be completed for four weeks by the Director of Nursing/Designee. o The results of on-going audits will be reviewed by the Quality Assurance Performance Improvement committee to ensure compliance. This deficiency represents non-compliance identified under Complaint Number OH00150058. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 3 of 3