Health inspection·November 22, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of the facility investigation, and interviews with staff, the facility failed to ensure Resident #41 was free from accident hazards. Actual harm occurred on 10/16/23 when Resident #41, who was cognitively impaired, at risk for falls, and dependent on two staff for bed mobility, fell out of bed while State Tested Nursing Assistant (STNA) #112 was providing incontinence care by himself. Resident #41 sustained a fracture to the right hip and hematoma to the back of her head. Resident #41 was transferred to the hospital and received surgical intervention to her right hip. This affected one resident (Resident #41) of three residents reviewed for accident hazards. The facility census was 57. Findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Resident #41's list of diagnoses included diabetes, diabetic polyneuropathy, protein-calorie malnutrition, intertrochanteric fracture of the right femur, atrial fibrillation, dysphagia, contusion to the scalp, psychotic disorders, major depressive disorder, mood disorder, anxiety disorder, malignant neoplasm of the skin, osteoarthritis, hypothyroidism, kidney disease, and glaucoma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had severely impaired cognition and had delusions. She had physical symptoms such as hitting or scratching herself and screaming daily. She required total assistance from two staff members for bed mobility and transfers. Review of the plan of care dated 03/17/23 revealed Resident #41 was at risk for falls and fall related injuries related to dementia with behaviors, visual impairment, psychosis, osteoarthritis, anxiety, mood disorders, depression, abnormalities of gait and mobility, lack of coordination, muscle weakness, decreased sensation, physical debility, impaired cognition, incontinence, medication use, and poor safety awareness. Interventions included assist resident with wheelchair or walker for mobility as needed, assist with wearing proper footwear, assist with toileting needs and incontinence care, keep call light within reach, and non-skid gripper socks when not wearing shoes. On 10/07/23 the plan of care was revised to include mat to the floor and revised again on 10/16/23 to include two persons to assist for bed mobility and transfers. Review of the physician orders revealed Resident #41 had an order for bilateral grab bars dated 10/24/22, padding added to the bilateral grab bars for altered skin integrity dated 07/28/23, and her bed to be in the lowest position when not providing direct care dated 10/07/23. Page 1 of 4 365342 365342 11/22/2023 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0689 Level of Harm - Actual harm Residents Affected - Few Further review of Resident #41's medical record revealed the State Tested Nursing Assistant (STNA) task documentation for October 2023 indicated the staff were using total or extensive assistance of two staff members for all bed mobility for Resident #41. Review of an incident note dated 10/16/23 at 1:00 A.M. revealed the nursing assistant (STNA #112) was assisting Resident #41 during care when the resident became combative and rolled out of bed. Resident #41 was assessed and noted to have a golf ball size fluid filled hematoma to back of her head. Resident #41 was complaining of right hip pain, her pupils were equal and reactive to light. Two-person assistance with bed mobility and transfer was listed as a potential new intervention. Resident #41 was sent to the emergency room for evaluation. Review of the hospital emergency room radiology report dated 10/16/23 at 3:33 A.M. revealed Resident #41 had an acute, displaced intertrochanteric right femur fracture and a right scalp hematoma with no fracture. Review of health status reports dated 10/16/23 at 8:10 A.M. and 10/16/23 at 11:11 A.M. revealed Resident #41 returned to the facility with no surgical intervention. Resident #41's physician was on the unit, the son was at the bedside and the son wanted Resident #41 to be sent to another hospital for another evaluation of the fracture and the physician agreed. Review of the second hospital emergency room report dated 10/16/23 revealed Resident #41 had been seen at another hospital the same day, diagnosed with right hip fracture, was sent back to the facility then the family requested she be sent back to another hospital. Resident #41 was in no distress, appeared comfortable, was alert to person and had an internally rotated right hip with mild angulation but not displaced and no skull fractures or brain bleed. Resident #41 would be cleared for surgery for the hip fracture. Review of a psychosocial note dated 10/17/23 at 11:00 A.M. revealed Resident #41 was still at the hospital and would be having surgery for her fractured hip. Review of the progress note dated 10/22/23 revealed Resident #41 returned to the facility with post-surgical aftercare orders following hip repair surgery. Review of the facility's fall investigation dated 10/16/23 revealed Resident #41 fell out of bed during care being provided by STNA #112. Review of the signed witness statement from STNA #112 dated 10/16/23 at 1:00 AM revealed he was assisting the resident with her disposable brief change and the resident reached out, scratched him, he lost his grip and she fell out of bed. Review of a second signed witness statement from STNA #112 dated 10/27/23 revealed he noticed Resident #41 had a bowel movement, so he gathered all the stuff he needed, raised the bed, lowered her head and feet in bed and removed the wedge and pillow from under her legs. STNA #112 then tucked the adult brief the resident was wearing to one side so he could pull the brief when he turned Resident #41. After telling the resident what he was about to do and turning her, he was getting ready to pull the old brief out when Resident #41 pinched and scratched the hand and arm he was using to steady her. STNA #112 reacted by letting go of her and that was when she fell out of the bed. Review of the signed witness statement from LPN #114 dated 10/16/23 revealed the nursing assistant came running down the hall stating the resident fell on the floor. LPN #114 followed him back to the room and a head-to-toe assessment was completed. Vital signs were normal, and the resident was found to have an area to the back of her head and a red area to the right hip. LPN #114 initiated 365342 Page 2 of 4 365342 11/22/2023 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0689 neurological checks while another nurse arranged transportation to the emergency room at the hospital. Level of Harm - Actual harm Review of the signed witness statement from Licensed Practical Nurse (LPN) #113 dated 10/16/23 revealed LPN #113 assessed the resident with the other nurse, the resident was having pain with palpation to the right hip, and she had redness noted to the area. She had a hematoma to the back of her head. Her range of motion (ROM) to the right hip was abnormal and she complained of pain with ROM. Residents Affected - Few On 11/21/23 at 2:24 P.M. an interview with the Director of Nursing (DON) verified STNA #112 was the aide working when Resident #41 had fallen out of bed. The DON stated STNA #112 was providing care to Resident #41, and she fell out of bed. The DON verified Resident #41 was a two person assist with turning and repositioning. On 11/21/23 at 2:40 P.M. an interview with STNA #109 revealed he had provided care to Resident #41 prior to her fall on 10/16/23 and Resident #41 required two staff members to provide care. On 11/21/23 at 2:45 P.M. an interview with STNA #110 revealed she provided care to Resident #41 prior to her fall on 10/16/23 and Resident #41 required two staff members to provide care. On 11/21/23 at 2:47 P.M. an interview with STNA #111 revealed Resident #41 required two staff members to provide incontinence care prior to her fall because she usually became combative and resisted care. STNA #111 stated she was very hard to roll with only one staff person so two staff were required, and the resident was a two person assist for transfers. On 11/21/23 at 2:53 P.M. an interview with LPN #103 revealed the nursing assistants usually used two STNAs when providing care to Resident #41 because she was difficult to turn and could become combative. On 11/21/23 at 4:00 P.M. an interview with STNA #112 verified on 10/16/23 he provided incontinence care to Resident #41 by himself, and Resident #41 rolled out of bed onto the floor. STNA #112 stated he did have another aide working with him, but she was in the other room. STNA #112 stated he was rolling Resident #41 to change her brief and she did not like to be rolled in the bed so would become combative and grab at staff. STNA #112 stated when he rolled her towards the window to pull the brief out from under her, she reached around, grabbed at his arm and hand, and scratched him. STNA #112 stated he let go of her as a reaction to being scratched and she fell out of the bed onto the floor between the bed and the wall and from a waist high position of the bed. He stated this was the first time he had ever had anyone fall out of bed and he ran out to get the nurse. On 11/22/23 at 10:15 A.M. an interview with STNA #106 revealed the STNAs have always used two staff to turn and position, provide incontinence care, and transfer Resident #41 because she was a heavy woman and had very limited mobility. STNA #106 added Resident #41 could become combative very easily with care. Review of the facility policy titled, Falls and Fall Risk Managing, date revised 05/06/2020, indicated staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. This deficiency represents non-compliance investigated under Complaint Number OH00147981. 365342 Page 3 of 4 365342 11/22/2023 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview with staff and review of the facility policy, the facility failed to implement the smoking policy to maintain a safe and clean environment free from discarded cigarette butts at the facility main entrance door. This had the potential to affect all the residents in the facility. The facility census was 57. Residents Affected - Many Findings included: Observation upon entrance to the facility on [DATE] at 8:00 A.M. revealed there were numerous (20 plus) cigarette butts on the left side of the entrance door laying in the mulch beds. On 11/21/23 at 8:30 A.M. an interview with Receptionist #102 verified the cigarette butts in the mulch by the front door, and verified there was no smoking receptacle at the main entrance to extinguish cigarettes properly. On 11/21/23 at 1:20 P.M. an interview with Maintenance Director (MD) #100 revealed there was not supposed to be anyone smoking at the entrance because it was not the designated smoking area. MD #100 explained the housekeepers were supposed to be checking outside for cigarette butts but evidently had not been checking for the cigarette butts. Review of the facility policy titled, Resident Smoking, dated 04/05/22 with a revision date of 11/20/23, revealed the facility would provide a safe and healthy environment for residents, visitors and employees including safety as related to smoking. Smoking was prohibited in all areas except the designated smoking areas. This deficiency represents non-compliance investigated under Complaint Number OH00147981. 365342 Page 4 of 4