Health inspection·September 25, 2025

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. Based on medical record review, staff interview, and review of the facility policy, the facility staff failed to safely and properly position a resident in bed during incontinence care in order to prevent falls. This affected one (Resident #10) of three residents reviewed for falls. The facility census was 66 residents.Findings include:Review of the medical record for Resident #10 revealed an admission date of 03/07/10 with diagnoses including dementia, depression, and cerebrovascular disease. Review of the care plan for Resident #10 dated 10/31/22 revealed the resident had a self-care deficit secondary to multiple diagnoses including Alzheimer's disease with severe cognitive impairment and aphasia. Resident #10 was dependent on staff for all areas of care. Review of the care plan for Resident #10 dated 11/16/22 revealed the resident was incontinent of bowel and bladder and staff were to check and change the resident regularly.Review of the incident note for Resident #10 dated 07/30/25 at 5:50 A.M. revealed Resident #10 fell out of bed while Certified Nursing Assistant (CNA)#35 was providing incontinence care. CNA had reached for a clean brief, and the resident fell out of bed. No injuries were noted at the time of the fall, and the resident was to have two caregivers present during incontinence care in the future. Review of the progress note for Resident #10 dated 07/30/25 at 12:26 P.M. revealed the resident had developed bruises to the left arm since the fall and the physician gave an order for x-rays which were negative. Review of a written statement regarding Resident #10's fall on 07/30/25 per CNA #35 dated 07/30/25 revealed when the aide was changing Resident #10, the resident rolled out of the bed and onto the floor. Review of a written statement regarding Resident #10's fall on 07/30/25 per Licensed Practical Nurse (LPN) #51 dated 07/30/25 revealed CNA #35 notified her that Resident #10 had fallen out of bed during peri-care. The nurse observed Resident #10 lying on the floor on her back to the left side of the bed. CNA #35 stated she laid Resident #10 on her side and while the aide was reaching for the clean brief at the end of the bed the resident rolled out of the bed and onto the floor. There were no injuries noted at the time of the fall. Review of the incident note for Resident #10 dated 07/31/25 at 12:25 P.M. revealed the Interdisciplinary Team (IDT) met to review the resident's fall on 07/30/25. CNA #35 had rolled Resident #10 onto her right side in the bed to provide incontinent care. CNA #35 stated she was grabbing for the incontinence brief at the end of the bed and trying to open it when Resident #10 rolled out of bed on to the floor on 07/30/25 at 5:50 A.M. Resident #10 had x-rays completed to left arm, bilateral hips, pelvis, and spine with no fractures. Resident #10 did sustain bruises to her left elbow and forearm. A new intervention to prevent further falls was for the facility to have two staff people assist with incontinence care.Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 08/18/25 revealed the resident had severe cognitive impairment and was dependent on staff for completing activities of daily living (ADLs.)Interview on 09/22/25 at 4:07 P.M. with CNA #25 confirmed when providing care, you should never roll a resident away from you because they could roll off the bed.Interview on 09/23/25 at 3:20 P.M. with CNA #35 confirmed while she was providing incontinence care to Resident #10 the bed was raised and she rolled the resident on her right side, which was away from the aide, and then the resident rolled out of bed.Review of an online clinical resource titled Turning Patients Over in Bed: Medline Plus Medical Encyclopedia undated at: https://medlineplus.gov/ency/patientinstructions/000426.htm#:~:text=Standing%20with%20one%20foot%20ahead,the%20p revealed the following steps should be followed when turning a resident in bed: explain to the resident what you are planning to do so they know what to expect, encourage the person to help if possible, stand on the opposite side of the bed the resident will be turning towards, move the patient towards you, step around to the other side of the bed, ask the resident to look (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 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 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 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 Level of Harm - Minimal harm or potential for actual harm towards you (this will be the direction in which the person is turning.)This deficiency represents noncompliance investigated under Master Complaint Number 2587988 and Complaint Number 1395095 (OH00160987.) Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 3 of 3