Health inspection·December 21, 2023

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 observation, staff interview, record review, and review of the facility policy, the facility failed to ensure fall interventions were in place. This affected one (#11) of three residents reviewed for falls. The facility census was 68. Findings include: Review of the medical record for Resident #11 revealed an admission date of 10/12/23. Diagnoses included congestive heart failure (CHF), osteoarthritis, and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had intact cognition and displayed no rejection of care. Review of the Morse Fall Scale (assessment tool that predicts the likelihood that a patient/resident will fall) dated 10/12/23 revealed Resident #11 was at high risk for falls. The Morse Fall Scale dated 10/15/23 revealed Resident #11 was at moderate risk for falls. Review of the care plan updated 11/24/23 revealed Resident #11 was at risk for falls. Interventions included a low bed with a floor mat. Review of a nurse's progress note dated 11/24/23 revealed Resident #11 was found on the floor after rolling out of bed. Review of the fall investigation completed after the fall on 11/24/23 revealed an intervention was implemented for Resident #11 to have the bed in the lowest position and a fall mat beside the bed. Observation of Resident #11 on 12/20/23 at 9:07 A.M. revealed the resident was lying in her bed. The bed was in a high position, with a perimeter mattress (a mattress with raised edges) and no fall mat was observed on the floor. Interview on 12/20/23 at 9:10 A.M. with State Tested Nurse Aide (STNA) #101 revealed Resident #11 recently fell out of a bed. STNA #101 confirmed Resident #11's bed was elevated and stated the bed did not need to be in a low position. STNA #101 also confirmed no fall mat was on the floor. A follow-up interview on 12/20/23 at 12:24 P.M. with STNA #101 revealed she could check the [NAME] (a quick-view section in the electronic medical record) to determine what fall interventions should be in place for Resident #11. STNA #101 stated she was unfamiliar with Resident #11's fall Page 1 of 2 365380 365380 12/21/2023 Autumnwood Care Center 670 E Sr 18 Tiffin, OH 44883

F 0689 Level of Harm - Minimal harm or potential for actual harm interventions and after checking the [NAME], STNA #101 verified Resident #11's bed should be in the low position and a fall mat should be in place. Review of the policy Fall Management, revised 10/24/22, revealed preventative measure shall be taken to decrease the number of falls and the facility would implement appropriate interventions/precautions. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00149047. 365380 Page 2 of 2