Health inspection·May 10, 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 record review, observations, staff interview and review of the facility policy, the facility failed to ensure physician ordered fall interventions were implemented for a resident at risk for falls and with a history of falls with major injury. This affected one (Resident #19) of three residents reviewed for falls. The facility census was 80. Findings include: Review of the medical record revealed Resident #19 had an admission date 03/14/23. Diagnoses included dementia, anxiety disorder, chronic kidney disease, hallucinations, and Colles' fracture of left radius. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was severely cognitively impaired. Resident #19 required extensive assistance of two persons for bed mobility and required extensive one-person physical assist for transfers. Review of the plan of care dated 03/14/23 revealed Resident #19 was at risk for falls due to safety awareness, and weakness. Interventions included to ensure the resident's room was free of accident hazards and remove wheelchairs from the resident's room when not in use. Review of the Fall Risk Observation Tool dated 03/31/23 revealed Resident #19 had a fall with injury in the last six months. Resident #19 had diminished safety awareness. Resident #19's ambulatory aid was a wheelchair and ambulation assistance was needed. Review of the Post Fall Evaluation dated 04/05/23 revealed Resident #19 had fallen on 04/04/23 at 7:45 P.M. in her room and fallen at the doorway. Review of the progress note dated 04/05/23 revealed Resident #19 was seen up reaching for her wheelchair in the hallway. The nurse went to assist her, and Resident #19 turned and fell. Resident #19 was holding her left wrist and complained of pain. The nurse practitioner was notified and ordered an x-ray of the left wrist. The wrist was elevated and ice applied. The progress note dated 04/05/23 revealed the nurse spoke with the power of attorney (POA) concerning Resident #19's fall. The POA agreed with moving Resident #19 closer to the nurse's station to aide with preventing future falls and requested her wheelchair to be removed from her eyesight while in bed. The x-ray results indicated a fracture to the left hand/wrist. Review of the physician orders dated 04/05/23 revealed Resident #19 had an order to remove the wheelchair from Resident #19's room when not in use per Power of Attorney (POA). There was also an order to send Resident #19 to the emergency room (ER) for evaluation and treatment due to left hand/wrist (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365424 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 365424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrook Healthcare Center 2299 S Yellow Springs Street Springfield, OH 45506 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)