Inspection·April 14, 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. Based on interviews, record review, and review of the facility policy on falls, the facility failed to ensure fall prevention interventions were implemented as care planned, and failed to ensure staff followed their policy and procedure on falls by assessing residents prior to moving them immediately after a fall if they had an injury. This affected one (Resident #37) of three residents reviewed for falls. The facility had a census of 64 residents. Findings include: Review of the medical record for Resident #37 revealed an admission date of 10/09/21 with diagnosis including Alzheimer's Disease and an abnormal posture. Review of the care plan for Resident #37 dated 05/08/18 revealed she had the potential for injury due to a history of falls. The fall prevention intervention dated 01/16/19 was to keep the bed in the proper position next to the wall with wheels locked. Review of the nursing progress note dated 03/22/23 at 6:00 A.M. by Licensed Practical Nurse (LPN) #215 revealed at 5:00 A.M. she was alerted by a state tested nurse aide (STNA) that Resident #37 was on the floor. LPN #215 stated when she entered the room, Resident #37 was lying in bed. She did have red areas across her forehead, right elbow and right wrist. Review of the fall investigation dated 03/22/23 revealed LPN #215 stated at 5:00 A.M. she was alerted by a STNA that Resident #37 was on the floor. LPN #215 stated when she entered the room, Resident #37 was lying in bed. She did have red areas across her forehead, right elbow and right wrist. The statement from STNA #214 on 03/23/23 revealed SR #37 had been checked on and provided care at 3:30 A.M. STNA #214 stated there was a possibility they misjudged the difference between the bed and the wall. STNA #214 stated when she and STNA #213 went to check on the resident at 5:00 A.M., they found her on the floor between the bed and the wall. She stated the bed was in the lowest position. The root cause dated 03/27/23 for the fall on 03/22/23 verified staff did not have bed up against the wall. Interview on 04/14/23 at 7:58 A.M. with the Administrator verified the nursing progress note dated 03/22/23 at 6:00 A.M. stated the STNAs found her on the floor, went to get the nurse and when the nurse entered the room the resident was noted to be in bed. The Administrator stated while performing their investigation, he had attempted to move the bed to see if it was possible Resident #37 was able to move the bed if the wheels were unlocked by twitching and he stated it was very hard to move and there were also cords under the bed which stopped it from moving. He stated he did not believe the bed was moved by Resident #37. He stated it was possible the bed had not been completely pushed (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: 365429 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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)