Inspection·June 4, 2024

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, review of hospital reports, review of facility investigation, and interview, the facility failed to ensure a safe and proper wheelchair transport resulting in a fall. This affected one resident (#7) of three residents reviewed for falls. The facility census was 113. Findings include: 1. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including dementia, chronic kidney disease, protein-calorie malnutrition, weakness, failure to thrive, and atrial fibrillation. Review of the fall risk assessment, dated 05/03/24, revealed Resident #7 was determined to be at an increased risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/08/24, revealed the resident was severely cognitively impaired. The assessment further revealed the resident was dependent on staff for activities of daily living and mobility. The resident's mobility device was a wheelchair. Review of the Care Plan dated 12/22/17 revealed the resident had the potential for falls related to weakness, abnormal gait/mobility, dementia, history of falling, neuropathy, hypotension, and psychotropic medication use with interventions including to apply Dycem to wheelchair and recliner as tolerated. Further review of the Care Plan dated 03/13/18 revealed Resident #7 was at risk for decline in activities of daily living (ADLs) status and has an ADL self-care performance deficit related to weakness, abnormal gait/mobility, non-ambulatory status, and dementia with interventions including the resident uses a wheelchair when out of bed, usually dependent on staff to propel. Review of a nursing progress note, dated 05/03/24 at 8:50 P.M., revealed the resident was status post fall with observation revealing the left side of forehead was swollen and bleeding. The area was cleansed with normal saline and pressure was applied to the area to stop the bleeding. Hospice was notified, 911 was called and the resident was transferred to the hospital. Review of the Falls- Incident Accident Checklist and the Fall Investigation, dated 05/03/24, did not reveal that the fall intervention for a Dycem to be applied to the seat of the wheelchair was in place at the time of the fall. Review of State-Tested Nursing Assistant (STNA) #48's Witness Statement, dated 05/03/24, revealed staff was pushing the resident to her room when the resident slid off the wheelchair and down to the (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: 365436 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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)