Health inspection·November 11, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, staff interviews, review of hospital documentation, review of witness statements, review of a fall policy, and review of the facility's fall investigation, the facility failed to ensure care was provided per Resident #71's plan of care, failed to prevent an avoidable fall with injuries and failed to conduct a thorough post-fall investigation including a root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls. This resulted in Actual Harm on 10/20/23 when State Tested Nursing Assistant (STNA) #180 provided care to Resident #71, who was cognitively impaired and dependent on two staff for bed mobility and toileting, without the assistance of two staff resulting in the resident rolling away from the STNA and falling onto the floor. Subsequently, Resident #71 was transported to the hospital where he was found to have lacerations to his head and mouth due to the fall which required sutures. This affected one (#71) of three residents reviewed for falls. The census was 64. Findings include: Review of the closed medical record for Resident #71 revealed the resident was admitted on [DATE] and discharged on 10/25/23. Resident #71 had diagnoses including chronic respiratory failure with ventilator (vent) dependent, tremor, constipation, cerebral vascular accident (stroke), muscle weakness, tracheostomy, encephalopathy, dysphagia, and pulmonary embolism. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #71 revealed the resident was cognitively impaired and required total dependence of two staff members for bed mobility, transfers, and toileting care. Review of the plan of care dated 08/21/23 for Resident #71, revealed the resident had an impaired musculoskeletal status, a self-care performance deficit and was at risk for falls and injuries related to respiratory failure, stroke, gunshot wound, multiple fractures, hepatic encephalopathy, history of physical injury and trauma, and muscle weakness and the resident was dependent on staff for all activities of daily living (ADLs). Interventions included for the resident to have assist bars for bed mobility and repositioning, bolsters to bed, Hoyer lift for transfers, and extensive assistance of two persons for bed mobility, and bathing. The care plan was revised on 10/20/23 to include fall mats to bilateral bedside. Review of the physician's orders dated 02/24/23 for Resident #71, revealed the resident was ordered to have a specialty air mattress with built in bolsters to establish safe parameters. The physician's orders dated 06/15/23, revealed the resident was ordered to be transferred via Hoyer lift with Page 1 of 4 365523 365523 11/11/2023 Arbors at Oregon 904 Isaac Streets Drive Oregon, OH 43616

F 0689 Level of Harm - Actual harm two staff members. The physician's orders dated 09/08/23, revealed the resident was ordered to have one quarter (1/4) side rails for bed mobility related to muscle weakness. The physician's orders dated 10/23/23, revealed the resident was ordered to be sent to the emergency room (ER) for an evaluation and for the resident to have floor mats placed to bilateral bedside to minimize risk of injury. Residents Affected - Few Review of the Nurse Practitioner (NP) progress note dated 10/18/23 for Resident #71, revealed the resident was awake, not alert, and could not follow any commands. Review of the nurse's progress note dated 10/20/23 at 1:00 P.M. for Resident #71, revealed during ADL care, the resident fell out of the bed, landed face down and received a laceration to his head, above his eyebrow, his head, and lip. The staff applied pressure to his head, 911 was called and the resident was transported to the hospital. The NP, who was in the building was notified. Review of the hospital notes dated 10/20/23 at 2:02 P.M for Resident #71, revealed the resident arrived in the ER with a chief complaint of a fall with lacerations to left forehead and lower left lip. The hospital notes indicated while the facility staff was performing morning bathing care, the resident rolled and fell on to floor, sustaining a left frontal scalp hematoma, lacerations to left forehead and left lower lip. The resident was diagnosed with a status post fall with lacerations, required sutures and was admitted to the intensive care unit (ICU) for lower left pneumonia. The hospital notes indicated a computerized tomography (CT) scan showed new areas of hypodensity in the brain which radiology reported as being subacute and a neurology consulted was ordered due to the abnormal CT scan and an magnetic resonance imagine (MRI) was ordered for further testing. Review of the initial fall report dated 10/20/23 at 2:16 P.M. for Resident #71, revealed the resident was getting a bed bath when he fell. The resident was bleeding from his head above his nose and his eyebrow. New interventions included floor mats on both sides of the resident's bed. Review of the nurse's progress notes dated 10/20/23 at 2:31 P.M. and recorded as a late entry for Resident #71, revealed per the hospital report, there were no serious injuries, and the resident had a laceration above his eyebrow and lip. The resident was being admitted for pneumonia. Review of the Situation Background Assessment Request (SBAR) communication form and progress note dated 10/20/23 at 2:24 P.M. for Resident #71, revealed the resident had a fall with an injury to his face. The resident was getting ADL's done by staff, when the resident turned, and he fell out of the bed. The resident landed face down next to the bed and had lacerations above his nose, left eyebrow, was bleeding from his mouth and his front tooth was loose. The NP was in the facility and ordered for the resident to be sent to the hospital. Review of a witness statement by State Tested Nursing Assistant (STNA) #180 dated 10/20/23 and recorded by Registered Nurse (RN) #150, revealed the STNA was doing the resident's ADLs and when she turned Resident #71 on his right side, his left leg went over the bolster and the resident kept going and she could not stop him. Review of the fall assessment dated [DATE] at 2:15 P.M., revealed Resident #71 had a fall on 10/20/23 where he rolled out of the bed during care. The report revealed the bed bolsters were in place and the cause of the fall was the resident's poor trunk control and poor safety awareness. The resident had lacerations on his eyebrow and lip and was transferred to the hospital. The assessment noted the resident had no serious injuries and was admitted for pneumonia. The Care plan modifications included placing floor mats on both sides of bed to minimize the risk of injury. 365523 Page 2 of 4 365523 11/11/2023 Arbors at Oregon 904 Isaac Streets Drive Oregon, OH 43616

F 0689 Level of Harm - Actual harm Residents Affected - Few Review of the facility's investigation and Quality Assurance Performance Improvement (QAPI) plan completed on 10/27/23, revealed STNA #180 was completing incontinence care for Resident #71 on 10/20/23 when the STNA rolled the resident on to his right side. The resident was noted with poor trunk control and began to roll and rolled over the bed bolster and on to the floor. The resident sustained lacerations above his eyebrow and lip and a bruise to his forehead. The resident was immediately sent to the ER for further evaluation and the hospital determined there were no other injuries. The resident was admitted for pneumonia. The resident was care planned for two staff members during bed mobility and this was also noted on the STNA's [NAME] (document for a resident's care needs) as well. The QAPI plan revealed the facility only provided education to the STNAs ensuring that residents were receiving the appropriate assistance based on their needs. The education/training did not include additional staff that may be called on to assist, including the nursing staff. The QAPI plan also did not include a root cause analysis on why the staff used only one-person to provide assistance to Resident #71 when they were aware the resident required a two-person assistance. The QAPI plan also failed to document what interventions the facility would put in place to prevent further avoidable falls with injuries. Interview with STNA #160 on 11/08/23 at 10:16 A.M., revealed Resident #71 required total assistance from staff including two staff for his care. STNA #160 revealed she heard of Resident #71's fall on 10/20/23 and noted STNA #180 was newer and provided care by herself as she rolled the resident off the bed and onto the floor. STNA #160 revealed at times the facility does not have enough staffing and the high acuity residents and the resident's care would often be provided with one staff. STNA #160 indicated Resident #71 was in a hall where almost all of the residents required two-person assistance, but only one STNA was scheduled for hall. Interview with STNA #170 on 11/08/23 at 10:21 A.M., revealed the staff were able to check the assistance needs of each resident by checking the [NAME]. STNA #170 was asked about a resident she provided care for, and the STNA referenced Resident #57, indicating this resident was independent with their ADLs. As STNA #170 was demonstrating how the staff could look up information on the [NAME], specifically for Resident #57, the STNA noted the [NAME] information for Resident #57 differed from what she was informed. STNA #170 noted Resident #57's [NAME] indicated the resident required assistance of one person assist. Interview with STNA #180 on 11/08/23 at 10:47 A.M., revealed she had worked at the facility for a few months and revealed she was caring for Resident #71 when he fell on [DATE]. STNA #180 revealed she was aware of Resident #71 needed two staff members for his care, but looked around and did not see any available staff so she decided to provide care by herself as she did not want resident sitting in a dirty brief. STNA #180 verified she did not ask anyone to assist her in the resident's care. STNA #180 revealed she first rolled the resident on his left side, which was closest to her and towards the resident's window. STNA #180 then rolled the resident towards the door and away from her. STNA #180 indicated the resident's leg must have gone over the bolster pad and once he started to roll off the bed, she could not stop or catch him. Interview with DON on 11/08/23 at 11:15 A.M., revealed the facility investigation found that STNA #180 was providing care to Resident #71, who was a dependent resident, unassisted, and the resident should have been cared for using two staff members. The DON stated after the fall, the facility put new interventions in place for fall mats to both sides of the resident's bed. The DON confirmed the fall interventions put in place for Resident #71 should have been related to the cause of the fall and to prevent a future fall and not necessarily an intervention for fall mats. The DON revealed the STNAs were educated related to using the [NAME] to ensure proper number of staff were present and 365523 Page 3 of 4 365523 11/11/2023 Arbors at Oregon 904 Isaac Streets Drive Oregon, OH 43616

F 0689 Level of Harm - Actual harm Residents Affected - Few available for assistance with the resident's care. The DON indicated Resident #71 had poor trunk control, poor core strength and lack of safety awareness, but verified the fall was caused by staff not following the care plan and procedures for providing care to a dependent resident. The DON stated her expectations would be if a resident was assessed and required the need for two staff members, then the staff should be following the care plans. Interview with RN #150 on 11/08/23 at 11:55 A.M., revealed she was working on 10/20/23 around shift change when STNA #180 yelled for help from Resident#71's room. RN #150 noted the resident was found on the floor and was assessed to have lacerations to his head and mouth and 911 was called. RN #150 stated STNA #180 did not ask for assistance prior to the fall, and she was unaware STNA #180 was in the room when the fall occurred. RN #150 revealed the residents at the facility required more assistance than most nursing facilities since they have a vent population and many of their residents required two-person assistance. Interview with Resident #71's family member on 11/08/23 at 12:20 P.M., revealed the resident fell out of bed, went to the hospital, and had to get sutures. Resident #71's family noted the resident's sister took care of his medical needs and she would have the sister call the Surveyor with additional details. At the time of exiting the facility on 11/11/23, no return call from Resident #71's sister had been received. Interview with Administrator on 11/08/23 at 1:29 P.M., revealed the facility did not have a policy related to providing ADL care for dependent residents. Review of 11/02/23 facility policy titled Falls-Clinical Protocol, revealed as part of an ongoing resident assessment, staff shall help identify falls risk factors and include information in the care plan including necessary and appropriate interventions taking into account a resident's abilities and deficits, balance, adaptive equipment needs and proper use of mechanical lifts and transfer devices, shower beds, shower chairs and bathroom safety. Interventions should also be placed on the care card for the aides as well as the [NAME] in the electronic health record. This deficiency represents non-compliance investigated under Complaint Number OH00148140. 365523 Page 4 of 4