Health inspection·August 7, 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 and interview, the facility failed to ensure fall prevention interventions were in place as ordered for Resident #12. This affected one resident (#12) of three residents reviewed for falls. The facility census was 99. Findings include: Review of the medical record for Resident #12 revealed an admission date of 07/03/23. Diagnoses included right side paralysis, hypertension, dementia, depression and anxiety. Review of the plan of care dated 07/03/23 revealed Resident #12 was at risk for falls due to a history of falls at home and cognitive impairment. Interventions included ensuring the call light was in reach, mats to the floor on both sides of the bed and ensuring needed items were within reach. Review of the fall risk assessment dated [DATE] revealed Resident #12 was at high risk for falls. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 was moderately cognitively impaired. Resident #12 required limited assistance from one person for bed mobility, dressing, toilet use, and personal hygiene and supervision of one person for eating. Review of the fall note dated 07/06/23 timed 1:21 A.M. revealed the nurse was walking past Resident #12's room and found him sitting on the floor on his left hip with both knees bent and his feet pulled back by his buttocks. Resident #12 was not wearing pants or an incontinence brief. Wet pants were observed approximately three feet away from Resident #12 and a wet incontinence brief was in the bathroom. Resident #12 was wearing non skin socks. Resident #12 told the nurse he was trying get a new pair of pants out of his closet. Resident #12 was assessed and no injuries were noted. A sign was placed in Resident #12's room as reminder to call for help, and Resident #12 was given a urinal. Review of the Interdisciplinary team (IDT) fall review dated 07/06/23 timed 10:16 A.M. revealed Resident #12 had an unwitnessed fall in his room without injury. Resident #12 reported to staff he was trying to get to the bathroom when he became incontinent and tried to get to his closet for clean pants, losing his balance and falling. The call light was in reach but not activated. A urinal was provided to assist with incontinence at night. Review of the fall note dated 07/21/23 timed 2:51 P.M. revealed Resident #12 was found on the floor next to the bed on his right side with his right arm behind his body. Resident #12 could not explain what happened. Resident #12 was assessed and no injuries were noted. An intervention of an alarm to the bed was put in place. Review of the IDT fall review dated 07/21/23 at 3:03 P.M. revealed Resident #12 experienced a fall Page 1 of 2 365604 365604 08/07/2023 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from the bed without injury. Resident #12 was lying on the floor next to his bed on his right side. The call light was in reach but not activated. All previous interventions were said to have been in place. Resident #12 was assisted into bed in the lowest position with the call light in reach and bed alarm applied. Mats were placed to both sides of the bed. Observation on 08/07/23 at 10:03 A.M. revealed Resident #12 was in his bathroom. The call light was observed to be in reach and floor mats were folded and propped against the television stand across from Resident #12's bed. Interview at the time of the observation with Licensed Practical Nurse (LPN) #204 confirmed the mats were not at the bedside. LPN #204 confirmed no urinal was at the bedside and she had no knowledge of a bed alarm, nor did she observe one at the time of the interview. Interview on 08/07/23 at 11:52 A.M. with the Director of Nursing (DON) revealed at the time of the fall on 07/21/23, the nurse implemented the bed alarm as an immediate intervention, but the IDT team did not implement it as an ongoing intervention. She confirmed a urinal and mats by the bedside should have been in place. Review of the facility policy titled Falls, undated, revealed effective interventions would remain in place to minimize the risk of falls. This deficiency represents non-compliance investigated under Complaint Number OH00145075. 365604 Page 2 of 2