Health inspection·November 27, 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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure fall interventions were implemented per physician order. This affected one (#18) of three residents reviewed for falls. The facility census was 87. Findings include: Review of Resident #18's medical record revealed an admission date of 03/19/24. Diagnoses included dementia, history of falling, weakness, hypertension, need for assistance with personal care, muscle weakness, and unsteadiness on the feet. Review of Resident #18's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #18's plan of care dated 03/19/24 revealed the resident was at risk for falls related to impaired mobility and cognition, ataxia, and incontinence. Interventions included the bed in the lowest position, engage bed locks, and providing assistive devices as needed. Review of the nursing progress notes dated 03/25/24 and timed 1:11 P.M. revealed Resident #18 sustained a fall when attempting to transfer from bed and therapy was to evaluate the resident for mobility bars. Review of Resident #18 active physician orders revealed an order dated 03/25/24 for bilateral bed rails for mobility. Review of the fall risk assessment dated [DATE] revealed Resident #18 was at risk for falls. Observation on 11/26/24 at 9:07 A.M. and on 11/26/24 at 3:50 P.M. revealed Resident #18 was lying in bed and there were no bed rails/mobility bars attached to the bed. An interview on 11/26/24 at 11:48 A.M. with Housekeeper #478 verified Resident #18 did not have bed rails on the bed. An interview on 11/26/24 at 12:14 P.M. with Certified Nurse Aide #595 also verified Resident #18 did not have bed rails on their bed and should have had them. Review of the undated facility policy titled, Fall Prevention and Management, revealed the facility (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 4 Event ID: 365623 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 365623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Health Care 3364 Kolbe Rd Lorain, OH 44053 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)