Health inspection·June 28, 2024

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 Based on record review and interview the facility failed to provide adequate assistance/supervision to prevent a fall with injury for Resident #58. This affected one resident (#58) of three residents reviewed for accidents. The facility census was 88. Actual Harm occurred on 06/08/24 when Resident #58, who was assessed as requiring substantial/maximal assistance with showers, was left unattended in the shower, resulting in a fall with a right hip fracture. Findings include: Review of the medical record for Resident #58 revealed an admission date of 01/04/18 with diagnoses including fracture of the left femur on 01/28/20, chronic pain syndrome, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/09/24, revealed Resident #58 had intact cognition. The assessment revealed the resident required substantial/maximal assistance for showers, upper body dressing, and lower body dressing. The assessment also noted the resident used a power wheelchair for mobility. Review of the plan of care (initiated 01/18/18) and last revised on 05/12/24 revealed the resident was at risk for falls due to a history of falls, poor safety awareness, and non-compliance with fall interventions. On 02/09/22 the care plan interventions were updated to include staff education to never leave the resident unattended during shower. Review of a nursing note dated 06/08/24 at 2:12 P.M. revealed Resident #58 had a fall in the shower. Agency Licensed Practical Nurse (LPN) #306 and Agency State Tested Nursing Assistant (STNA) #305 were sitting at the nursing station and heard the resident call out for help. Agency STNA #305 went to check on the resident and came back to the nursing station and stated the resident was on the floor. When the nurse got into the shower room the resident was lying on her left side. The resident stated she was trying to fold a blanket that was on the floor and fell onto her right side. The resident stated she couldn't move her leg and that her hip was hurting her badly, rating her pain a ten, on a scale from zero to ten, ten being severe. The nurse gave the resident as needed (PRN) pain medication and called 911 for transport. Resident #58 was taken out via stretcher to the hospital. Review of the nursing note dated 06/08/24 at 6:23 P.M. revealed the nurse spoke with the hospital. Resident #58 had a right hip fracture. Review of the fall investigation dated 06/08/24 revealed the investigation reflected the contents Page 1 of 2 365658 365658 06/28/2024 Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057

F 0689 of the corresponding nursing note. Witness statements from Agency STNA #305 and Agency STNA #307 confirmed they had not supervised or assisted Resident #58 with her shower or dressing afterwards. Level of Harm - Actual harm Residents Affected - Few Interview on 06/28/24 a 9:50 A.M. with Resident #58 revealed she usually showered without (staff) assistance. The day of the fall, the resident stated she had already finished her shower and gotten dressed. The resident stated she was standing and had bent over to pick up one of the shower blankets when she fell. Interviews on 06/28/24 from 12:20 P.M. through 12:40 P.M. with Registered Nurse (RN) #302, STNA #303 and STNA #304 revealed Resident #58 wanted to remain as independent as possible and the resident did not like anyone helping with her shower. The resident would tell staff she could do it herself, so staff stated they would set the resident up and quietly check on her every three to ten minutes. Interview on 06/28/24 at 1:29 P.M. with Agency STNA #305, who was Resident #58's STNA on 06/08/24 at the time of the fall with injury, revealed when she had worked at the facility before, Resident #58 only needed for staff to get her towels and set her up. The Agency STNA revealed Resident #58 had been in the shower for about thirty minutes. Agency STNA #305 revealed she didn't go into the shower room during the resident's shower. When Agency STNA #305 then did go into the shower room (after hearing the resident call for help) the resident was on the floor in pain. Interview on 06/28/24 at 2:24 P.M. with the Administrator verified there was a care plan for Resident #58 to have supervision/assistance in the shower, and the resident was not supervised or assisted with a shower on 06/08/24 resulting in a fall with fracture/injury. This deficiency represents non-compliance investigated under Complaint Number OH00154828. 365658 Page 2 of 2