Health inspection·February 22, 2022

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. Based on record review, staff and guardian interview, facility incident investigation documentation, and facility policy, the facility failed to ensure Resident #34 was transported correctly in a tilt-n-space chair and sustained a laceration to the forehead requiring sutures. This affected one (#34) of six residents reviewed for accidents. The facility census was 116. Findings include: Review of the medical record for the Resident #34 revealed an admission date of 07/29/20. Diagnoses included metabolic encephalopathy, cerebrovascular disease, chronic obstructive pulmonary disease, and type two diabetes mellitus. Review of the most recent Minimum Data Set (MDS) assessment, revealed the resident had impaired cognition. The resident was total dependence of one staff for locomotion off the unit, and extensive assist of two staff for transfer. Hematoma and laceration noted to forehead. Review of the care plan dated 12/05/22 revealed tilt-n-space chair to be reclined/position while transporting. Review of the progress note 02/8/22 at 7:08 P.M. revealed State Tested Nursing Assistant (STNA) #210 approached the nurse's station and asked nurses to identify this resident at that time Registered Nurse (RN) #300 told her the resident's name and to tilt her chair back because she will slide out of the chair. STNA #210 began wheeling resident from the television to her room. Then nurse heard a loud thump and at that time saw resident on the floor face down. Head to toe body check and range of motion (ROM) of all extremities was assessed. Assisted off the floor with assist of three and gait belt. Abrasion noted above the right brow, hematoma and laceration on the forehead. Neurological checks started and medicated with Acetaminophen for pain. Review of the fall investigation worksheet dated 02/08/22 at 7:08 P.M. revealed Resident #34 being transported in upright tilt-n-space chair, Resident #34 leaned forward and fell out of chair. Hematoma and laceration noted to forehead. Resident #34 sent to the emergency room and returned with three sutures to forehead as well as bruising. In Addition, received new orders for routine Acetaminophen 325 (mg) milligrams twice a day and to tilt back tilt-n-space chair while transporting. Interview on 02/14/22 at 3:29 P.M. with the guardian stated agency staff was wheeling Resident #34 to bed and did not tilt back her tilt-n-space wheelchair while transporting her down the hallway and she fell forward out of the chair and sustain a minor laceration. (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 5 Event ID: 365685 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 365685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare North Ridgeville 38600 Center Ridge Rd North Ridgeville, OH 44039 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)