Health inspection·June 22, 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 observation, record review, interview, and facility policy review the facility failed to ensure interventions were in place to aid in the prevention of falls. This affected one resident (#17) of three residents reviewed for falls. The facility census was 58. Findings include: Review of the medical record for the Resident #17 revealed an admission date of 08/30/22 with diagnoses included ataxia (difficulty walking), osteoarthritis, anemia, and vitamin D deficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired. The resident required extensive assistance of one person for bed mobility, transfers, and ambulation. Review of the fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of the plan of care dated 12/21/22 revealed the resident was at risk for falls due to difficulty walking. Interventions included the call light being in reach, a perimeter mattress to bed, bolsters to the air mattress, wheelchair brake extenders, and non-skid footwear or shoes when out of bed. Review of physician orders for June 2023 identified orders for a perimeter mattress to bed. Review of the nurse's notes dated 04/01/23 at 2:15 P.M. revealed Resident #17 had an unwitnessed fall. The State Tested Nurse's Aide (STNA) was answering the resident's call light when she was observed Resident #17 on the floor lying on her left side in a lateral position next to her bed with the wheelchair behind her. When asked what happened, she replied she was not sure, but believed she was fixing her wheelchair. An assessment was done, and no injuries were noted. Review of the fall investigation dated 04/01/23 revealed no evidence of a perimeter mattress, non-skid socks, bed bolsters, or wheelchair brake extenders being in place at the time of the fall. The care plan was updated to include a Dycem (non-slip pad) to be placed in the wheelchair. Observation on 06/20/23 at 11:48 A.M. of Resident #17 revealed she was sitting in her wheelchair in the dining room. A Dycem was observed in use on the wheelchair and wheelchair brake extenders were in place. Page 1 of 2 365730 365730 06/22/2023 Embassy of Euclid 3 Gateway Dr Euclid, OH 44119

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/20/23 at 2:15 P.M. with the Director of Nursing (DON) confirmed no evidence of a perimeter mattress, non-skid socks, bed bolsters, or wheelchair brake extenders being in place at the time of the fall. Observation on 06/20/23 at 2:31 P.M. of the Resident #17's room revealed no evidence of a perimeter mattress on her bed and no bed bolsters. Interview at the time of the observation with the DON confirmed there was no perimeter mattress on the bed, and a set of bed bolsters resting against the wall behind a chair and wrapped in plastic. Review of the facility policy titled Fall Management, dated 01/29/20, revealed the facility would implement interventions to manage falls. This deficiency represents noncompliance investigated under Complaint Number OH00143558. 365730 Page 2 of 2