Inspection·June 20, 2023

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the facility's incident report, review of the hospital record, and review of a personnel file, the facility failed to ensure a resident was provided with sufficient staff supervision when positioned in bed during direct care. This resulted in Actual Harm when Resident #74 sustained multiple fractures, when State Tested Nursing Assistant (STNA) #117 rolled the resident away from the STNA during care, the resident rolled off the bed, landed on the floor, and was subsequently sent to the local hospital where the resident was diagnosed with a fractured right hip, pelvis, and right knee. This affected one resident (#74) of five residents reviewed. The facility census was 80. Findings include: Review of the medical record for Resident #74 revealed an admission date of 06/15/15. Diagnoses included Alzheimer's disease, fractured neck of the right femur (02/27/23), fracture of the right tibia (03/03/23), multiple fractures of the pelvis (03/03/23), and a displaced fracture of right femur (03/03/23). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 required total assistance of one person for bed mobility. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #74 was rarely/never understood and was totally dependent on one person for bed mobility, transfers, toilet use, and hygiene. Review of the current care plan for Resident #74 revealed she had an activities of daily life (ADL) self-care performance deficit and was dependent for bed mobility. Review of a progress note dated 02/25/23 at 6:00 P.M. revealed Resident #74 was receiving care from staff when Resident #74 tumbled out of the bed onto the floor and sustained a hematoma (bruise) on the back of her head. Resident #74 was alert and gave no indication of pain at that time. Review of a progress note dated 02/26/23 at 4:48 A.M. revealed Resident #74 was grimacing during care. Review of a progress note dated 02/26/23 at 8:47 P.M. revealed an X-Ray of Resident #74 was ordered. (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 2 Event ID: 365752 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 365752 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foundation Park Care Center 1621 S Byrne Rd Toledo, OH 43614 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)