Inspection·August 30, 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 observations, medical record review, staff interview, and review of facility policy, the facility failed to ensure a visually impaired resident who was at risk for falls, was provided a proper room set up to prevent falls. This resulted in actual harm when Resident #10 had a room change on 08/03/23 at 11:45 A.M., fell in the new room on 08/03/23 at approximately 3:50 P.M., was transported to the hospital and found to have a fracture of the right humerus (shoulder). This affected one (Resident #10) of three residents reviewed for falls. The facility census was 88. Finding include: Review of the medical record for Resident #10 revealed an admission date of 04/09/18. Diagnoses included dementia with behavioral disturbance, skin cancer, fracture of right arm humerus (08/03/23), fracture of lower end of left radius (07/27/23), fracture of left ulna styloid process (07/27/23), paranoid schizophrenia, bilateral cataracts, and macular degeneration. Review of Resident #10's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was not able to be completed. Staff assessment for mental status was completed and indicated Resident #10 had memory impairment and had short and long-term memory problems. Resident #10 was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. Resident #10's vision was severely impaired. Resident #10 displayed verbal behavioral symptoms directed toward others four to six days during the review period and rejection of care behaviors daily during the review period. Resident #10 had two or more falls since admission with major injury. Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively impaired and required supervision set up only with walking in her room, walking in the corridor, and locomotion on and off the unit. It was noted Resident #10 required supervision with toilet use. Resident #10 was noted to be steady (at all times) with moving from the seated to standing position, walking, turning around and facing the opposite direction, moving on and off the toilet and transferring surface to surface. Resident #10 utilized a walker. Review of Resident #10's Care Plan revised 08/30/23 revealed supports and interventions for seeing smoke everywhere related to cataracts, self-care deficit, resistive to care, potential for verbal and physical aggression, impaired cognitive function, and risk for falls. Resident #10's risk for falls was related to her cognitive impairment, decreased safety awareness, decreased judgement, impulsiveness, visual deficits, and terminal condition. (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 3 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 08/30/2023 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)