Health 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. Page 1 of 3 365752 365752 08/30/2023 Foundation Park Care Center 1621 S Byrne Rd Toledo, OH 43614

F 0689 Level of Harm - Actual harm Residents Affected - Few Review of Resident #10's Fall Risk Assessments completed 04/24/23, 07/24/23, 07/26/23, 08/06/23, and 08/08/23 revealed Resident #10 was at high risk for falls. It was noted Resident #10 over estimated or forgot her limits and had an impaired gait. Review of Resident #10's progress notes revealed on 07/31/23 the Administrator noted he spoke with Resident #10's daughter about moving Resident #10 to a private room as Resident #10 had not been able to have a roommate for years due to her behaviors and paranoia. Resident #10's daughter was in agreement but wanted a room that was the same as Resident #10's prior room due to Resident #10's vision impairment. Review of Resident #10's Census Information revealed Resident #10 resided in the same room since 2018 and moved rooms two times on 08/03/23. Further review of Resident #10's medical record revealed Resident #10 had a fall on 08/03/23, which resulted in a fracture. Review of Resident #10's Fall Investigation dated 08/03/23 revealed Resident #10 had an unwitnessed fall in her new room at approximately 3:15 P.M. Resident #10 was found on the floor in her room with her right hand extended against her back. Resident #10 was assisted up from the floor and she complained of pain in her right shoulder. Range of motion was performed, and Resident #10 continued to complain of pain in her right shoulder. Resident #10's Power of Attorney (POA) and physician were notified. The Assistant Director of Nursing (ADON) called Emergency Medical Services (EMS) to transport Resident #10 to the hospital for proper evaluation. When interviewed, Resident #10 stated she fell. Resident #10 had been assessed and helped from the floor. Resident #10 reported pain to her right shoulder and her vitals were within normal limits. Resident #10 was transferred to the hospital for evaluation. Resident #10 was orientated to person only. Predisposing factors included confusion, impaired memory, and recent room change. Resident #10's care plan was reviewed and updated. Review of Resident #10's 08/03/23 hospital visit documentation revealed Resident #10 was diagnosed with a closed fracture of proximal end of the right humerus (shoulder). It was noted Resident #10 presented to the hospital following a fall. Resident #10 declined any labs or medications. Resident #10 was only agreeable to an x-ray of her shoulder. Resident #10 declined any further interventions, and a sling was placed. Resident #10's daughter was present and agreed with the current treatment plan. At the time of discharge, Resident #10 was stable. Resident #10 was to take over the counter Tylenol as needed and wear the sling for comfort. Interview on 08/29/23 at 2:06 P.M. with Resident #10's family (Family Member #500) verified Resident #10 had a fall resulting in a fracture due to the resident's recent room change. Family Member #500 reported the family requested and had the impression the resident's new room would be the exact same set up as the original room, which is the only reason the family was agreeable to the room change. Observation on 08/30/23 between 10:35 A.M. and 10:43 A.M. of Resident #10's original room and new room Resident #10 was moved to on 08/03/23, revealed upon entering the original room, the bathroom was located on the right side and the closet was on the left. Upon entering the new room, the bathroom was located on the left side and the closet was on the right. Coinciding interview with Floor Monitor (FM) #208 verified the rooms were different, stating the closets and bathrooms were located on different sides of the room. 365752 Page 2 of 3 365752 08/30/2023 Foundation Park Care Center 1621 S Byrne Rd Toledo, OH 43614

F 0689 Level of Harm - Actual harm Residents Affected - Few Observation on 08/30/23 at 10:43 A.M. of Resident #10 found her in a room with the same set up as her original room (with the bathroom located on the right side of the room). An interview was attempted with Resident #10, but she was unable to be interviewed. Interview on 08/30/23 at 10:49 A.M. with the Assistant Director of Nursing (ADON) verified Resident #10 had an unwitnessed fall in her room on 08/03/23. The ADON verified factors that contributed to Resident #10's fall were confusion and a recent room change. The ADON reported Resident #10 was found in the entry area between the bathroom and closet and the bathroom was on the opposite side of the room from her previous room. Resident #10 was transferred to the hospital and returned to a different room, which had the same layout as her original room. Resident #10 returned from the hospital with a fractured right arm. Interview on 08/30/23 at 11:01 A.M. with the Administrator revealed Resident #10's daughter provided permission for Resident #10 to be moved from a semi-private room to a private room. Resident #10's daughter agreed with the move but requested the room be the same as the room her mom had resided in for the last few years. The Administrator verified the room Resident #10 was moved to was a mirror image of the room Resident #10 had resided in with the bathroom on the opposite side. The Administrator reported the room was on the same hallway and had the same staff Resident #10 had been used to having. The Administrator verified after Resident #10 returned from the hospital she was moved to a room at the end of the hallway which had the bathroom on the same side as her original room. The Administrator verified Resident #10 had vision impairment. Follow up interview on 08/30/23 at 1:56 P.M. with the Administrator revealed the Maintenance Director reported to him Resident #10's room change was completed on 08/03/23 at approximately 11:45 P.M. Resident #10 was then found on the floor on 08/03/23 at approximately 3:45 P.M. Review of the undated facility policy titled, Free of Accidents/Hazards/Supervision, Devices, revealed the facility would assess the environment to ensure it remained free from accident hazards to which the facility had control including identifying risks and implementing resident-centered interventions to reduce hazards and risk. This deficiency represents non-compliance investigated under Complaint Number OH00145574. 365752 Page 3 of 3