Inspection·March 5, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review the facility failed to implement the facility policy regarding the requirement to report a resident to resident altercation to the state agency. This affected one resident (#15) reviewed for abuse. The facility census was 92. Residents Affected - Few Findings include: Review of Resident #15's medical record revealed an admission date of 01/08/19. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease and atrial fibrillation. Review of Resident #15's quarterly Minimum Data Set (MDS) dated [DATE] revealed she had an impaired cognition and behaviors included wandering and rejection of care. Review of Resident #15's nurses note dated 02/20/25 revealed the resident was in the dining room sitting at the table eating lunch. An altercation between two other residents happened and in the process Resident #15 was hit in the face with a plate receiving a cut to her forehead. The nurse separated residents. Resident #15 was assessed by staff and received wound care. Neurological checks were begun. Review of Resident #15's health status note dated 02/20/25 revealed the resident had a small laceration to the forehead. The resident removed the dressing which resulted in bleeding. The site was cleaned and antibiotic ointment applied with a clean dressing. Review of Resident #15's nurses note dated 02/21/25 revealed the resident had a large hematoma to the forehead. Observation on 03/04/25 at 10:25 A.M. revealed Resident #15 was ambulating through the facility with the assistance of a walker. Observation of her forehead revealed a healing bruise the size of a coffee saucer along with an approximate 1 1/2 inch healing cut in the center of the bruising. Interview with the Director of Nursing (DON) on 03/04/25 at 11:01 A.M. verified Resident #15 was hit with a dinner plate on accident. The DON stated it really was not an altercation involving Resident #15. The altercation was between two other residents when one resident attempted to leave the dining room holding the plate in the air and when a second resident attempted to pull the plate away, the plate hit Resident #15 in the forehead. Interview with Registered Nurse #120 on 03/05/25 at 7:25 A.M. verified Resident #15 did get hit in the face with a dinner plate and suffered a laceration to her forehead. The nurse stated that (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 4 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 03/05/2025 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)