Inspection·November 26, 2024

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. Based on observation, staff interviews and medical record review, the facility failed to implement interventions to prevent falls as per the plan of care. This affected two of three residents (#29 and #35) reviewed for falls. The facility census was 53. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 08/09/24 and diagnoses including atrial fibrillation, anemia, chronic obstructive pulmonary disease, and hypertension. Review of Resident #35's fall assessments for the previous month revealed the resident had fallen on 10/25/24,10/26/24 and 11/11/24. Review of Resident #35's care plan revealed the following fall prevention interventions were to be in place for the resident: On 08/26/24 encourage the resident to wear non-skid socks at all times, 09/11/24 a perimeter (concave) mattress to the resident's bed to allow the resident to define the edges of the bed, 09/18/24 a fall mat to the floor on the right side of bed, 09/18/24 a low bed, 09/18/24 the resident to be up in his wheelchair when restless, 09/30/24 dycem (a thin non-slip, rubber-like material used to help prevent slipping from the wheelchair) to be placed on top of the wheelchair cushion, and 11/21/24 anti-rollbacks (a device to prevent the wheelchair from rolling backward while the resident transfers into or out of the chair) to the wheelchair. Observation on 11/24/24 at 8:00 A.M. revealed Resident #35's wheelchair did not have the care planned intervention of anti-rollbacks applied to the chair. Interview on 11/24/24 at 8:00 A.M. Certified Nursing Assistant (CNA) #172 verified that anti- rollbacks were not present on Resident #35's wheelchair. 2. Review of Resident #29's medical record revealed an admission date of 09/26/24 and diagnoses including a fracture of the lumbar vertebrae, moderate protein calorie malnutrition, chronic obstructive pulmonary disease and manic episode with psychotic symptoms. Review of Resident #29's fall assessments for the past month revealed the resident had fallen on 10/25/24, 10/26/24, 11/11/24, and 11/16/24. Review of Resident #29's orders and care plan revealed the following fall prevention interventions were to be in place for the resident: On 10/03/24 offer the resident assistance with toileting in advance of need, 10/14/24 encourage the resident to wear non-skid footwear at all times, 10/16/24 leave the resident's bathroom light on at all times for a night light, 10/23/24 place the resident's bed against the wall, 10/26/24 remind the resident often to ask for assistance to transfer, 10/26/24 remind the resident to use the wheelchair brakes when up in the wheelchair, 10/28/24 anti-rollbacks to the resident's wheelchair, 10/28/24 dycem to the resident's wheelchair seat. Observation on 11/24/24 at 10:30 A.M. revealed Resident #29 resting in his bed with his feet bare and his wheelchair pulled up to the side of the bed. Observation of Resident #29's wheelchair revealed the care planned fall prevention intervention of dycem was not present in the wheelchair. Further observation of Resident 29's wheelchair revealed the care planned fall prevention intervention of anti-rollbacks were not present on the wheelchair. Observation of Resident #29's bathroom revealed the light was not on as care planned to provide a night light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365780 If continuation sheet Page 2 of 3 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 365780 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marietta Heights Post Acute 5001 State Route 60 Marietta, OH 45750 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Interview on 11/24/24 at 10:30 A.M. Registered Nurse (RN) #122 verified Resident #29 did not have non-skid footwear on, dycem was not present in the wheelchair seat, anti-rollbacks were not on the wheelchair and the bathroom light was not turned on. This deficiency represents non-compliance investigated under Complaint Number OH00159474. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365780 If continuation sheet Page 3 of 3