Health inspection·December 7, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #9 received proper assistance with activities of daily living to prevent a fall. This affected one resident (Resident #9) out of three residents reviewed for falls. Findings include: Review of Resident #9's medical records revealed an admission date of 09/06/17. Diagnoses included vascular dementia, neoplasm of endometrium, atrial fibrillation, cerebrovascular disease, obesity, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, depressive disorder, anxiety disorder, and diastolic congestive heart failure. Review of Minimum Data Set (MDS) dated [DATE] revealed resident required extensive two plus assistance for bed mobility, transfers, toileting and extensive one person assistance with dressing and personal hygiene. Review of care plan dated 09/21/23 revealed resident was at risk for falls related to dependence on staff for transfers using lift equipment, balance deficits, obesity, use of psychoactive medication, pain, diuretic medications, history of fall, history of left ankle fracture, impaired mobility, left weakness and neglect related to history of TIA with residual effects, debility, malaise, cognitive declines, impaired safety awareness, seizure disorder. Interventions included assist with mobility as needed, do not leave alone/unsupervised in bathroom, keep frequently used items in reach, offer to lay resident down after dinner, provide and encourage use of adaptive equipment, mobility devices as ordered, therapies as ordered and transfers per orders. Review of undated [NAME] revealed resident was assist of two staff for all hands-on care. Review of progress note dated 11/16/23 at 6:49 A.M. authored by Licensed Practical Nurse (LPN) #242 revealed she was alerted by state tested nursing assistant (STNA) that Resident #9 rolled out of bed while being changed. Upon inspection, the patient was sitting on her bottom, on the left side of her bed. Vital signs completed as followed blood pressure 110/62, heart rate 74, temperature 98.3, respirations 20 and pulse oxygenation 94 % on room air. Patient had no injuries noted at this time. LPN #242 and STNA's assisted patient back into bed via Hoyer lift. Notification to Director of Nursing (DON), Unit Manager, and Nurse Practitioner (NP). NP to see the resident and evaluate. Family was notified. Interview on 11/29/23 at 2:12 P.M. with DON verified Resident #9 was to be two persons assist for Page 1 of 2 365783 365783 12/07/2023 Aventura at Assumption Village 9800 Market Street North Lima, OH 44452

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few all hands-on care. DON reported STNA #324 was providing incontinence care with only one assist when resident rolled out of bed. DON reported no negative outcomes or injuries noted. Interview on 11/30/23 at 2:41 P.M. via phone with Resident #9's family revealed she received a phone call from the facility that indicated the resident was receiving care from an aide and had rolled out of bed. Resident #9's family reported the resident is a two assist for all care related to her not being able to move herself around due to a Stroke she had in 2017. Resident #9's family reported the facility nurse told her Resident #9 was to be a two person assist and the STNA provided care by herself. Interview on 12/04/23 at 1:11 P.M. via phone with STNA #324 revealed she provided incontinence care to Resident #9 with only one assist and Resident #9 rolled out of bed. Interview on 12/04/23 at 2:19 P.M. via phone with LPN #242 revealed STNA #324 notified her that Resident #9 had fallen out of bed. LPN #242 reported she immediately went to Resident #9's room to find here sitting on the floor. LPN #242 assessed the resident with no injuries, and she was hoyered back to bed with four assists. LPN #242 reported all shift she reminded STNA #324 (agency STNA) that SR #9 was a two person assist for all care and she didn't come to get her when providing incontinence care. LPN #242 notified physician, family, DON and on call unit manager. Daughter called back at 7:00 A.M. and was notified of the fall. LPN #242 reported SR #9's family did not seem to understand how it happened. Review of facility investigation dated 11/16/23 revealed the LPN #242 was alerted by STNA #324 that Resident #9 had rolled out of bed during incontinence care and landed on her bottom. Assessment completed by nurse and Resident #9 hoyered back into bed with four assists. All notifications completed to NP, DON, Unit Manager, and family. NP reported she would be in soon and evaluated Resident #9 at that time. Witness statements were included. X-rays were taken later that day of left forearm, left elbow, left Shoulder, left Scapula, and left Wrist which were all negative. Review of facility policy, Falls and Fall Risk, managing, revised 08/2022, revealed staff with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. This deficiency represents non-compliance investigated under Complaint Numbers OH00148746. 365783 Page 2 of 2