Health inspection·February 25, 2025

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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, family interview, staff interview, review of the facility therapy to nursing communication form and review of facility policy, the facility failed to provide adequate staff assistance during transfers to prevent falls. This resulted in actual harm on 01/15/25 at approximately 12:25 P.M. to Resident #100 when Certified Nursing Assistant (CNA) #20 completed a hands-on transfer of the resident from the wheelchair to the bed without the assistance of additional staff. Resident #100 sustained a fall to the floor during the transfer, resulting in a left femur fracture. This affected one resident (#100) of three residents reviewed for falls. The facility census was 84. Findings include: Review of the medical record for Resident #100 revealed an admission date of 01/13/25. Diagnoses included cerebral infarction (stroke), spastic hemiplegia (causes muscle tightness and involuntary contractions on one side of the body), diabetes mellitus, epilepsy, seizures, depression, anxiety, foot drop (difficulty lifting the front part of the foot), and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #100 revealed no information for this resident due to the length of stay in the facility. Review of the care plan, dated 01/14/25, revealed Resident #100 had an activities of daily living (ADLs) self-performance deficit and required staff assistance related to hemiplegia, foot drop, cerebral infarction, and overall medical condition. Interventions included total staff dependence with transfers and the resident required the assistance of one or more staff with transfers. Review of the facility Therapy to Nursing Communication Form, dated 01/14/25 and completed by Physical Therapy Assistant (PTA) #40, revealed Resident #100 had left-sided hemiplegia due to a previous cerebral infarction and was evaluated to need two staff assistance for all transfers. Further review revealed Licensed Practical Nurse (LPN) #10 acknowledged the communication on 01/14/25. Review of a nursing progress note, dated 01/15/25 at 12:35 P.M., revealed LPN #30 immediately responded to the room of Resident #100 after hearing her screaming in pain. Upon arrival, she witnessed CNA #20 and Resident #100 both on the floor, after an attempted transfer. Further review revealed Resident #100 was screaming in excruciating left hip pain. LPN #30 documented she was unable to complete an assessment due to the position of both CNA #20 and Resident #100. In addition, the note (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: 365786 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 365786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Georgetown Rehabilitation and Healthcare Cen 8065 Dr Faul Road Georgetown, OH 45121 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)