Health inspection·February 21, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure residents representatives were notified of a change in condition. This affected two (#25 and #42) of three residents reviewed for a change in condition. The facility census was 41. Findings include: 1. Review of the medical record of Resident #42 revealed an admission date of 01/03/24. The resident was discharged from the facility on 01/11/24 to another nursing home. Diagnoses included Coronavirus (COVID-19), hyperlipidemia, essential hypertension, shortness of breath, chronic obstructive pulmonary disease (COPD), depression, atrial fibrillation, and urinary retention. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition. The resident required partial/moderate assistance with toileting, personal hygiene, and all mobility. Review of a progress note dated 01/11/24 at 5:04 A.M. revealed Resident #42 had a witnessed fall at approximately 4:50 A.M. when transferring to her wheelchair. Resident #42 was noted to hit her head on the bed site tray table and the State Tested Nursing Assistant (STNA) assisted her the rest of the way to the floor. Resident #42 stated she lost her balance and leaned forward. The resident was assessed, assisted back to bed, and ice was placed to the resident's forehead. The physician was notified via an urgent fax. The progress note revealed no documented evidence that the resident's representative was notified. Review of the Change in Condition Evaluation dated 01/11/24 at 5:11 A.M. revealed the resident experienced a change in condition related to a fall. The name of family/healthcare agent notified was documented as self on 01/11/24 at 5:00 A.M. Review of the post-fall interdisciplinary team (IDT) progress note dated 01/11/24 at 11:26 A.M. revealed, on 01/11/24 at 4:50 A.M., staff was assisting Resident #42 with a transfer from her bed to the wheelchair when Resident #42 lost her balance and went forward, hitting her head on the bed side tray table. The STNA then assisted the resident to the floor. The nurse assessed the resident and noted redness to the forehead, which turned into a bump. Prior interventions were to have the call light in reach and to anticipate the residents' needs. A new intervention was to use a gait belt for all transfers with the assistance of two staff. The IDT note revealed no documented evidence that the resident's representative was notified. Page 1 of 4 365812 365812 02/21/2024 Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/20/24 at 4:08 P.M., the DON confirmed there was no documented evidence of the resident's representative being notified of the Resident #42's fall. The DON reported, despite Resident #42 having intact cognition, her representative should have been notified of the fall. 2. Review of the medical record of Resident #25 revealed an admission date of 01/17/24. Diagnoses included cerebral infarction, humeral fracture, Alzheimer's disease, dementia, repeated falls, morbid obesity, major depressive disorder, and gastro-esophageal reflux disease (GERD). Review of the comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required substantial/maximal assistance with toileting, personal hygiene, and was dependent on staff for all mobility. Review of a progress note dated 01/25/24 at 5:52 A.M. revealed Resident #25 was observed lying on the floor at the right side of the bed as the aide entered the resident's room. The on-call physician was notified. The progress note revealed no documented evidence that the resident's representative was notified. Review of the Change in Condition Evaluation dated 01/25/24 at 6:17 A.M. revealed the on-call physician's name was listed in the area for the name of family/healthcare agent notified on 01/25/24 at 6:30 A.M. The evaluation revealed no documented evidence that the resident's representative was notified. Interview on 02/20/24 at 3:55 P.M., the DON verified there was no documented evidence of the representative for Resident #25's being notified when the resident had a fall on the morning of 01/25/24. The DON verified the representative should have been notified of the fall and the notification should have been documented in the medical record. Review of the facility policy titled, Determining Change in Condition, dated 06/27/22 revealed the facility will promptly notify the resident, attending physician, and the representative (sponsor) of changes in the resident's medical condition or status. This deficiency represents non-compliance investigated under Complaint Number OH00150436. 365812 Page 2 of 4 365812 02/21/2024 Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215

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 medical record review, staff interview, and policy review, the facility failed to ensure staff utilized appropriate practices to ensure residents were free from falls. This affected one (#42) of three residents reviewed for falls. Additionally, the facility also failed to ensure all falls were investigated. This affected one (#25) of three residents reviewed for falls. The facility census was 41. Findings include: 1. Review of the medical record of Resident #42 revealed an admission date of 01/03/24. The resident was discharged to another nursing home facility on 01/11/24. Diagnoses included (Coronavirus) COVID-19, hyperlipidemia, essential hypertension, shortness of breath, chronic obstructive pulmonary disease (COPD), depression, atrial fibrillation, and urinary retention. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition. The resident required partial/moderate assistance with toileting, personal hygiene, and all mobility. Review of the plan of care dated 01/04/24 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to activity intolerance, disease process, and shortness of breath (SOB). Interventions included utilizing a gait belt and one to two persons assist, depending on her physical functioning abilities and SOB. Review of a progress note dated 01/11/24 at 5:04 A.M. revealed Resident #42 had a witnessed fall at approximately 4:50 A.M. when transferring to her wheelchair. Resident #42 was noted to hit her head on the bed site tray table and the State Tested Nursing Assistant (STNA) assisted her the rest of the way to the floor. Resident #42 stated she lost her balance and leaned forward. The resident was assessed, assisted back to bed, and ice was placed to the resident's forehead. The physician was notified via an urgent fax. Review of the post-fall interdisciplinary team (IDT) progress note dated 01/11/24 at 11:26 A.M. revealed, on 01/11/24 at 4:50 A.M., staff was assisting Resident #42 with a transfer from her bed to the wheelchair when Resident #42 lost her balance and went forward, hitting her head on the bed side tray table. The STNA then assisted the resident to the floor. The nurse assessed the resident and noted redness to the forehead, which turned into a bump. Prior interventions were to have the call light in reach and to anticipate the residents' needs. A new intervention was to use a gait belt for all transfers with the assistance of two staff. Interview on 02/21/24 at 9:12 A.M., STNA #340 stated, on the morning of 01/11/24, Resident #42 requested help with getting up and going to the bathroom. STNA #340 stated, as she was attempting to transfer Resident #42, the resident shifted faster than she anticipated, lost her balance, and fell forward. STNA #340 stated she was not utilizing a gait belt for the transfer because she did not have time to put it on the resident. Interview on 02/20/24 at 4:08 P.M., the DON confirmed STNA #340 was transferring Resident #42 without a gait belt when the fall occurred. The DON verified a gait belt should have been used when transferring Resident #42 from her bed to the wheelchair. 365812 Page 3 of 4 365812 02/21/2024 Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy titled, One Person Transfer, dated 07/08/21, revealed residents who have been evaluated/assessed as requiring one-person manual assistance will utilize a transfer belt to promote safety of the resident. 2. Review of the medical record of Resident #25 revealed an admission date of 01/17/24. Diagnoses included cerebral infarction, humeral fracture, Alzheimer's disease, dementia, repeated falls, morbid obesity, major depressive disorder, and gastro-esophageal reflux disease (GERD). Review of the comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required substantial/maximal assistance with toileting, personal hygiene, and was dependent on staff for all mobility. Review of a nurse's progress note dated 01/25/24 at 5:52 A.M. revealed Resident #25 was observed lying on the floor at the right side of the bed as the aide entered the resident's room. The on-call physician was notified. Further review of the medical record revealed no documented evidence of a fall investigation being completed for Resident #25's fall on the morning of 01/25/24. Interview on 02/20/24 at 3:55 P.M., the DON verified there was no investigation completed for the fall which occurred on the morning of 01/25/24. The DON stated she was not aware of the fall and therefore an investigation was not completed. Review of the facility policy titled, Fall Management Program Guideline, dated 12/15/23, revealed all falls must be investigated to the causative reasons/contributing factors. This deficiency represents non-compliance investigated under Complaint Number OH00150436. 365812 Page 4 of 4