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. (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: 365812 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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)