Health inspection·August 27, 2025

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 reviews, fall investigation reviews, interviews and facility policy review, the facility failed to ensure falls were thoroughly investigated for Residents #17 and #72. This affected two residents (#17 and #72) of three residents reviewed for falls. The facility census was 70. Findings include:1. Review of the medical record for Resident #17 revealed an admission date of 03/07/25. Diagnoses included history of falling, protein calorie malnutrition, hypertension, high cholesterol, gastroesophageal reflux disease (GERD), glaucoma, delirium, muscle weakness and hearing loss. Review of the fall risk assessment dated [DATE] revealed Resident #17 was at moderate risk for falls. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired. She required supervision for eating, partial to moderate assistance for oral hygiene and showering and was dependent on staff for toileting and dressing. She was frequently incontinent of urine, always incontinent of bowel and was dependent on staff for rolling left to right, sitting to lying, lying to sitting on one side of the bed and sitting to standing or chair to bed transfers. Review of the physician's orders for August 2025 revealed an order for two quarter top positioning bars when up in bed to aid in positioning which began on 03/10/25, an alarm to the bed and wheelchair for safety which began on 05/08/25, a perimeter mattress which began on 05/23/25, and an order for one person assist with bed mobility, transfers and toileting using a front wheeled walker which began on 08/14/25. Review of the nursing note dated 05/22/25 at 5:51 P.M. revealed Licensed Practical Nurse (LPN) #201 was notified by Certified Nurse Aide (CNA) #207 that Resident #17 was out of bed. LPN #201 observed Resident #17 with both legs on the floor and her left arm in between the mattress and the bed railing facing into the mattress. When asked what happened, Resident #17 was unable to respond appropriately and stated, they are calling my mother. Vital signs were obtained, and the resident's blood pressure was 159/98, heart rate 88, pulse ox 94%, temperature 98.2 degrees Fahrenheit (F) and range of motion was within normal limits. The resident denied pain, and no injuries were noted. Resident #17's family, physician and the Director of Nursing (DON) were notified. The call light was noted to be in reach, the bed was in the lowest position, and an intervention of a perimeter mattress and floor mat were put into place. Review of the facility incident report dated 05/22/25 revealed Resident #17 was observed with both legs out of bed, with her left arm wedged in between the mattress and the arm rail. No injuries were noted. The resident was noted to be confused, incontinent with an unsteady gait, impaired memory, recent medication changes and weakness. She was oriented to person only. No predisposing factors were identified. There was no documented evidence of when she had last been toileted. Review of the care plan dated 05/25/25 revealed Resident #17 was at risk for falls due to gait and balance problems, history of falling and glaucoma. Interventions included a bed alarm, ensuring the call light within reach, a chair alarm and two quarter top positioning bars when up in bed to aid in positioning. Review of the nursing note dated 06/13/25 at 2:18 P.M. Page 1 of 3 365822 365822 08/27/2025 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed LPN #202 was outside Resident #17's room when she heard her yelling for help. She went into the room to find the resident holding on to the side rail but still on the bed with her legs hanging out of the bed with blood on the floor and sheets. She called for assistance and CNAs #206 and #208 came into the room and assisted in applying pressure to Resident #17's lower extremity. The resident was assisted back into bed and presented with a large deep laceration into the fatty layers of her upper thigh. An ambulance was already in the facility for another resident; however, it was determined Resident #17's needs were greater, therefore she was taken to the emergency department (ED). Resident #17's daughter was notified; her vital signs were not able to be obtained before ambulance transport. The resident returned from the ED approximately 6:00 P.M. with 15 stitches to the laceration on the inside of her right thigh. Review of the facility incident report dated 06/13/25 revealed Resident #17 was yelling for help and found almost out of bed with blood all over. CNAs #206 and 208 assisted in getting the resident back into bed while LPN #202 attended to and addressed the injury, a deep laceration to inner right thigh. The resident was oriented to person in place, hearing impaired and did not use her call light for assistance. She was immediately sent to the ED. There was no description of the condition of the room, no indication if the bed alarm was in use or activated, no information regarding a perimeter mattress or floor mat and no evidence that the call that was within reach. Witness statements obtained as part of the investigation revealed LPN #202 was outside Resident #17's room when she heard her yell for help. The resident was found halfway out of her bed with the upper half of her body in her bed holding onto the side rail. Blood was noted on the sheets on the floor. Additional staff came to the room and assisted in getting Resident #17 back into bed. The resident was transported to the ED by ambulance. There was no documented evidence to determine if the call light was in reach, if the perimeter mattress was in place, what the room looked like, or when Resident #17 had last been toileted in the witness statements. Interview on 08/25/25 at 9:57 A.M. with LPN #202 revealed she happened to be walking by Resident #17's room when she heard her scream, so she entered her room. She said her tray table was at the end of her bed and she looked around but could not locate any source that may have caused the laceration to her leg. Interview on 08/25/25 at 10:12 A.M. with LPN #205 revealed Resident #17 was incontinent of both bowel and bladder at the time of the fall on 06/13/25. She confirmed Resident #17 should have been toileted every two hours and she believed the last time she had seen the resident was approximately 15 to 20 minutes prior to the incident. She confirmed there was a bed alarm on Resident #17's bed; however, it had not been activated because the resident was still halfway on the bed. She revealed the residents' bedside table was between the middle and the head of the bed at an angle and there was no indication of what may have caused the injury. Interview 10/25/25 at 10:20 A.M with CNA #206 revealed she had helped Resident #17 into bed approximately 10 minutes before the incident and toileted her at that time. She heard the resident scream and found her on her bed with her elbows propped up on the bed and her legs on the floor. She revealed that tray side table was over the top of her legs, but no blood was noted on the tray side table. She stated Resident #17 was incontinent of both bowel and bladder at the time of the fall. She could not confirm if a perimeter mattress was in place at the time but confirmed her call light was within reach. Interview on 08/25/25 at 12:14 P.M. with the DON verified the facility's fall investigations likely needed to be updated to ensure accuracy and thoroughness and should have included all interventions in place at the time of the falls for Resident #17 to determine a root cause analysis of the fall. 2. Review of the medical record for Resident #72 revealed an admission date of 04/14/25 and a discharge date of 07/17/25. Diagnoses included urinary tract infection, osteoporosis, hypertension, vitamin D deficiency, anxiety, muscle weakness and history of falling. 365822 Page 2 of 3 365822 08/27/2025 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the fall risk assessment data 04/14/25 revealed Resident #72 was at moderate risk for falls. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #72 was moderately cognitively impaired. She required supervision for eating oral and personal hygiene and partial to moderate assistance with toileting and showering. She was occasionally incontinent of urine and bowel. Review of the care plan dated 04/21/25 revealed Resident #72 was at risk for falls due to muscle weakness, history of falls, and difficulty walking. Interventions included ensuring the call light was within reach, maintaining a clear pathway and two quarter top positioning bars when up in bed to aid in positioning. Review of the nursing note dated 05/15/25 at 3:00 P.M. revealed Resident #72 was found on the floor in front of her wheelchair in her room. She said she was attempting to self-ambulate and was unable to keep her balance. She said she hit her head on the floor. A red area to her left hip and left upper head were noted. Here vital signs were noted to be within normal limits; however, they were not documented. The resident was assisted to her wheelchair, and her physician, the DON and daughter were notified. Her daughter asked that the resident be sent to the ED. Review of the facility incident report dated 05/15/25 revealed Resident #72 was attempting to self-ambulate when she lost her balance, there was an alarm (no order for an alarm) sounding at the time of the incident. The resident was assessed and both neurological checks and vital signs were stated to be within normal limits; however, neither were included in the report. Resident #72 was listed as confused but oriented to person. Predisposing factors were listed as weakness, gait imbalance and ambulating without assistance. The investigation revealed no evidence of the residents' call light being in reach. Review of the nursing note dated 07/11/25 at 10:58 A.M. revealed Resident #72 was found on the floor with no signs of injury. The resident was confused and unable to answer questions, could not follow the light with her eyes. The resident was sent to the ED, and both her daughter and son were notified as well as the physician and DON. Review of the facility incident report dated 07/11/25 revealed Resident #72 was found on the floor by LPN #205 and was assisted into her wheelchair along with an unnamed CNA. A skin assessment was completed, and no visible signs of injury were noted. The resident could not indicate if she hit her head but was unable to answer questions or follow direction. The resident's vital signs were obtained with a blood pressure of 116/70, pulse ox 99%, temperature 97.9 degrees F, heart rate 80, and no pain. Neurological checks were reported as within normal limits; however, there was no documented evidence of the neurological checks. The resident was sent to the ED for an evaluation. The resident was confused with predisposing factors of incontinence, gait imbalance and not using her call light for assistance. The investigation did not reveal if the resident's call light was within reach or when she was last toileted. Interview on 08/25/25 at 12:14 P.M. with the DON revealed Resident #72 had no physician's order or care plan addressing a bed or chair alarm. She verified the facility's fall investigations likely needed to be updated to ensure accuracy and thoroughness and should have included all interventions in place at the time of the falls for Resident #72 to determine a root cause of the fall. Review of the undated facility policy titled Fall Prevention Procedure/Policy revealed the facility would document and evaluate any fall that occurred while the patient resided at the facility including when and where and observations of the event. The facility would assess, and document vital signs, recent injuries, neurological status, precipitating factors and details of how a fall occurred. The nurse would assess the patients' vital signs, range of motion and any injuries as well as identify environmental factors that may have contributed to the fall. This deficiency represents noncompliance investigated under Complaint Number 2584229. 365822 Page 3 of 3