Inspection·October 29, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident family interview, staff interview, orthopedic staff interview, review of hand written statements, review of the facility incident and accident log, and policy review, the facility failed to investigate an injury of unknown origin as required. This affected one (#24) of three residents reviewed for abuse, neglect, mistreatment, exploitation, and misappropriation. The facility census was 67. Residents Affected - Few Findings included: Review of Resident #24's medical record revealed an admission date of 10/17/24. Diagnoses included infection and inflammatory reaction due to an internal left knee joint prosthesis, periprosthetic fracture around internal prosthetic right hip joint, atrial fibrillation, transient ischemic attack, and muscle weakness. Review of Resident #24's clinical admission note dated 10/17/24 revealed the resident required use of a wheelchair and knee immobilizer. She had a range of motion impairment of one unspecified lower extremity. Resident #24's gait was documented as unsteady and balance was poor. Staff were to maintain proper joint alignment while turning and positioning. Review of Resident #24's admission note dated 10/17/24 revealed a knee immobilizer to left leg was in place. Review of Resident #24's fall risk assessment dated [DATE] revealed the resident was at a high risk for falls. Review of Resident #24's medical record found no mention of a fall or injury noted from the date of admission until 10/25/24. Review of the facility incident and accident log revealed no falls or injuries were log for Resident #24 between 10/17/24 and 10/25/24. Review of a hand written statement dated 10/22/24, written by Registered Nurse (RN) #165 revealed Resident #24 and a certified nurse aide (CNA) were in the bathroom when RN #165 entered to administer medications. Further review of the written statement revealed Resident #24 indicated her knee popped and was given pain medication. Resident #24 was administer additional pain medication 30 minutes later and then denied any further pain or issues. Review of Resident #24's health status note dated 10/25/24 revealed the resident returned from an (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: 365837 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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)