Health inspection·September 20, 2023

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 review, interview and policy review, the facility failed to ensure interventions were implemented after a resident suffered a fall. This affected one (Resident #29) of three residents reviewed for falls. The facility censes was 92. Findings include: Review of the medical record Resident #29 revealed an admission date of 02/11/19. Diagnoses included traumatic subdural hemorrhage without loss of consciousness, closed fracture of unspecified part of neck of left femur, need for assistance with personal care, and dementia with psychotic disturbance. Review of the Morse Fall Scale dated 07/28/23 indicated Resident #29 was a high risk for falling. No additional assessments were located in the medical record. No further fall risk assessments were located in the record. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #29 had impaired cognition. The resident was assessed as requiring extensive assistance of two staff with toileting, dressing, and transfers. Review of the progress note dated 07/28/23 at 5:21 A.M. revealed a nurse was alerted Resident #29 was on the floor. She was in the middle of the room with her head near her roommate's bed. Resident #29 stated I fell. Resident #29 complained of pain to left hip and a physical assessment revealed pain to the left hip with palpation. Resident #29 was sent to the emergency room and the resident's responsible party was notified. Review of the progress note dated 09/02/23 at 6:45 P.M. revealed Resident #29 stood out of wheelchair and attempted to walk and fell to the floor. Resident #29 stated she may have hit her head; neurological checks were started, and no further injuries were documented. The resident's responsible party was notified of the fall. Review of the progress note dated 09/11/23 at 12:38 A.M. revealed Resident #29 was found on the floor beside her bed. She was lying on her right side and a laceration to the right forehead was documented. The resident's responsible party was notified. Review of the care plan for falls was dated 09/16/23. New interventions were added on this date that included a floor mat to side of bed, low air loss mattress with bolsters, bed to be in low position while in bed, wear non-skid socks. Interventions in place prior to falls included assist with toileting every two hours, remind and reinforce safety awareness, ensure call light is within reach and remind resident to use it, and frequent monitoring and anticipation of needs as resident forget to use call light. Resident #29 was sent to the hospital on [DATE] for abdominal distention and had not yet returned to the facility. During interview on 09/19/23 at 2:00 P.M., the Director of Nursing stated the new interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 2 of 3 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 365882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springmeade Healthcenter 4375 South County Road 25 A Tipp City, OH 45371 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm were added to the care plan for falls after the fact. There was not an intervention or root cause analysis done after ever fall. She also verified no fall risk assessments had been completed since July 2023. Review of the policy titled Fall Prevention Policy dated October 2020, revealed a fall assessment will be completed on on new admissions, quarterly and when a resident has a fall. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00146294. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 3 of 3