Health inspection·September 20, 2023

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. Based on record review, interview and policy review, the facility failed to notify a resident's responsible party of the need to change treatment to a pressure ulcer. This affected one (Resident #29) of three residents reviewed. The census 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 admission screener for Resident #29, dated 07/31/23, revealed a pressure wound to the left heel measuring 5.5 centimeters (cm) in length, 11 cm in width and no depth. A progress note dated 09/06/23 at 1:12 P.M. revealed the previous area to the left heel was now open with serosanguinous drainage. The area was cleaned, and a new daily treatment was put into place. The Unit Manager and physician were notified. There was no documentation the resident's responsible party was notified of the change in the treatment plan. During interview on 09/20/23 at 10:22 A.M., Licensed Practical Nurse (LPN) #323 confirmed there was no documentation the resident's responsible party was notified of the change in treatment to the hell ulcer. Review of the facility policy titled Notification of Change dated August 2021 revealed the resident and/or the resident ' s legal representative or interested family member when there is a development of skin areas. This deficiency represents non-compliance investigated under Complaint Number OH00146294. Page 1 of 3 365882 365882 09/20/2023 Springmeade Healthcenter 4375 South County Road 25 A Tipp City, OH 45371

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 365882 Page 2 of 3 365882 09/20/2023 Springmeade Healthcenter 4375 South County Road 25 A Tipp City, OH 45371

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. 365882 Page 3 of 3