Health inspection·March 21, 2024

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 a comprehensive fall investigation was completed following a fall with major injury. This affected one resident (Resident #21) of three residents reviewed for accidents. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, weakness, difficulty walking, anxiety, and osteoarthritis. Review of the plan of care, dated 10/24/23, revealed Resident #21 was at risk for injury related to falls with interventions including bed and chair alarms to alert staff of unassisted transfers. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/02/24, revealed the resident's Brief Interview for Mental Status (BIMS) score could not be assessed due to the resident rarely/never being understood. The resident required physical assistance activities of daily living (ADLs). The resident's mobility devices were a walker and a wheelchair. The assessment indicated there was one fall without injury since admission or the prior assessment. Review of the fall risk assessment, dated 01/07/24, revealed Resident #21 was at risk for falls. Review of the Fall Investigation, dated 02/01/24, revealed the resident could not tell what happened due to her level of orientation. Current fall interventions were in place. The resident was wandering out of her wheelchair in the hallway, right outside of her room. The resident fell on her left side, mainly on hip, and the fall was witnessed by state-tested nursing assistant (STNA). The resident was sent to the emergency room (ER) for evaluation. Further review of the fall investigation section titled, Observations at the Time of Fall, did not indicate if any alarms were sounding or not sounding. Both choices were left blank. The resident sustained a fall on 02/01/24 which resulted in a left intertrochanteric femur fracture. During interview on 03/20/24 at 3:52 P.M. with Licensed Practical Nurse (LPN) #100 confirmed that although her nursing progress note failed to indicate if Resident #21's wheelchair alarm was sounding, the chair alarm was properly working and sounding at the time of the fall. During interview on 03/20/24 at 4:40 P.M. with Regional Clinical Consultant #400 and the DON both (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 3 Event ID: 365891 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 365891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Pointe Nursing & Rehab Ctr 620 East Main Street West Lafayette, OH 43845 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)