Health inspection·February 12, 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. Based on medical record review, observation, staff interview and review of the facility policy the facility failed to ensure fall prevention interventions were in place to prevent resident injury from falls. This affected two (Residents #20 and #41) of three residents reviewed for falls. The facility census was 111 residents. Findings include: 1.Review of the medical record for Resident #20 revealed an admission date of 05/24/11 with diagnoses including diabetes, malnutrition, heart disease, anxiety, chronic pain, and dementia. Review of the Minimum Data Set (MDS) assessment for Resident #20 dated 12/26/23 revealed the resident was cognitively impaired and required partial to moderate assistance for ambulation, moving in bed, and moving from a sitting to a standing position. Review of the plan of care for Resident #20 updated 02/07/24 revealed the resident was at risk for falls due to decreased endurance, impaired judgment and cognitive impairment. Interventions included the following: assist with toileting as needed, bilateral bedrails to enable mobility in bed, keep call light and frequently used items in reach, monitor for safety, non-skid footwear, non-skid strip to toilet and side of bed and bathroom, keep pathways free of clutter and well-lit, perimeter mattress, signage on walker to remind resident to use walker when ambulating, staff to anticipate needs, toileting program, toileting schedule initiated, transfer using maxi-move, unplug bed remote at appropriate height, resident to be up in common area for increased supervision while awake, signage to remind staff to take resident to the common area. Observation on 02/07/24 at 10:38 A.M. revealed Resident #20 was resting in bed, and the bed was in a high position. Interview on 02/07/24 at 10:38 A.M. with Licensed Practical Nurse (LPN) #210 confirmed Resident #20 was resting in bed and the bed was in a high position. LPN #210 confirmed she was not sure if Resident #20's bed was supposed to be in a high or low position. Interview on 02/08/24 at 10:40 A.M. with State Tested Nursing Assistant (STNA) #205 confirmed Resident #20 was in bed resting with her bed in the high position, and the resident's bed was supposed to be kept in a low position when the resident was in bed to prevent the risk of injury from falling. The Surveyor attempted to interview Resident #20 on 02/08/24 at 11:10 A.M. but the resident was unable to participate in an interview or answer questions due to cognitive impairment. Page 1 of 2 365917 365917 02/12/2024 Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/08/24 at 2:55 P.M with Minimum Data Set Nurse (MDSN) #220 confirmed Resident #20 was at risk for falls and her fall care plan interventions included ensuring the resident's bed was at an appropriate and safe height to prevent injury if the resident fell out of bed. 2. Review of the medical record for Resident #41 revealed an admission date of 04/22/23 with diagnoses including hemiplegia and hemiparesis, malnutrition, fractured hip, heart failure and depression. Review of the care plan for Resident #41 dated 04/24/23 revealed the resident was at risk of falls. Interventions included a bolstered mattress and a mattress to be placed on the floor to the open side of the bed. Review of physician orders for Resident #41 revealed an order dated 11/08/23 for a mattress to be placed on the floor to the open side of the bed. Review of the MDS assessment for Resident #41 dated 12/29/23 revealed the resident was cognitively impaired and required substantial/maximum assist for transfers and activities of daily living. Observation on 02/08/24 at 2:35 P.M. with Resident #41 revealed the resident was sleeping in bed and the fall prevention mattress was propped up on its side and was not in place on the floor to the open side of the bed per the resident's care plan. The Surveyor attempted to interview Resident #41 on 02/08/24 at 2:35 P.M. but the resident was unable to participate in an interview or answer questions due to cognitive impairment. Interview on 02/08/24 at 2:47 P.M. with LPN Unit Manager #215 confirmed Resident #41 was supposed to have a mattress placed on the floor to the open side of the bed when the resident was in bed to prevent injuries from falling. LPN Unit Manager #215 confirmed staff had removed the mattress a few hours earlier when they gave the resident his lunch tray in bed and staff had failed to put the mattress back in place on the floor to prevent injury. Interview on 02/08/24 at 2:55 P.M. with MDSN #220 confirmed Resident #41 was at risk for falls with injury and the resident's care plan included the intervention to place a mattress on the floor to the open side of the resident's bed to prevent injuries from falling. MDSN #220 confirmed the mattress should only be removed if resident was up in a chair and not located in his bed. Review of facility policy titled Falls and Managing Falls Risk dated August 2022 revealed staff would identify interventions related to residents' specific fall risks and causes to try to prevent the resident from falling and try to minimize complications from falling. An evaluation of a resident's fall risk would be completed and interventions would be initiated. Review of facility policy titled Care plan and Comprehensive Care Plans dated 03/16/23 revealed the facility would implement the interventions included the resident's care plan. The care plan interventions should be derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Residents had the right to receive services or items named in the care plan. This deficiency represents non-compliance investigated under Complaint Number OH00150632 and Complaint Number OH00150381. 365917 Page 2 of 2