Health inspection·October 31, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observations, record reviews, and interviews, the facility failed to ensure residents were transferred in a manner to prevent major injury. This affected one resident (#24) out of the three residents reviewed for accidents. The facility census was 86. Actual harm occurred on 10/05/23 at approximately 1:00 P.M. when Resident #24 sustained a fracture of the right distal tibia during a staff assisted transfer from the resident's room to the shower room in a shower chair which did not have leg and foot support. Findings include: Record review for Resident #24 revealed an admission date of 02/28/20 and diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right side, spastic hemiplegia affecting the right side, anxiety disorder, dementia, unspecified visual loss, age-related nuclear cataract, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/13/23, revealed Resident #24 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 03. Resident #24 was assessed to require extensive assistance from two staff members for bed mobility, extensive assistance from one staff member for transfers and toileting and was dependent on one staff member for locomotion on the unit. Resident #24 was assessed to utilize a wheelchair for mobility. Review of the care plan, most recently revised on 05/23/22, revealed Resident #24 had an Activities of Daily Living (ADL) Self Care Performance Deficit and required assistance with ADLs and mobility related to weakness, lack of coordination, impaired mobility, and hemiplegia. Interventions included resident was unable to ambulate and required a wheelchair for locomotion, resident needed to be pushed (extensive assistance of one) but could assist with propelling own wheelchair at times. Review of the late entry nurses progress note, dated 10/05/23 and timed 2:00 P.M., revealed the writer was notified that while Resident #24 was in shower chair being transported to her room Resident #24's right foot became caught under the shower chair. The physician was notified, and new orders were obtained for a two view x-ray of the right foot. Review of the facility incident report, dated 10/05/23, revealed on 10/05/23 around 1:00 P.M. State (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: 365994 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 365994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Hillsboro 175 Chillicothe Avenue Hillsboro, OH 45133 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)