Health inspection·March 6, 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 observation, interview, record review, and facility policy review the facility failed to ensure fall interventions were in place for Resident #47. This affected one resident (#47) of three residents reviewed for falls. The facility census was 50. Findings Include: Review of Resident #47's medical record revealed an admission date of 06/07/23 and diagnoses including acute pulmonary edema, bipolar disorder, generalized anxiety disorder, hypertension, depression, dementia with other behavioral disturbance, and moderate protein calorie malnutrition. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 was cognitively impaired and did not reject care. Resident #47 required substantial/partial assistance to sit to stand. Resident #47 could wheel 50 feet in her wheelchair with two turns with supervision or touching assistance. Resident #47 had two falls coded since the prior assessment. Review of a fall risk evaluation dated 02/27/24 revealed Resident #47 had one to two falls in the past three months and had intermittent confusion. The assessment indicated a score of 10 or higher meant the resident was at a high risk for falls; Resident #47 had a score of 11 thus was at risk for falls. Review of the plan of care dated 06/08/23 and revised 02/13/24 revealed Resident #47 was at higher risk for falls due to gait and balance problems due to osteoarthritis of the knee and psychoactive drug use as well as being unaware of safety needs. Interventions listed included Dycem (non-slip material) to wheelchair for safety (dated 06/21/23) and place call before you fall signage in plain view in room (dated 07/12/23). Observation on 03/06/24 starting at 8:03 A.M. of Resident #47 revealed she was dressed and seated in her wheelchair by the nurses' station. Registered Nurse (RN) #116 and RN #103 were asked if Resident #47 had Dycem on her wheelchair as it could not be visualized on the wheelchair while Resident #47 was seated. RN #103 assisted Resident #47 to stand, and no Dycem was noted on her wheelchair. RN #103 then reviewed Resident #47's current care plan for falls with the surveyor and verified the Dycem was not in place per Resident #47's plan of care. During this time RN #103 was questioned regarding the call before you fall signage intervention also listed on Resident #47's plan of care. At 8:08 A.M. RN #103 accompanied the surveyor to Resident #47's room and no sign was visualized. RN #103 verified the lack of signage at the time of observation. Page 1 of 2 366021 366021 03/06/2024 Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122

F 0689 Level of Harm - Minimal harm or potential for actual harm Interview on 03/06/24 starting at 9:15 A.M. with the Director of Nursing (DON) revealed Dycem would have been listed in Resident #47's physicians' orders once it was identified as a fall intervention. Resident #47's historical and current physicians' orders were searched with the DON during the interview and no order for Dycem was found. The DON verified the lack of physicians' order for Resident #47's Dycem at the time of discovery. Residents Affected - Few Review of the undated facility policy, Fall Prevention and Management Program, revealed each resident would have a care plan for potential for falls developed and implemented upon admission and updated with each review and when appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00151229 and is an example of continued non-compliance from the complaint survey dated 02/13/24. 366021 Page 2 of 2