Health inspection·November 14, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, witness statement review, review of a facility investigation, and staff interview, the facility failed to notify the physician and the responsible party timely of a resident fall. This affected one (#7) of three residents reviewed for falls. The facility census was 84. Findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included hypertension, depression, anxiety, seizures, history of falling, lack of coordination, unspecified psychosis, and muscle wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 was severely cognitively impaired. The resident was dependent on staff for activities of daily living, including showering and bathing. Review of the undated staff witness statement provided by State Tested Nurse Aide (STNA) #512 revealed on 10/25/23, Resident #7 was attempting to stand while in the shower and slid herself from the shower chair to the floor. STNA #512 assisted the resident back to her room, and another STNA retrieved the nurse. The nurse asked if the resident fell and STNA #512 stated, No, she slid herself down to the floor. The nurse performed an assessment and the resident appeared to be fine. Review of the staff witness statement provided by STNA #988, dated 10/30/23, revealed on 10/25/23, STNA #512 reported Resident #7 slipped out of the shower chair and STNA #512 had to put the resident back in the chair. STNA #988 retrieved the nurse, who came in to assess the resident. The nurse asked STNA #512 what happened, and STNA #512 reported Resident #7 fell out of a chair. Review of the undated staff witness statement provided by Registered Nurse (RN) #933 revealed STNA #512 assisted Resident #7 with a shower on 10/25/23. STNA #7 reported no falls, and that the resident was trying to get out of the shower chair. The resident had a reddish-purple area with no open area to her left buttocks. The resident did not appear in or report pain. Review of the incident report dated 11/14/23 revealed STNAs reported on 10/30/23 that Resident #7 slipped out of a chair during a shower on 10/25/23. The resident was assisted to bed. A bruise was noticed and the nurse was notified. The nurse assessed the resident. A nurse practitioner and Resident #7's guardian were notified on 10/30/23 at 12:39 P.M. Review of the electronic and paper medical records, the facility investigation, and supplemental Page 1 of 4 366067 366067 11/14/2023 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documentation, revealed no evidence Resident #7's physician or responsible party were notified of Resident #7 sustaining a fall prior to 10/30/23. Interview on 11/13/23 at 12:47 P.M. with STNA #512 stated while assisting Resident #7 with a shower on 10/25/23, the resident attempted to stand and slid down the shower chair. STNA #512 reported notifying the nurse on duty after assisting the resident back to her room. Interview on 11/14/23 at 7:47 A.M. with Licensed Practical Nurse (LPN) #555 revealed anytime a resident unintentionally ended up on the floor it would be considered a fall. LPN #555 stated anytime a resident sustained a fall, the physician and responsible party were notified, and the notification was documented in the resident's medical record. Interview on 11/14/23 at 10:34 A.M. with the Director of Nursing (DON) verified the physician and responsible party were not notified of Resident #7 falling on 10/25/23 until 10/30/23. This deficiency represents an incidental finding discovered during investigation under Complaint Number OH00148011. 366067 Page 2 of 4 366067 11/14/2023 Vista Care Center of Milan 185 S Main St Milan, OH 44846

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 medical record review, witness statement review, review of a facility investigation, staff interview, and review of a facility policy, the facility failed ensure appropriate care was provided following a resident fall. This affected one (#7) of three residents reviewed for falls. The facility census was 84. Findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included hypertension, depression, anxiety, seizures, history of falling, lack of coordination, unspecified psychosis, and muscle wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 was severely cognitively impaired. The resident was dependent on staff for activities of daily living including showering and bathing. Review of a fall risk assessment dated [DATE] revealed Resident #7 was assessed at risk for falls. Review of the late entry nursing progress notes, entered on 10/30/23 at 11:03 A.M. and 11:07 A.M., backdated for 10/25/23 at 3:30 P.M., revealed a state tested nurse aide (STNA) called the nurse to the bedside after Resident #7 received a shower, and indicated the resident was trying to get up and down from the shower chair, and did not fall. An eight centimeters (cm) long by eight cm wide reddish-purple area was noted on the resident's left buttocks. The resident was assessed with no signs of distress noted. Review of the undated staff witness statement provided by STNA #512 revealed on 10/25/23, Resident #7 attempted to stand while in the shower and slid herself from the shower chair to the floor. STNA #512 picked the resident up and set her back in the shower chair. STNA #512 then transferred Resident #7 into her wheelchair. STNA #512 asked the resident if she was in pain and the resident denied pain. STNA #512 then took Resident #7 to her room and transferred her into bed. While helping the resident roll, STNA #512 noticed a purplish-red area on the resident's buttocks. STNA #512 asked another STNA to come into the room to help her. The other STNA indicated she did not know what happened, so STNA #512 asked the other STNA to get the nurse. STNA #512 showed the nurse the purplish-red area that appeared to be old. The nurse asked if the resident fell, and STNA #512 stated, No, she slid herself down to the floor. The nurse performed an assessment and the resident appeared to be fine. Review of the staff witness statement provided by STNA #988 dated 10/30/23 revealed on 10/25/23, STNA #512 reported Resident #7 slipped out of the shower chair, and STNA #512 had to put the resident back in the chair. STNA #512 observed an abrasion on Resident #7's left buttocks. STNA #988 went and retrieved the nurse, who came in to assess the resident. The nurse asked STNA #512 what happened, and STNA #512 reported Resident #7 fell out of a chair. Review of the undated staff witness statement provided by Registered Nurse (RN) #933, revealed STNA #512 assisted Resident #7 with a shower on 10/25/23. STNA #7 reported no falls, and that the resident was trying to get out of the shower chair. The resident had a reddish-purple area with no open area to her left buttocks. The resident did not appear in pain and did not report complaints of pain. 366067 Page 3 of 4 366067 11/14/2023 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the electronic and paper medical records, the facility investigation, and supplemental documentation, revealed no evidence a fall, post-fall assessment, immediate intervention, or corresponding investigation was documented for Resident #7 prior to 10/30/23. Interview on 11/13/23 at 12:47 P.M. with STNA #512, revealed while assisting Resident #7 with a shower on 10/25/23, the resident attempted to stand and slid down the shower chair. STNA #512 then picked the resident up and sat her back in the shower chair. STNA #512 then transferred the resident to her wheelchair, took her back to her room, and transferred her into bed. STNA #512 then noticed a purplish-red area on the resident's buttocks and the nurse on duty came to evaluate the resident. STNA #512 verified she should have retrieved the nurse after the resident fell, prior to picking her back up, and placing her into the shower chair. Interviews on 11/14/23 from 6:54 A.M. to 7:47 A.M. with Licensed Practical Nurse (LPN) #555 and STNA #748, revealed anytime a resident unintentionally ended up on the floor it was considered a fall. Both staff members reported staff were not to assist residents in getting up until the resident was assessed by a nurse. LPN #555 reported that in the event of a fall, the nurse on duty was required to assess the resident which included assessing for range of motion, obtaining vital signs, and documenting the fall in the medical record. Interview on 11/14/23 at 10:34 A.M. with the Director of Nursing (DON) verified STNA #512 should not have assisted Resident #7 in getting up following the fall on 10/25/23, prior to a nurse assessing the resident. The DON also verified there was no documentation regarding Resident #7 sustaining a fall on 10/25/23, prior to 10/30/23. Review of the undated facility policy titled, Falls Program, revealed The Falls Committee will be notified at the time of the fall to determine the resident's condition and to initiate the investigation of the potential root cause of the fall. The licensed nurse will complete an incident report as well as the post fall worksheet. The occurrence will be documented in the nurses' notes and an immediate intervention will be implemented. This deficiency represents non-compliance investigated under Complaint Number OH00148011. 366067 Page 4 of 4