Health inspection·May 18, 2023

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, and record review, the facility failed to ensure fall interventions were in place per the plan of care for Resident #100. This affected one (#100) of three residents reviewed for falls. The facility census was 119. Findings include: Review of the medical record for Resident #100 revealed an admission date of 11/16/22. Diagnoses included Alzheimer's disease, dementia, fracture around internal prosthetic right hip joint (03/14/23), age related physical debility, difficulty in walking, and unsteadiness on feet. Review of the care plan dated 11/16/22 revealed Resident #100 was at-risk for falls due to deconditioning, Alzheimer's, hypertension, congestive heart failure, and debility. Interventions included educate resident and family about safety reminders and what to do if a fall occurs, encourage resident to rest when they feel fatigued, provide assistive devices as needed, anti-rollbacks to wheelchair, bed in low position, mat to floor beside bed, and call light touch pad within reach. Review of the comprehensive nursing evaluation dated 02/07/23 revealed Resident #100 was at-risk for falls due to a history of falls, fear of falling, urinary urgency, impaired cognition, and taking medications the increased potential for falls. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had one fall with major injury since the last assessment. Review of the significant change MDS assessment dated [DATE] revealed Resident #100 had severe cognitive impairment and required extensive assistance from staff for bed mobility and transfers. The assessment indicated Resident #100 had one fall with no injury since the last assessment. Review of the incident log revealed Resident #100 experienced falls on 01/31/23, 02/01/23, 03/10/23, and 04/06/23. Review of the progress note dated 03/10/23 at 6:34 P.M. revealed Resident #100 was found on the floor in her bedroom after attempting to self-ambulate and her wheelchair was located on her roommates side of the room with the brakes not engaged. A note dated 03/10/23 at 6:42 P.M. indicated Resident #100 was laying on her back on the floor with her legs out in front of her. A note dated 03/10/23 at 8:38 A.M. revealed Resident #100 was complaining of pain to her right thigh. A noted dated 03/11/23 at 12:56 P.M. revealed Resident #100 had a periprosthetic fracture of the right femoral shaft. A note dated 03/11/23 at 1:15 P.M. revealed Resident #100 was sent to the hospital for evaluation. Review of the fall investigation dated 03/10/23 revealed Resident #100 was found laying on her back on the floor and had no obvious injuries at the time of the fall. On 03/11/23, Resident #100 was complaining of right leg pain and a fracture was identified. At the time of the fall, there were anti-rollbacks to her wheelchair and her wheelchair brakes were not engaged. New interventions implemented after the fall included education on call light use and a fall mat beside the bed. Review of the progress note dated 04/06/23 at 3:00 P.M. revealed Resident #100 was found laying on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 2 of 3 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her left side on the floor after attempting to self-transfer to bed. Resident #100 had gripper socks on and her wheelchair was beside her with brakes unlocked. No documentation of fall mat in place beside bed. Review of the fall investigation dated 04/06/23 revealed Resident #100 was found on the floor on her left side and Resident #100 stated she was attempting to lay down in bed. At the time of the fall, her wheelchair brakes were not engaged and she had gripper socks on. There was no evidence a fall mat was in place at the time of the fall. New interventions included offering to put to bed between lunch and dinner. On 05/16/23 at 9:16 A.M., observation of Resident #100 revealed she was laying in bed and there was no fall mat in place beside the bed. On 05/16/23 at 9:42 A.M., interview with Licensed Practical Nurse (LPN) #418 verified the fall mat was not beside the bed. Upon further observation of the room, LPN #418 located the fall mat propped vertically between two cupboards in Resident #100's room. On 05/17/23 at 10:11 A.M., interview with the Director of Nursing verified the fall investigation dated 04/06/23 indicated Resident #100 was laying on the floor and not on a fall mat. She also stated that on the evening of 05/16/23, Resident #100's fall mat was underneath her bed rather than beside it. Review of facility policy titled Fall Management, dated 08/18/22, revealed falls would be reviewed within 24 to 72 hours after a fall and the plan of care would be revised to minimize repeat falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 3 of 3