Health inspection·March 4, 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, review of the medical record, review of the facility fall investigation, review of facility policy and interview with the resident and staff, the facility failed to provide adequate assistance with care to prevent a fall for Resident #34. This affected one resident (Resident #34) of three residents reviewed for falls. The facility census was 44. Findings include: Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, muscle wasting and atrophy, Alzheimer's disease, diabetes, and cerebral infarction. Review of the plan of care dated 01/30/20 revealed Resident #34 had alterations in self bed mobility. Interventions included a bed mobility program and two-person assistance with all bed mobility. The care plan had subsequent revisions on 10/06/21, 04/10/23 and 07/24/23 to add Resident #34 was at risk for impaired functional range of motion related to left side weakness, had a behavior problem of refusing care and was at risk for falls and potential injury related to impaired gait and mobility, and level of assistance needed for transfers. Interventions included bed stabilizers, locked bed, keep commonly used items in reach, Hoyer lift with two-person assistance with transfers and low bed. The revisions did not indicate what level of assistance Resident #34 required with bed mobility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had moderately impaired cognition, was incontinent of bladder and bowel and required extensive assistance of two staff members for bed mobility. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #34 had severely impaired cognition, was incontinent of bowel and bladder, and was dependent on staff for rolling in bed. Review of the fall assessment dated [DATE] revealed Resident #34 was at risk for falls. Review of the Point Click Care nursing assistant Task charting from 01/01/24 to 01/12/24 revealed Resident #34 was dependent on staff or required two staff assist for rolling side to side. Review of the progress notes dated 01/12/24 at 9:10 P.M. revealed the nurse was called to the room of Resident #34 by the nursing assistant. The nursing assistant stated that during incontinence care while the resident was turned onto her right side her left leg went too far, and she lost her balance and slid off the bed. When the nurse entered the room, the resident was kneeling on the right Page 1 of 4 366087 366087 03/04/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few side of the bed on her knees while holding onto the bed rail. The resident denied hitting her head. The nursing assistant stated the resident had not hit her head. She was assisted back to bed by three staff members. She had no visible injuries. The resident reported pain in her left knee and elbow. Her range of motion remained at baseline. Review of progress notes dated 01/12/24 at 9:20 P.M. and 9:55 P.M. revealed messages were left to the physician and Resident #34's niece to notify them of the incident. Review of a physician order dated 01/13/24 revealed an order for an x-ray of the left elbow and right knee. Review of the x-ray results dated 01/13/24 for Resident #34 revealed no fractures. Review of the fall investigation revealed a signed witness statement by STNA #200 dated 01/12/24 at 9:10 P.M. The witness statement indicated STNA #200 was changing Resident #34 when her left leg went too far over, and she fell off the bed onto the floor onto her knees. She did not hit her head, but she did hit her right knee hard, and she stated it hurt. She also stated her left arm was sore, but she never fell on her left arm. The investigation did not contain any information regarding whether the bed was in a locked position at the time of the incident. Review of the Medication Administration Record for January 2024 revealed pain was being monitored every shift and there were no reports of pain by Resident #34. Further review of the medical record and progress notes from 01/13/24 through 01/20/24 revealed no documentation Resident #34 was experiencing any pain. Review of the physician's progress note dated 01/21/24 at 7:47 A.M. revealed Resident #34 stated she was having right elbow pain ever since she fell over a week ago. Interview was conducted on 02/28/24 at 2:10 P.M. with the Director of Nursing (DON) who revealed STNA #200 was providing care to Resident #34, turned the resident towards the wall and she fell out of bed between the wall and the bed. The DON stated she was complaining of her left side hurting after the fall so an x-ray of her left side was obtained by the physician. Interview was conducted on 02/28/24 at 3:15 P.M. with STNA #201 who provided care for Resident #34. STNA #201 stated it depended on what mood Resident #34 was in as to how many staff it took to turn her in bed. STNA #201 stated sometimes Resident #34 would help, and it only took one when she helped. STNA #201 stated most of the time she did not help and it took two staff members to turn her in bed. Interview was conducted on 02/28/24 at 3:17 P.M. with STNA #202 who cared for Resident #34. STNA #202 revealed sometimes it took one or two to turn Resident #34 depending on how well she was turning. Observation of incontinence care and bed mobility on 02/28/24 at 3:20 P.M. revealed Resident #34 was pleasantly confused and obese. As STNA #201 and #202 provided incontinence care to Resident #34, Resident #34 made no attempt to help the staff role her in bed so it took both to roll her in the bed and keep her stable on her side while the STNAs cleaned and changed her. 366087 Page 2 of 4 366087 03/04/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview by phone was attempted with STNA #200, however, the telephone number had been changed and the STNA no longer worked at the facility. Interview was conducted on 02/29/24 at 10:00 A.M with the DON who revealed she was not sure if the brakes were locked on Resident #34's bed at the time of the incident, but the brakes should be always locked when providing resident care. The DON indicated Resident #34's bed was usually against the wall, but the investigation revealed the bed had been pulled away from the wall leaving a space between the bed and the wall where Resident #34 fell. The DON verified Resident #34 was dependent on staff for rolling side to side and thought Resident #34 required either one or two staff to roll in the bed. Interview was conducted on 02/29/24 at 10:55 A.M. with Resident #34 who was alert and able to carry on a reciprocal conversation with the surveyor. When asked if she remembered falling on 01/12/24, Resident #34 revealed she remembered the night she fell out of bed one aide was providing care and turned her towards the wall. Resident #34 stated she had a hold of the side rail on the right side of the bed towards the wall, but her leg went forward, and she started yelling she was falling. She stated she fell out onto her left knee, but she caught her right arm in the right bed [NAME] when she fell. She stated she yelled oh my god my elbow when she fell. She stated she was having some pain in her right elbow, but the pain was not severe. It only hurt when she moved it. She said she had been telling the staff of this pain with movement since she fell on [DATE]. Review of the undated facility policy titled, Falls Program, revealed the purpose of the falls program was to determine and monitor those residents at risk for falls and to increase the awareness of the staff to attempt the prevention of falls. The falls program would promote a pro-active approach to nursing care and resident safety. The goal was to enhance and heighten the staff awareness and to focus on frequent and timely response to resident needs specific to assistance with toileting, offering of food and fluids, intervening with unsafe self-transfer, redirecting, and assisting more frequently with care or redirection. This deficiency represents non-compliance investigated under Complaint Number OH00150966. 366087 Page 3 of 4 366087 03/04/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and interview the facility failed to ensure food was properly labeled and dated in the refrigerator to prevent risk of food borne illness. This affected all 44 residents who ate food from the kitchen, as the facility did not identify any residents who did not eat by mouth. The facility census was 44. Findings included: Observation of the facility kitchen on 02/28/24 from 8:22 A.M. through 8:50 A.M. revealed in the refrigerator there was a bag of gravy-like liquid sitting in a stainless steel pan with no label to indicate what it exactly was, when it was opened nor a use-by date. In addition, there were several other food items having no dates to indicate when the items were prepared or opened and/or when they should be discarded by the staff. These items included a large bag of shredded cabbage and carrots (coleslaw mix), a bag of deli ham slices, a large stainless steel container which had three peanut butter and jelly sandwiches, two plates with tomato, lettuce and onion wrapped in plastic wrap, two plates with just lettuce wrapped in plastic wrap, two small bowls of peaches, two large bowls of salad and one large plate of salad. These were all verified by [NAME] # 300 at the time of the observation. On 02/28/24 at 9:40 A.M. an interview with Activity Director #301,who was also the interim dietary manager, stated all food items should be labeled and dated before being stored in the refrigerator. This deficiency represents non-compliance as an incidental finding during the investigation of Complaint Number OH00150966. 366087 Page 4 of 4