Inspection·December 2, 2025

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 record review, staff interview, physician services interview, and policy review, the facility failed to complete thorough investigations following a resident's falls and do neurological (neuro) checks following a resident's fall. This affected one (Resident #57) of seven residents reviewed for accidents. The facility census was 52. Findings include: Review of the medical record for Resident #57 revealed an admission date of 12/27/22. Diagnosis included multiple fractures of pelvis with stable disruption of pelvic ring, subsequent encounter for fracture with routine healing, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. There was no documented history of seizures. Review of the Incidents Log dated 04/01/25 through 09/29/25, revealed Resident #57 had un-witnessed falls on 05/08/25, 05/09/25, 06/27/25, 06/30/25, 07/13/25, 07/14/25, and 08/15/25. Resident #57 had a witnessed fall on 08/31/25.Review of the Falls Report revealed Resident #57 had falls on 05/08/25, 05/09/25, 06/27/25, 06/30/25, 07/13/25, 07/14/25, and 08/15/25. Thorough investigations, neuro checks and fall assessments were not completed. There was also no Interdisciplinary Team (IDT) follow-up.Review of the Falls Report revealed Resident #57 had a fall on 07/14/25 at 4:45 A.M. when the resident was found on the floor lying beside her bed. Resident#57 was sent to the emergency room (ER) due to hip pain and diagnosed with a pelvic ring fracture. The fall intervention implemented was to educate the staff on placement of pressure alarms on the resident's wheelchair and bed. Resident #57 had an additional fall on 08/31/25 at 5:17 P.M. in the dining room where she fell from her wheelchair and was sent to the hospital. Following the fall on 08/31/25, a thorough investigation to determine a root cause analysis was not completed. Review of the Significant Change Minimum Data Set (MDS) dated [DATE], revealed resident had moderate cognitive impairment and was dependent on staff for assistance with oral hygiene, toileting hygiene, showering, personal hygiene, and transfers. Interview on 12/01/25 at 2:00 P.M., Director of Nursing (DON) stated Resident #57 had an unwitnessed fall from her bed on 07/14/25 and sustained a pelvic fracture. The intervention was to educate the staff on placement of pressure alarms on the resident's wheelchair and bed and for the alarms to be in place at all times. The DON stated Resident #57 fell out of her wheelchair in the dining room on 08/31/25 after suffering a seizure. The DON also confirmed there were no neuro checks completed following Resident #57's falls on 05/08/25, 05/09/25, 06/27/25, 06/30/25, 07/13/25, and 08/15/25. The DON also verified thorough investigations or fall assessments were not completed following the resident's falls. Interview on 12/01/25 at 2:15 P.M., LPN #375 stated when Resident #57 fell out of her bed on 07/14/25 at 4:45 A.M., the pressure alarm was not in place. LPN #375 stated Resident #57 was sent to the ER and found to have a pelvic fracture. Interview on 12/02/25 at 10:02 A.M., Nurse Practitioner (NP) #395 stated Resident #57 was a very high fall risk, and the pressure alarms were to be used to try and prevent falls. NP #395 stated neuro-checks should be completed on any un-witnessed falls and if the resident was unable to say what (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 4 Event ID: 366109 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 366109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodland Country Manor Inc 4166 Somerville Rd Somerville, OH 45064 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)