Health inspection·July 31, 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, interview and review of facility policy, the facility failed to conduct complete and thorough post-fall investigations to mitigate risk of falls . This affected one resident (Resident #94) of four residents reviewed for falls. The facility census was 93.Findings include: Record review for Resident #94 revealed an admission date of 05/23/25 with diagnoses including unspecified dementia, anxiety, difficulty walking, malnutrition and right femur fracture. Pertinent physician orders included non-skid pad to wheelchair, body pillow to open side of bed, non-skid pad to wheelchair cushion, floor mat to open side of bed, non-skid socks on at all times, brake sentry to wheelchair, and physical therapy evaluate and treat.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #94 had moderate cognitive impairment, had a fall with fracture prior to admission and had a fall since admission. Resident #94 was incontinent bladder.Review of Resident #94's plan of care, date initiated 05/28/25, revealed Resident #94 was at risk for falls related to history of falls, impaired cognition, and safety awareness with history of dementia, decreased abilities to transfer and ambulate, decreased balance, lower extremity strength and endurance. The interventions included to anticipate and meet needs, non-skid pad on top of and underneath wheelchair cushion (06/03/25); be sure call light is within reach, body pillow to open side of bed per order (06/03/25); ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair (06/03/25); follow facility fall protocol , resident needs activities that minimize the potential for fall providing diversion and distraction (06/03/25); one person staff assistance with wheeled walker for transfers (06/04/25), and floor mat to open side of bed (06/17/25); and assist to toilet as needed and per schedule for incontinence; assure that break century is present and functioning properly (06/24/25). Further review of the care plan, date initiated 06/04/25, for Resident #94 revealed she was incontinent of bladder related to impaired functional mobility and incontinence. The interventions included check and change every two hours for incontinence and assist, remind and encourage resident to toilet as per scheduled toileting program. Further review of Resident #94's medical record revealed Resident #94 had falls in the facility on 05/26/25, 06/12/25, 06/16/25, 06/20/25, 06/24/25 and 07/04/25 and concerns were identified regarding complete and thorough post-fall investigations with the following incidents:Review of a progress note dated 06/12/25 revealed staff observed Resident #94 sitting in her wheelchair talking to another resident. Resident #94 was leaning over towards the other residents and slid from the seat of the wheelchair onto the floor landing on her right side with her arm under her head. Vital signs were obtained, and a body assessment revealed no injuries. The resident was placed back in the wheelchair with dycem (non-skid mat) placed under the chair cushion. The physician and family were notified. Review of the facility fall investigation dated 06/12/25 revealed the fall occurred at 10:42 A.M. Resident #94 was found lying on the floor on her right side with right arm underneath her head. There were no obvious injuries noted. A non-skid pad was Page 1 of 3 366129 366129 07/31/2025 Gillette Nursing Home 3310 Elm Rd Warren, OH 44483

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few placed to the top of the wheelchair underneath the buttocks of the residence. The incident occurred in the dining room. Review of the six witness statements within the investigation revealed staff indicated they were unaware of the incident unless notified by other staff to assist in response. There was no documentation within the investigation to indicate when the last time the resident was seen by staff, or last checked or changed for incontinence care. The investigation summary indicated the conclusion was that Resident #94 was leaning to talk to someone and slid out of her wheelchair sustaining no injuries.Review of a progress note dated 06/16/25 revealed the nurse was told by the nurse aide that Resident #94 was on the floor. The nurse found Resident #94 naked, lying on her back in front of her dresser. Resident #94 stated she was not sure what happened. The nurse and aide assisted the resident back to bed. Vital signs were obtained and were within normal limits. A skin assessment revealed a one centimeter skin tear to the right elbow which was treated. Resident #94 denied hitting her head and there were no wounds. An interventions of a floor mat to the left side of the bed was initiated. The residents daughter and the physician were notified. Review of the facility fall investigation dated 06/16/25 revealed the fall occurred at 8:15 P.M. and Resident #94 was found lying on her back naked with her legs out in front of her. A skin tear to the right elbow was noted. The resident had removed all of her clothing, her non-skin socks and her brief. Resident #94 was incontinent of urine. Review of the witness statements by staff within the investigation revealed there was no documentation to indicate when the resident was last seen by staff or when the resident was last toileted or checked and changed for incontinence care prior to the fall. The investigation summary indicated Resident #94 was found on the floor naked after attempting to self transfer. There was no mention in the root cause analysis and investigation of when the resident was last seen by staff or when she was last checked and changed for incontinence care. Review of a progress note dated 06/20/25 revealed Resident #94 was observed on the floor mat on the side of her bed. The body pillow was across the room and her brief was removed. The brief was noted to be wet. An assessment of Resident #94's body revealed no injuries. The resident was placed back in bed and a clean brief was applied. The residents daughter and the physician were notified. Review of the facility fall investigation dated 06/20/25 at 6:40 P.M. revealed Resident #94 was found sitting on the floor mat next to their bed. No injuries were noted. The resident was unable to state what happened and had removed the body pillow. She was not wearing anything on her feet. The root cause analysis was completed and revealed the cause of the fall was Resident #94 was attempting to get out of bed unassisted. Review of the witness statements by staff within the investigation revealed there was no documentation to indicate when the resident was last seen by staff or when the resident was last toileted or checked and changed for incontinence care prior to the fall. The investigation summary indicated Resident #94 was attempting to self transfer and fell. There was no mention in the root cause analysis or investigation of when the resident was last seen by staff or when she was last checked and changed for incontinence care. On 07/30/25 at 4:02 P.M. an interview with the family member of Resident #94 revealed Resident #94 had fallen six times in five weeks and the facility was blaming Resident #94 for the falls. The family member stated she had asked the facility if an alarm could be used to try to help prevent falls and the facility told her they did not use alarms. On 07/30/25 at 4:32 P.M. an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #212 verified the missing information on the witness statements in the fall investigations for falls occurring on 06/12/25, 06/16/25 and 06/20/25. The DON stated when witness statements do not contain the time the resident was last seen by staff, last toileted or other pertinent details, the DON then will investigate that area. The DON verified there was no documentation within the investigation for the falls occurring on 366129 Page 2 of 3 366129 07/31/2025 Gillette Nursing Home 3310 Elm Rd Warren, OH 44483

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 06/12/25, 06/16/25 and 06/20/25 of the last time staff checked on Resident #94. On 07/31/25 at 4:03 P.M. an interview was conducted with the DON and ADON #212 to review the facility protocol for fall prevention. The DON stated change of condition is of consideration such as ordering a urine specimen if needed or a medication review for residents who fell. Both nurses verified the fall policy and stated if the individual continues to fall the staff and physician will reevaluate the situation and consider other possible reasons for the resident falling and will reevaluate the continued relevance of current interventions. Both nurses stated that the physician will also document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful. Both nurses stated the physician had been notified of the falls for Resident #94 and interventions were put in place to try to prevent falls. The DON verified the facility did not use alarms or seat belts as fall prevention interventions.A review of the policy titled Falls Clinical Protocol, dated 11/13/12, revealed the staff would evaluate and document falls that occur while the individual was in the facility. For example, when and where the falls happen and any observations of the events. The policy also stated for an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. If the cause of the fall was unclear, the fall may have a significant medical cause such as a stroke or an adverse drug reaction or if the individual continues to fall despite attempted interventions a physician will review the situation and help identify contributing causes. If the individual continues to fall, the staff and physician will reevaluate the situation and consider other possible reasons for the residents falling. As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful.This deficiency represents non-compliance investigated under Complaint Number OH00167403 (1363493). 366129 Page 3 of 3