Health inspection·September 7, 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 record review, staff and resident interview, and review of the facility policy, the facility failed to maintain fall safety interventions to prevent a resident from falling. This affected one (Resident #1) of three residents reviewed for falls. The facility census was 59. Findings include: Review of the medical record for Resident #1 revealed an admission date of 06/24/23. Diagnoses included multiple sclerosis (MS), moderate protein calorie malnutrition, lymphedema, adult failure to thrive, and anxiety. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 06/30/23, revealed Resident #1 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, and ambulation. Review of the fall risk assessment dated [DATE] revealed Resident #1 was at high risk for falls. Review of the plan of care dated 06/26/23 revealed Resident #1 was at risk for falls due to history of fall, multiple sclerosis, and decreased mobility. Interventions included implementing preventative fall interventions/devices, call light in reach, non-skid footwear, wheelchair pedals to be on when transporting resident, and administering medication as ordered. Review of the fall investigation dated 08/12/23 revealed Resident #1 was sitting on side of bed. One state tested nursing aide (STNA) was assisting her with transferring to wheelchair, the floor was wet and slippery. The statement from STNA stated as she was getting Resident #1 up to her chair, she slid and lost balance and she assisted her down to the floor. The care plan stated two-person assists for transfers. A new intervention was making sure the floor was dry prior to getting Resident #1 up. Interview on 09/06/23 at 12:48 P.M. with Resident #1 revealed she had had a couple of falls a few weeks ago. Resident #60 stated she fell when she was being transferred from bed to wheelchair with one staff and her feet got tangled and she fell by bed. Resident #1 stated she has MS and at times her feet don't work like they should. Interview on 09/06/23 at 2:20 P.M. with the Director of Nursing (DON) and Administrator verified Resident #1 was a two-person assist for transfers and one STNA should not have transferred Resident #1 by herself. Interviews on 09/06/23 from 12:50 P.M. through 4:05 P.M. with Licensed Practical Nurse (LPN) #300, Page 1 of 2 366131 366131 09/07/2023 Bellevue Care Center One Audrich Square Bellevue, OH 44811

F 0689 #301, STNA #302 and #303 revealed Resident #1 was a two-person assist for transfers. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Fall Management, dated 12/09/19, revealed individualized interventions will be based on assessment and care plan accordingly. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00146056. 366131 Page 2 of 2