Health inspection·April 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 observation, interview, record review, and review of the facility policy review the facility failed to ensure Resident #36's chair alarm was in place as ordered by the physician. This affected one resident (#36) of three residents reviewed for falls. The facility census was 62. Findings include: Review of the medical record for Resident #36 revealed an admission date of 05/06/21. Diagnoses included Parkinson's disease, Alzheimer's disease, generalized anxiety disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was unable to complete the Brief Interview for Mental Status (BIMS) calculator to determine cognitive status. Per staff assessment, Resident #36 had short- and long-term memory problems. Resident #36 required supervision of one-person physical assist for transfers and walking in corridors, supervision with set-up for walking in room, locomotion, and toilet use. Review of the Morse Fall Scale dated 02/23/23 revealed Resident #36 was at high risk of falling. Review of the 03/21/23 progress note revealed Resident #36 had a fall on 03/21/23. Review of the physician's orders for Resident #36 revealed an order dated 03/28/23 for a [NAME] alarm while in the chair. Review of the care plan dated 05/07/21 revealed Resident #36 was at risk for falls related to unsteady gait, impaired cognition, and lack of safety awareness. Interventions included a chair sensor alarm. Review of the tasks in the electronic record for Resident #36 revealed no chair alarm was listed. Observation and interview on 04/07/23 at 12:03 P.M. with State Tested Nurse Aide (STNA) #459 revealed Resident #36 was sitting in her room in her chair. The chair alarm was observed sitting on top of the bedside table. Per STNA #459, she was not to have alarms, and if Resident #36 was to have alarms, it would be listed on her [NAME] on the inside of the door to her closet. Observation of Resident #36's [NAME] with STNA #459 revealed a chair alarm was not listed as an intervention. Interview on 04/07/23 at 12:05 P.M. with Licensed Practical Nurse (LPN) #458 confirmed Resident #36 did have an order for a bed and chair alarm and should have the alarm on while in the chair. (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 2 Event ID: 366186 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 366186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Humility House 755 Ohltown Road Austintown, OH 44515 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)