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.
Based on resident interview, medical record review, fall investigation review and staff interview the facility
failed to implement fall interventions as ordered. This affected one (Resident #37) of three residents
reviewed for accidents. The census was 40.
Findings included:
On 08/15/22 at 11:17 A.M., interview with Resident #37 revealed a fall last month during care with a staff
member, and she slid off her bed and was lowered to the ground by the staff member.
Review of Resident #37's medical record revealed an admission date of 01/27/21 with diagnoses that
included Parkinson's disease and difficulty walking.
Review of Resident #37's Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of
04/22/22 indicated Resident #37 had an independent cognition level and required two staff members for
assistance with transfers.
Review of Resident #37's nurse's notes revealed on 07/09/22 Resident #37 slid off the bed when sitting on
the edge of the bed being assisted by staff with morning care.
Review of the fall investigation completed following the fall on 07/09/22 revealed a State Tested Nurse Aide
(STNA) was assisting Resident #37 with morning hygiene and dressing, when Resident #37 lost her
balance and slid off the bed. The STNA lowered Resident #37 to the floor. A new intervention was
implemented following the fall and indicated Resident #37 was to have two staff members assist with all
care.
Review of Resident #37's physician orders revealed on 07/18/22 a new physician's order in place indicating
two staff members for all resident care.
Review of the STNA Activities of Daily Living (ADL) Tasks revealed documentation of numerous days with
one staff member providing dressing and hygiene assistance. Dressing assistance documentation indicated
one staff member on 07/20/22 A.M., 07/21/22 P.M., 07/28/22 A.M., 08/01/22 A.M., 08/04/22 P.M., 08/05/22
A.M., 08/07/22 P.M., 08/08/22 A.M., 08/10/22 P.M., 08/11/22 A.M. and P.M., 08/12/22 P.M., 08/14/22 P.M.,
08/15/22 A.M. and 08/16/22 A.M. and P.M. Personal hygiene documentation revealed one staff member
assistance on 07/20/22 A.M., 07/21/22 A.M., 07/23/22 P.M., 07/24/22 A.M., 07/25/22 P.M., 07/26/22 P.M.,
07/28/22 A.M., 07/29/22 A.M., 07/30/22 P.M., 07/31/22 A.M., 08/01/22 A.M. and P.M., 08/02/22 P.M.,
08/03/22 P.M., 08/04/22 P.M., 08/05/22 A.M., 08/06/22 A.M., 08/07/22 P.M., 08/08/22 A.M. and P.M.,
08/09/22 A.M. and P.M., 08/10/22 P.M., 08/11/22 P.M., 08/12/22 A.M. and P.M.,
(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 3
Event ID:
366190
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
366190
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/18/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Belmont Manor
51999 Guirino Drive
St Clairsville, OH 43950
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)
F 0689
08/14/22 P.M., 08/15/22 A.M. and P.M. and 08/16/22 A.M. and P.M.
Level of Harm - Minimal harm
or potential for actual harm
On 08/17/22 at 10:05 A.M. interview with STNA #51 revealed Resident #37 was a two person assist with
care, but one staff person can assist with dressing and hygiene. STNA #51 indicated one person can
provide hygiene and dressing assistance if she is lying in bed.
Residents Affected - Few
On 08/17/22 at 10:10 A.M. interview with STNA #55 also revealed Resident #37 was a two person assist
with care, but one staff person can assist with dressing and hygiene.
On 08/17/22 at 10:15 A.M. interview with STNA #59 indicated Resident #37 was a two person assist with
care, but one staff member will assist with dressing and hygiene.
On 08/17/22 at 10:20 A.M. interview with the Director of Nursing verified Resident #37 had a physician's
order in place for the resident to have two staff members assist during all care and STNA ADL Tasks
documentation indicates one staff member providing assistance for dressing and hygiene.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366190
If continuation sheet
Page 2 of 3
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
366190
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/18/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Belmont Manor
51999 Guirino Drive
St Clairsville, OH 43950
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)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to ensure weights were obtained as ordered for Resident #16.
This affected one (Resident #16) of two residents reviewed for weights. The facility census was 40.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #16 revealed an admission date of 06/28/22 with diagnoses
including dementia, depression and diabetes mellitus.
Review of the physician's order dated 06/28/22 for Resident #16 revealed an order for monthly weights.
Review of the admission weight for Resident #16 revealed she weighed 107.1 pounds on 06/29/22.
Review of the plan of care for Resident #16 dated 07/12/22 revealed she was underweight with a low body
mass index. The staff were to weigh the resident per their policy and notify the physician of significant
weight changes.
Review of the nutritional assessment dated [DATE] revealed the most recent weight the facility had
obtained was on 06/29/22 and was 107.1 pounds.
Interview on 08/16/22 at 1:21 P.M. with Dietitian #500 verified the staff had not obtained monthly weights on
Resident #16 and the last weight obtained was on 06/29/22.
Review of the facility policy titled, Weight Policy, revised February 2022, revealed residents are to be
weighed upon admission within 48 hours and then once a month or as ordered by the physician.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366190
If continuation sheet
Page 3 of 3
