Health inspection·December 30, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility self-reported incident (SRI), staff and Detective #40 interviews, and policy review, the facility failed to thoroughly investigate an injury of unknown injury. This affected one (#11) out of three residents reviewed for injuries of unknown origin. The facility census was 57. Residents Affected - Few Findings include: Review of medical record for Resident #11 revealed admission date of 10/24/23. Diagnoses include late onset Alzheimer's, right femoral head fracture, depression, heart failure, and dementia with mood disturbance. Resident #11 was discharged to the hospital on [DATE] and did not return to the facility. Review of Resident #11's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed she required set up for eating and was dependent for toileting hygiene, bed mobility and transfers. Review of the care plan revealed Resident #11 had impaired Activities of Daily Living (ADL's) with the goal to maintain existing ADL self-performance created on 12/07/23. Review of Resident #11's medical record revealed a fall assessment dated [DATE] which documented the resident scored an 11 indicating moderate risk for falls. Review of Resident #11's nurse's notes dated 11/21/24 at 8:38 P.M. revealed the resident was complaining of severe pain to right knee/hip/leg this shift, and holding right leg out to the side in an abnormal position. Resident #11's physician was contacted and also in the facility to assess the resident. Resident #11's physician was concerned for a possible fracture or hip displacement, and gave orders for the resident to be sent to the emergency room for evaluation and treatment of right leg pain. The family was also notified. Resident #11 was transferred to the hospital. Review of Resident #11's hospital medical record revealed on 11/21/24 the resident was seen in the emergency room and was admitted to the hospital for a right femur fracture. Review of a facility SRI dated 11/22/24 for an injury of unknown origin revealed Resident #11 returned from an appointment outside of facility. Resident #11 had the inability to bear weight noted to increase after her return to the facility and continued throughout the next day following her return. Resident #11 was assessed by the physician and was sent to the hospital for evaluation. Resident #11 found to have a fracture to right distal femur. The facility conducted an investigation and determined it to be unsubstantiated. Further review of the SRI and investigation revealed there was no Page 1 of 6 366235 366235 12/30/2024 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0610 evidence of interviews being conducted with Certified Nursing Assistants (CNA) #43, #44 or #49. Level of Harm - Minimal harm or potential for actual harm Interview on 12/23/24 at 4:51 P.M. with Detective #40 revealed he had been contacted by Resident #11's family regarding a concern of possible abuse. Detective #40 stated the facility contacted him shortly after to report the incident allegation as well involving Resident #11 regarding the fractured femur. Detective #40 verified he had reviewed Resident #11's hospital records and the injury was consistent with a fall. Detective #40 shared the facility had cooperated with him during his investigation. Detective #40 stated he had given a voice test, which he explained was essentially a lie detector test to six staff members with no concern about the results in regarding to caring for Resident #11. Detective #40 stated he had one outstanding interview with the staff member (CNA #44) who put Resident #11 to bed the morning prior to her 11/20/24 doctor appointment. Residents Affected - Few Interview on 12/23/24 at 5:05 P.M. with the Director of Nursing (DON) revealed Resident #11 had been sent to the hospital on [DATE]. The DON stated the hospital completed an x-ray had determined Resident #11 had a right femur fracture. The DON stated she initiated a SRI related to an injury of unknown origin. The DON explained family had come to the facility with allegations of abuse after Resident #11's hospitalization. The DON stated the facility called the Sheriff and Detective #40 came to the facility regarding the Resident #11's injury allegation. The DON shared and supplied the names of six staff members who had been interviewed and voluntarily given what she understood to be a lie detector test by the Sheriff Department with no concerns. The DON stated Detective #40 had one more staff member (CNA #44) to interview before closing his case. The DON confirmed the facility did not interview CNA #44 and this CNA provided care to Resident #11. Interview on 12/24/24 at 9:41 A.M. with CNA #44 revealed she had worked on 11/19/24 and had assisted Resident #11 out of bed and transferred her directly into a shower chair. CNA #44 shared Resident #11 had an appointment the following morning and needed a shower. CNA #44 stated Resident #11 was being resistant during the shower and threw herself from the shower chair and onto the floor. CNA #44 stated Resident #11 did not have any obvious injuries. CNA #44 stated Resident #11's fall on 11/19/24 was reported to Licensed Practical Nurse (LPN) #45 but she did not come to assess the resident and CNA #43 assisted with getting the resident off the shower room floor. Interview on 12/24/24 at 9:58 A.M. with CNA #43 denied assisting CNA #44 with getting Resident #11 off of the floor after a fall on 11/19/24 or any other time. CNA #43 further denied any knowledge of the incident or fall involving Resident #11. Interview on 12/24/24 at 10:26 A.M. with the DON and the Administrator revealed they were unaware of the fall of Resident #11 from 11/19/24. Interview on 12/24/24 at 12:27 P.M. with LPN #45 denied having been informed or any knowledge Resident #11 had a recent fall. A follow up interview with the DON on 12/24/24 at 2:29 P.M. revealed she had not interviewed CNA #44 regarding Resident #11's injury allegation. The DON stated Detective #40 had informed her to only interview facility staff and CNA #44 had been terminated on 12/02/24. The DON acknowledged she did not have any documentation of the Detectives request. Interview on 12/30/24 at 10:11 A.M. with CNA #49 who worked on the evening shift on 11/19/24 with CNA #43 denied knowledge Resident #11 had a fall that night or any other night. 366235 Page 2 of 6 366235 12/30/2024 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 12/30/24 at 2:10 P.M. with the DON revealed she did not interview CNA #43 or #49 because although they were on the locked unit they were not assigned to care for Resident #11. DON acknowledged she would not know without interviewing CNA #43 or #49 if they had provided care for Resident #11 on 11/19/24. Review of the facility policy titled Freedom from Abuse, Neglect and Exploitation dated 10/20 revealed the investigation would include an interview with staff members having contact with the resident during the relevant periods. This deficiency represents non-compliance investigated under Complaint Numbers OH00160651 and OH00160238. 366235 Page 3 of 6 366235 12/30/2024 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to develop a comprehensive care plan to address the amount of assistance a resident required with activities of daily living (ADL's). This affected one (#11) out of three resident reviewed for ADL assistance. The facility census was 57. Findings include: Review of medical record for Resident #11 revealed admission date of 10/24/23. Diagnoses include late onset Alzheimer's, right femoral head fracture, depression, heart failure, and dementia with mood disturbance. Resident #11 was discharged to the hospital on [DATE] and did not return to the facility. Review of Resident #11's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed she required set up for eating and was dependent for toileting hygiene, bed mobility and transfers. Review of the care plan revealed Resident #11 had impaired Activities of Daily Living (ADL's) with the goal to maintain existing ADL self-performance created on 12/07/23. Further review of Resident #11's care plan revealed there was care plan or instructions regarding the amount of staff assistance the resident required with any ADL's. Review and interview on 12/30/24 at 12:54 P.M. with the Director of Nursing (DON) regarding the [NAME] for Resident #11 revealed there were no specifics or instructions for transfers. The DON explained if a resident required a mechanical lift or two-person assistance it would state accordingly on the [NAME]. The DON continued to explain since Resident #11 did not have a transferring section on her [NAME], she would only require one person assistance, however two may be used. Interview on 12/30/24 at 1:13 P.M. with MDS Coordinator #50 verified Resident #11's care plan did not indicate the amount of staff assistance required for ADL's including how much assistance was required with transfers. This deficiency represents non-compliance investigated under Complaint Numbers OH00160651 and OH00160238. 366235 Page 4 of 6 366235 12/30/2024 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

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 medical record review, staff interviews and policy review, the facility failed to assess a resident and complete a post fall investigation after a resident experienced a fall. This affected one (#11) out of three residents reviewed for falls. The facility census was 57. Findings include: Review of medical record for Resident #11 revealed admission date of 10/24/23. Diagnoses include late onset Alzheimer's, right femoral head fracture, depression, heart failure, and dementia with mood disturbance. Resident #11 was discharged to the hospital on [DATE] and did not return to the facility. Review of Resident #11's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed she required set up for eating and was dependent for toileting hygiene, bed mobility and transfers. Review of the care plan revealed Resident #11 had impaired Activities of Daily Living (ADL's) with the goal to maintain existing ADL self-performance created on 12/07/23. Further review of Resident #11's care plan revealed there was care plan or instructions regarding the amount of staff assistance the resident required with any ADL's. Review of Resident #11's medical record revealed a fall assessment dated [DATE] which documented the resident scored an 11 indicating moderate risk for falls. Further record review for Resident #11 revealed there was no documentation regarding the resident experiencing a fall on 11/19/24. There were no documented falls for Resident #11 in the past six months. Interview on 12/24/24 at 9:41 A.M. with Certified Nursing Assistant (CNA) #44 revealed she had worked on 11/19/24 and had assisted Resident #11 out of bed and transferred her directly into a shower chair. CNA #44 shared Resident #11 had an appointment the following morning and needed a shower. CNA #44 stated Resident #11 was being resistant during the shower and threw herself from the shower chair and onto the floor. CNA #44 stated Resident #11 did not have any obvious injuries. CNA #44 stated Resident #11's fall on 11/19/24 was reported to Licensed Practical Nurse (LPN) #45 but she did not come to assess the resident and CNA #43 assisted with getting the resident off the shower room floor. Interview on 12/24/24 at 9:58 A.M. with CNA #43 denied assisting CNA #44 with getting Resident #11 off of the floor after a fall on 11/19/24 or any other time. CNA #43 further denied any knowledge of the incident or fall involving Resident #11. Interview on 12/24/24 at 12:27 P.M. with LPN #45 denied having been informed or any knowledge Resident #11 had a recent fall. Interview on 12/24/24 at 10:26 A.M. with the Director of Nursing (DON) revealed she had not been informed by any staff member that Resident #11 had fallen during a shower on 11/19/24. A second interview on 12/30/24 at 2:10 P.M. with the DON revealed a fall investigation had not been completed for Resident #11 for a fall on 11/19/24 and it would be the expectation of the facility, staff would 366235 Page 5 of 6 366235 12/30/2024 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0689 Level of Harm - Minimal harm or potential for actual harm report a fall. The DON confirmed a fall investigation should then be completed and the resident should be assessed following a fall. Interview on 12/30/24 at 10:11 A.M. with CNA #49 who she also worked on the evening shift on 11/19/24 with Resident #11 and denied knowledge Resident #11 had a fall that night or any other night. Residents Affected - Few Review of the facility policy, Fall Prevention Policy last reviewed 12/01/21 revealed post fall nursing would assess resident and follow up as appropriate. This deficiency represents non-compliance investigated under Complaint Numbers OH00160651 and OH00160238. 366235 Page 6 of 6