Health inspection·October 17, 2019

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to update care plan interventions following a resident fall. This affected two (#9 and #79) of two residents reviewed for accidents. Facility census was 31. Findings include 1. Review of medical record revealed Resident #79 was admitted to the facility on [DATE]. Diagnoses included vertebral fracture of thoracic vertebrae 11 and 12, brain cancer, hypertension, and history of falling. Review of the comprehensive assessment dated revealed 10/02/19 revealed the resident had moderate cognitive impairment. Resident #79 required partial to moderate assistance for sit to stand, toilet transfers, and bed to chair transfers. Review of the comprehensive assessment dated [DATE] revealed Resident #79 had a history of falls prior to admission, one of which resulted in a fracture. The resident had fallen since admission and received an injury (not a major injury). Review of progress notes revealed on 09/23/19 Resident #79 was washing his/her hands in the bathroom, reached to get a paper towel while holding onto the walker and lost balance, falling straight back and hitting his/her head on the wall. The state tested nurses assistant (STNA) was in the bathroom with the resident. The nurse, physician and family were notified. Resident #79 was transported to the emergency room (ER) for evaluation. Review of the fall investigation dated 09/23/19 revealed a hematoma was noted to the back of the resident's head. Resident #79 reported a pain level of six and was alert and oriented to person, place, time, and situation. The interdepartmental team (IDT) investigated the fall and identified the STNA was present with the resident in the bathroom but did not have hands on the resident as the resident was washing hands. Staff was reminded to have hands on the resident while ambulating, transferring, and during care. Review of Resident #79's care plan revealed the resident had a self-care performance deficit and required limited assistance of one staff member for toileting. Resident #79's care plan also included a risk area for falls with the following interventions: - Anticipate and meet the resident's needs - Ensure the resident's call light was within reach and encourage the resident to use the call light for assistance as needed. The resident needed prompt response to all requests for assistance - Educate the resident/family/caregivers about safety reminders and what to do if a fall occurred - Encourage the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility - Ensure the resident was choosing and wearing appropriate footwear when ambulating or mobilizing in the wheelchair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366246 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 366246 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherith Care Center at Willow Brook 100 Willow Brook Way, South Delaware, OH 43015 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 0657 - Tab alarm to bed and chair at all times Level of Harm - Minimal harm or potential for actual harm - The resident needed a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, handrails on walls, personal items within reach. Residents Affected - Few The care plan did not include the new fall intervention identified by the IDT to have hands on the resident while ambulating, transferring, and during care. Interview on 10/17/19 at 10:48 A.M. interview with the Director of Nursing (DON) verified the fall intervention identified by the IDT was not included in Resident #79's care plan. 2. Review of the medical record for Resident #9 revealed an admission date of 01/28/18 with diagnoses including heart failure, peripheral vascular disease, and depression. Further review of the medical record revealed Resident #9 fell out of her wheelchair on 08/07/19. Review of the fall investigation for the Resident #9's fall which occurred on 08/07/19 revealed the intervention taken to prevent the incident from reoccurring was to ensure Resident #9's wheelchair brakes were locked prior to transferring transferring the resident into it as well as to ensure the resident had proper and safe positioning when in her wheelchair. Review of the comprehensive care plan for Resident #9 revealed Resident #9 was at risk for falls. Further review of the comprehensive care plan for Resident #9 revealed the interventions to ensure Resident #9's wheelchair brakes were locked prior to transferring transferring the resident into it and to ensure the resident had proper and safe positioning when in her wheelchair were not included on the comprehensive care plan. Interview with Director of Nursing on 10/17/19 at 10:55 A.M. verified Resident #9's comprehensive care plan was not revised to include the above fall interventions. Review of the facility's undated policy titled Policy & Procedure for Falls revealed the plan of care will be updated as needed between reviews to reflect new or modified interventions. Review of the facility's undated policy titled Care Plans - Comprehensive revealed care plans are revised as changes in the resident's condition dictates. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366246 If continuation sheet Page 3 of 3