Inspection·July 3, 2019

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, medical record review, staff interview the facility failed to have the appropriate fall interventions in place for Resident #69. This affected one (Resident #69 of six reviewed for accidents). The facility census was 68. Findings include: A medical record review revealed Resident #69 was admitted to the facility on [DATE] with the diagnoses of nocturia, poly arthritis, generalized anxiety disorder, major depression, heart failure, over-active bladder, intraocular lens, and osteoporosis. Review of the quarterly Minimum data Set 3.0 assessment dated [DATE] revealed Resident #69 had intact cognition, required extensive assistance with transfers and bed mobility, and had a fall with major injury. Observations on 07/03/19 at 8:30 A.M., 10:30 A.M. and 1:00 P.M. revealed Resident #69 was in bed and did not have the floor mat in place on the right side of the bed. A review of a plan of care dated 02/05/19 revealed Resident #69 was at risk for future falls. Interventions included; would encourage to ask for help, observe for unsteadiness, have the call light within reach, toilet in advance of need every two hours, the bed against the wall to create more space in the bedroom, bright orange tape to the call light, a floor mat next to the bed and non-skid footwear at all times. Review of physician's orders dated 06/18/19 revealed Resident #69 was to have a floor mat next to her bed for safety. An interview on 07/03/19 at 1:33 P.M. Registered Nurse #320 indicated the fall mat should be by the resident's bed while she was in bed. RN #320 verified the fall mat was not on the floor while the resident was in bed. An interview on 07/03/19 at 1:37 P.M. State Tested Nurse Aide #395 indicated she had not placed the fall mat on the floor beside Resident #69 bed when she put her to bed. 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: 366248 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 366248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Home Inc 10680 Steiner Road Rittman, OH 44270 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)