Health inspection·May 12, 2022

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 record review, observation, resident interview, staff interview and policy review, the facility failed to ensure fall prevention interventions were in place for a resident who had a history of falls and was also known to be a fall risk as per the resident's plan of care. This affected one (Resident #42) of two residents reviewed for falls. The facility census was 44. Findings included: A review of Resident #42's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a history of falls, syncope and collapse (fainting), lack of coordination, muscle wasting and atrophy, history of seizures, essential tremors, morbid obesity, adult onset diabetes mellitus, hypertension, congestive heart failure and dementia. A review of Resident #42's physician's orders revealed she had an order that she could be up in a recliner or chair as tolerated. The only fall prevention intervention included as part of the physician's orders was for the use of a fall mat to the side of her bed while the resident was in bed. A review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adequate vision with the use of corrective lenses. She did not have any communication issues and was cognitively intact. She was not known to have displayed any behaviors or reject care during the seven days of the assessment period. She required an extensive assist of two for transfers and ambulation. A review of Resident #42's care plans revealed she had a care plan in place for being at risk for falls and fall related injuries related to abnormalities of her gait and mobility, history of a stroke, weakness, osteoarthritis, dementia, history of falls, poor safety awareness, medications, and diabetes mellitus. Her interventions included assisting the resident with a wheelchair or walker for mobility as needed and the use of Dycem (non-slip material used to prevent sliding out of a chair) to the seat of her wheelchair when up. That intervention had been in place since 01/18/22. On 05/10/22 at 10:20 A.M., an observation of Resident #42 noted her to be sitting up in her wheelchair in her room reading a book. She was noted to be sitting on a cushion while up in her wheelchair. An interview with the resident, at the time of the observation, revealed she did not have Dycem under her while in her wheelchair as per her fall prevention interventions. Dycem was found folded over and on top of another cushion that was sitting on top of her nightstand. She reported the Dycem was in her wheelchair when she was up yesterday but, was not placed in her wheelchair when they got her up earlier that day. (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 5 Event ID: 366249 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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)