Health inspection·March 13, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on record review, interviews, and policy review, the facility failed to prevent a resident from falling out of bed. This resulted in Actual Harm when Resident #11 fell out of bed and was transferred to the hospital where she was found to have a thoracic (section of the spine between the neck and end of ribs) compression fracture. This affected one (Resident #11) out of three residents reviewed for falls. The facility census was 38. Findings include: Review of the medical record for Resident #11 revealed an admission date of 01/06/21. Diagnoses included type two diabetes mellitus without complications, generalized anxiety disorder, hypertensive heart disease without heart failure, depression, moderate protein-calorie malnutrition, age-related osteoporosis without current pathological fracture, acute respiratory failure with hypoxia, intervertebral disc disorders with radiculopathy lumbar region, muscle weakness, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the plan of care, initiated on 09/09/22, revealed Resident #11 was at risk for falls related to balance problems, muscle weakness, lack of coordination, dementia, and diabetes mellitus. Interventions included anticipating and meeting the resident's needs, ensuring call light is within reach, encouraging the resident to use the call light for assistance, and physical therapy evaluation and treatment as ordered or as needed. Review of the plan of care, revised on 12/12/24 revealed Resident #11 had activities of daily living self-care performance deficit related to activity intolerance, impaired balance, lack of coordination, history of right femur fracture, diabetes mellitus, and need for varying levels of assistance. Interventions included extensive assistance by one staff for turning and repositioning in bed at least every two hours and as necessary. Review of the annual Minimum Data Set (MDS) assessment, dated 01/13/25, revealed Resident #11 had moderately impaired cognition. Resident #11 required setup assistance for eating, partial/moderate assistance for oral hygiene, and was dependent for toileting, bathing, dressing, personal hygiene, and bed mobility. Review of the incident report, dated 02/16/25, revealed Resident #11 was found face down on the floor between her bed and recliner and could not provide a description of what happened. Resident #11 was transported to the hospital via ambulance. No injuries were noted, but staff were unable to fully assess the resident due to her position on the floor. (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 2 Event ID: 366263 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 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 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)