Health inspection·April 4, 2024

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, job description review, and interview the facility failed to ensure a medication assistant did not perform duties outside her scope of practice. This affected four residents (#25, #32, #35 and #38 ) of nine residents reviewed for care and service. The facility census was 50. Findings included: 1. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE]. Diagnoses included low back pain, diabetes, hypertension, chronic kidney disease, osteoarthritis, osteoporosis, anxiety disorder, depression, thyroid nodule, seasonal allergies, gout, malignant neoplasm of large intestines, cataracts, cerebral infarction, and traumatic brain injury. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 had intact cognition. Review of the April physician's orders revealed Resident #25 had an order for tramadol (a narcotic pain medication) 50 milligrams (mg) once daily. Review of the February 2024 medication administration records (MAR) revealed Medication Assistant (MA-C) #101 documented pain levels for Resident #25 on 02/03/24, 02/04/24, 02/12/24, 02/17/24, 02/18/24, 02/21/24, 02/22/24, and 02/23/24. Review of the March 2024 MAR revealed MA-C #101 documented pain levels for Resident #25 on 03/02/24, 03/03/24, 03/06/24, 03/07/24, 03/08/24, 03/16/24, 03/17/24, 03/20/24, 03/21/24, 03/25/24, 03/26/24, 03/30/24, and 03/31/24. Review of the progress note dated 03/11/24 at 9:30 A.M. revealed MA-C #101 had documented details about Resident #25 sliding out of her chair under the nursing section of the progress notes. The details documented included Resident #25 told the medication assistant she had slid out of her recliner chair yesterday around 3:00 P.M. She said when the nurse helped her up, she hit her knee off the floor and it was bleeding. It was not bleeding now but the resident asked her to clean it and put a bandage on it. Review of the progress note dated 03/17/24 at 3:28 P.M. revealed MA-C #101 documented details about a fall for Resident #25 under the nursing section of the progress notes. The details documented included Resident #25 was found on the floor at 2:30 P.M. Resident #25 stated she was messing around with her stuff. Her vital signs were okay. The Nurse Practitioner (NP) and family were aware. There (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 6 Event ID: 366268 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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)