Health inspection·September 18, 2024

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 and staff interview, the facility failed to ensure Resident #56 received adequate assistance to prevent a fall from bed while care was being provided. This affected one (Resident #56) of three residents reviewed for falls. The facility census was 63. Findings include: Review of the medical record revealed Resident #56 was re-admitted to the facility on [DATE] with diagnoses including cerebral infarction, type II diabetes mellitus, aphasia, retention of urine, and encephalopathy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had cognitive impairment. Resident #56 had impairment to one side and required substantial to maximal assistance for turning. Review of the State Tested Nursing Assistant (STNA) documentation for bed mobility revealed Resident #56 required extensive to total dependence of staff to turn side to side with the assistance of one to two staff. A health status note dated 09/03/24 at 11:00 P.M. revealed Resident #56 slid out of the right side of the bed during care. STNA #107 had rolled Resident #56 to the right side to wash Resident #56's back during a bed bath. Resident #56 sustained a one centimeter skin tear to the left ear. A fall investigation dated 09/03/24 at 11:00 P.M. revealed Resident #56 had no previous falls and Resident #56 slid to the floor during care. Resident #56 was rolled to the right side during a bed bath and rolled out of bed. A new intervention was to make sure Resident #56 was centered in the bed. A written statement dated 09/03/24 by STNA #107 revealed Resident #56 fell out of bed while STNA #107 was giving Resident #56 a bed bath. STNA #107 washed Resident #56's back and while drying Resident #56's back, Resident #56 rolled out of the bed. The incident occurred around 10:35 P.M. Interview on 09/17/24 at 11:30 A.M. with Director of Nursing (DON) verified Resident #56 fell from bed while care was being provided. Page 1 of 2 366374 366374 09/18/2024 Trueman Pointe Care Center 4660 Trueman Blvd Hilliard, OH 43026

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on review of thee facility policy, observations, resident and staff interview, and record review, the facility failed to ensure residents did not receive foods against their dietary preferences and allergies. This affected one (Resident #34) of one resident reviewed for food preferences. The Facility census was 63. Finding include: Review of the medical record for Resident #34 revealed an admission date of 08/06/19. Diagnoses included respiratory failure, lymphedema, and heart disease. Review of the physician orders dated 04/19/24 revealed Resident #34 had an order for mechanical soft diet with thin consistency, allergies of strawberries and pineapples, with a no added salt and large protein portions. Review of lunch meal ticket dated 09/17/24 revealed Resident #34 had pineapple listed under dislikes and also had it identified in two spots on the meal ticket as well as strawberries. Interview and observation on 09/17/24 around 11:50 A.M. with Kitchen Staff #144 revealed regular diets received melon, mechanical soft received crushed pineapple, and puree diet received puree pineapple. Kitchen Staff #144 revealed mechanical soft and puree diets were unable to have melon. It was observed Kitchen Staff #144 placed mechanical soft pineapple on Resident #34's tray along with the ticket that included a dislike for pineapple and allergy to pineapple. Observation and interview on 09/17/24 at 12:50 P.M. with Resident #34 revealed she was served crushed pineapple as her lunch dessert. Resident #34 stated she was allergic to pineapple and strawberries and she frequently received these items on her tray. Resident #34 showed her meal ticket which displayed pineapple as a dislike and also as an allergy twice. Interview and observation on 09/17/24 at 12:55 P.M. with Registered Nurse (RN) #163 confirmed Resident #34 received crushed pineapple and also confirmed it stated she had an allergy to this item on her tray ticket. RN #163 left the pineapple on her tray and exited the room. Interview on 09/18/24 at 2:00 P.M. with Diet Technician #180 verified Resident #34 should not have been given pineapple unless requested as melon can be chopped and pureed. She also verified resident's tray tickets shall be reviewed when doing tray line to monitor for likes, dislikes and allergies. Review of the menu spreadsheet for lunch meal on 09/17/24 revealed mechanical soft diet should have also received diced melon and puree diets should receive pureed melon. Review of the facility policy titled Religious, Ethnic, and Cultural Food Preferences dated 08/07/14 revealed food preferences shall be accommodated by the facility. Resident food allergies shall be included on the diet order form. 366374 Page 2 of 2