Health inspection·February 2, 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 interview and record review, the facility failed to provide Resident #70 proper assistance with incontinence to prevent the resident from falling. This affected one Resident (#70). The facility census was 69. Findings include: Review of Resident #70's medical records revealed an admission date of 10/21/22 and a discharge date of 01/31/24. Diagnoses included corticobasal degeneration, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, gastrostomy, abnormal posture, contracture left hand, COVID-19, protein-calorie malnutrition, gastrostomy status, urogenital implants, neuromuscular dysfunction of bladder, pressure ulcer of sacral region, stage 4, diabetes mellitus due to underlying condition with food ulcer, adult failure to thrive, disorder of white blood cells, tachycardia, history of transient ischemic attack (TIA), and hypertension. Review of Resident #70's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had impaired cognition. Resident #70 required dependent assistance with toileting. Review of care plan dated 10/24/22 revealed Resident #70 had a person-centered plan of care. Interventions included the assistance of two for toileting. Review of Resident #70's progress note dated 12/20/23 at 12:16 P.M. revealed Licensed Practical Nurse (LPN) #143 was called to Resident #70's room with the resident on the floor. State Tested Nursing Assistant (STNA) #158 stated while she was performing peri care the residents leg shifted off the edge of the bed causing her to roll form her grasp and she landed on the floor beside her bed. Review of Resident #70's fall investigation report revealed on 12/20/24 at 11:40 A.M. the STNA alerted the floor nurse that while she was giving hygiene care to the resident, the resident rolled out of bed. When the nurse entered the room the resident was lying on the floor, on the left side of the bed, on her right side. The wound care nurse was called to the room to assist with the head to toe assessment. The resident had a reddened area to the right side of her chin and neck and the area was blanchable. A new abrasion was noted to the right buttocks measuring 0.3 centimeters (cm) by 3.0 cm by 0.1 cm deep. The area was bright red in color with drainage noted. An abrasion was noted to right knee measuring 1 cm by 2 cm with no drainage noted a this time. During this assessment the resident denied any pain or discomfort and range of motion within normal limits for the resident. Neurological checks initiated per facility protocol. Vitals signs were obtained with blood pressure 132/70, temperature 97.7 degrees Fahrenheit, heart rate 84, oxygen 94% on room area. The resident was assisted off floor and back in the bed via hoyer lift with four staff members. Wound care was rendered to Page 1 of 2 366460 366460 02/02/2024 Canfield Acres LLC Dba Windsor House at Canfield 6445 State Route 446 Canfield, OH 44406

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few new areas using clean technique. Area cleansed with normal saline solution. Areas patted dry, adaptic applied and covered with a Allevyn. Resident #70's brief was changed and the resident was repositioned back in bed. Resident #70 began complaining of pain to the right hip. New orders for stat X-rays of the entire body were ordered. Resident #70's daughter was notified of the incident and she requested that her mother be sent to the emergency room to be evaluated at this time. Resident #70 was admitted to the hospital with pneumonia. Interview on 02/02/24 at 9:56 A.M. with Corporate Nurse (CN) #202 revealed Resident #70 was two assists for incontinence care and STNA #158 provided incontinence care with one assist. CN #202 reported Resident #70 had a fall with no injuries. CN #202 reported physician was notified and ordered x-rays. CN #202 reported the family was notified and refused x-rays and wanted sent to hospital for evaluation. CN #202 reported physician was updated and Resident #70 was sent to hospital. Interview on 02/02/24 at 11:02 A.M. with LPN #143 revealed STNA #158 provided incontinence care with one assist and should have been two assists. LPN #143 reported Resident #70 had a fall with no injuries. CN #202 reported physician was notified and ordered x-rays. CN #202 reported the family was notified and refused x-rays and wanted sent to hospital for evaluation. CN #202 reported physician was updated and Resident #70 was sent to hospital. Interview on 02/02/24 at 11:19 A.M. via phone with STNA #158 revealed on 12/20/23 she provided incontinence care to Resident #70 with only one assist which resulted in a fall with no injuries. STNA #158 reported for incontinence care resident #70 required two staff assistance. Interview on 02/02/24 at 11:34 A.M. with Wound LPN #126 revealed on 12/20/23 STNA #158 provided incontinence care to Resident #70 with only one assist and resulted in a fall with no injuries. Resident #70 was a two person assist for peri care. Interview on 02/02/24 at 11:51 A.M. with Director of Nursing (DON) revealed on 12/20/23 STNA #158 provided incontinence care to Resident #70 with only one assist which resulted in a fall with no injuries. Resident #70 was a two person assist for incontinence care. DON reported [NAME] for Resident #70 listed toileting as two person assist. Interview on 02/02/24 at 12:11 P.M. with Assistant Director of Nursing (ADON) revealed on 12/20/23 STNA #158 provided incontinence care to Resident #70 with only one assist which resulted in a fall with no injuries. Resident #70 was a two person assist for incontinence care. Review of facility policy, Fall Prevention and Fall Management, revised 08/2023, revealed after completion of the assessment a falls plan of care is developed for those residents identified as being at risk for falls and develop a care plan with interventions based on risk review. This deficiency represents non-compliance investigated under Complaint Number OH00150071. 366460 Page 2 of 2