Health inspection·June 4, 2025

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. Based on record review, staff interviews, and policy review, the facility failed to ensure fall prevention interventions were utilized in accordance with physician orders. This affected one (#50) out of three residents reviewed for falls. The facility census was 49. Findings include: Review of the closed medical record for Resident #50 revealed an admission date of 04/01/25 and a discharge date of 05/04/25. Diagnoses included encephalopathy, acute respiratory failure with hypoxia, congestive heart failure, acute kidney failure, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment, dated 04/07/25, revealed Resident #50 had severely impaired cognition. Resident #50 was assessed to require supervision for eating, oral hygiene, and personal hygiene, substantial/maximal assistance for toileting, bathing, lower body dressing, and partial/moderate assistance for upper body dressing, bed mobility, and transfer. Review of the plan of care initiated on 04/14/25 revealed Resident #50 was at risk for falling related to chronic obstructive pulmonary disease. Interventions included encourage resident to assume standing position slowly, ensure the floor is free of liquids and foreign objects, keep call light, personal items, and frequently used items within reach, provide non-skid footwear, and assist with transfers as needed. Review of the progress note dated 04/28/25 at 1:40 A.M. revealed Resident #50 was found on the floor on his back with no clothes or shoes on and had his hands under his head. His head was pointed towards the door and his legs were towards the bed. Resident #50 was assessed and noted to have a small abrasion to the right side of his right foot, which was cleaned and covered with a dressing. Review of the progress note dated 04/28/25 at 2:20 A.M. revealed new interventions implemented were bed in lowest position and mat next to bed. Review of the progress note dated 04/28/25 at 10:49 P.M. revealed Resident #50 had a fall in his room. The note indicated a new intervention was mat next to bed. Review of the physician orders revealed an order was entered 04/28/25 at 10:52 P.M. for fall mats on both sides of the bed and bed in lowest position. Review of the progress note dated 04/28/25 at 11:22 P.M. revealed Resident #50 was lying on the floor on the right side of his bed. Resident #50 was assessed and observed to have a skin tear to his (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: 366461 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 366461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooded Glen 2900 Bechtle Avenue Springfield, OH 45504 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)