Health inspection·August 20, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of hospital records, resident representative interview, staff interview, and review of facility policy, the facility failed to ensure appropriate care and services were provided to residents following accidents with injury. This affected one (Resident #99) of three residents reviewed for accidents. The facility census was 79 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #99 revealed an admission date of 07/02/24 with diagnoses including diffuse large B-Cell lymphoma, muscle weakness, viral hepatitis B, and atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment for Resident #99 dated 07/06/24 revealed the resident had mildly impaired cognition and required partial/moderate assistance with turning from side to side. Review of the nurse progress note for Resident #99 dated 08/03/24 revealed the resident was being changed and assisted with bed mobility and hit her head on the side rail. There was no swelling or redness was noted. The facility did not notify the physician of the incident, nor did they initiate neurological checks or follow up assessments. On 08/04/24 Resident #99 was transferred to the hospital because the resident's representative was concerned the resident was not acting like herself. Resident #99 was admitted to the hospital with a diagnosis of sepsis. Review of the hospital computed tomography (CT) results for Resident #99 dated 08/04/24 revealed the resident had a mid-left parietal scalp hematoma without skull fracture present. Telephone interview on 08/20/24 at 9:25 A.M. with Resident #99's representative confirmed facility staff reported the resident's head hit the bed frame while care was being provided by staff. Resident #99's representative confirmed staff did not initiate neurological check following the incident, the physician was not notified of the incident, and no follow up care was provided to the resident after the incident initially occurred. Interview on 08 /20/24 at 12:00 P.M. with Licensed Practical Nurse (LPN) #215 confirmed Resident #99 hit her head on the bed frame while staff were providing care. LPN #215 confirmed the facility staff did not complete an incident report, did not initiate neurological checks, did not notify the physician of the incident, and did not conduct follow-up assessments of the resident following the incident. Review of the facility policy titled Accident and Incident Policy revised 08/18/23 revealed the (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 4 Event ID: 366462 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 366462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110 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)