Stoney Ridge Senior Living

Based on record review, interview with facility staff, interview with Hospice staff, review of incident reports, review of emergency medical services (EMS) report, review of Hospice notes, review of a death certificate, and review of facility policy on falls, the facility failed to adequately investigate falls to determine a root cause of falls, identify trends and patterns of falls, failed to implement appropriate fall interventions to reduce and/or eliminate falls, and failed to provide a timely response to falls and assess residents for injuries after falls.

This resulted in Real and Present Danger and serious life-threatening harm on 02/23/26 at approximately 2:30 A.M. when Resident #115 had an unwitnessed fall in her room and sustained a large hematoma (a localized collection of clotted or partially clotted blood that has leaked from damaged blood vessels into surrounding tissues or body spaces) to the right side of her forehead which occluded her right eye along with dark purple bruising with uncontrolled bleeding. Instead of completing a thorough assessment on the resident, Licensed Practical Nurse (LPN) #279 called the Hospice service to come in and assess the resident. Hospice services arrived at approximately 3:47 A.M. and 911 was finally called at 4:40 A.M. to transport the resident to the hospital. Resident #115 was transported to the hospital then transferred to an inpatient Hospice setting where she passed away on 02/28/26. This affected one (Resident #115) of the six residents reviewed for accidents. The facility census was 113.

On 03/31/26 at 3:56 P.M., the Executive Director (ED), Health Services Director (HSD) #213, Regional Director of Health Services (RDHS) #951, Vice President of Clinical Operations (VPCO) #952, Vice President of Regulatory and Quality Services (VPRQS) #953, Vice President of Operations (VPO) #954 and Regional Director of Operations (RDO) #955 were notified Real and Present Danger began on 02/23/26 at approximately 2:30 A.M. when Resident #115 who was at risk for falls, had prior falls on 11/17/25, 12/30/25, 01/07/26 and 02/13/26 with no fall interventions implemented to reduce or eliminate falls, was observed lying on the floor of her room with a head injury including uncontrolled bleeding, bruising and a large hematoma that completely occluded the resident's right eye and the facility did not timely and appropriately assess the resident for injuries. Instead of completing a timely and thorough post-fall assessment, LPN #279 called Hospice services to come to the facility and assess the resident. Hospice Registered Nurse (RN) #850 arrived at 3:47 A.M. and the facility called 911 at 4:40 A.M. to transport the resident to the hospital. Subsequently, the resident was transferred to an inpatient Hospice center where the resident passed away secondary to blunt force trauma of the head on 02/28/26.

The Real and Present Danger was removed on 04/04/26 when the facility implemented the following corrective actions:

Beginning on 03/31/26 at 9:00 A.M., Staff education was initiated by HSD #213 and the Executive Director via telephone, COVR (an internal electronic platform used for communication and scheduling) and in person. The staff educated was completed by 04/04/26. The staff who did not complete the required education by 04/04/26 were removed from the schedule until completion. The Topics include: Falls management and post-fall interventions, Alert charting (a structured monitoring process in the electronic health record [EHR] that requires staff to document ongoing resident status, interventions, and outcomes at defined intervals following an incident and ensuring close observation and timely reassessment and resident monitoring), timely notification requirements, abuse and neglect recognition and reporting, and change of condition evaluation process.

Beginning 03/31/26, the Executive Director, HSD #213 or designee will review all incidents documented on the community's Incident Log, with special focus on falls and events requiring intervention and monitoring four times per week to ensure: timely notifications completed, Alert Charting initiated, interventions implemented, Temporary Service Plans in place and care plans were updated.

Beginning on 03/31/26, any identified violations (defined as facility's failure to follow established policies, incomplete documentation, delayed notifications, or failure to implement interventions) will have immediate correction, then re-education and competency validation then escalation to Regional leadership if patterns persist.

On 04/01/26, RDHS #951 in conjunction with the VPCO #952 conducted a review of fall-related incidents from 02/13/26 through 03/31/026. A total of 54 witnessed and unwitnessed falls were reviewed. No incidents of adverse outcome or delay of care were identified. 30 residents required updates to their care plans to include individualized fall interventions. Eight residents required a change of condition evaluation related to falls.

On 04/02/26, all 38 identified residents were assessed by HSD #213 and licensed nurses. No additional concerns or adverse outcomes were identified.

On 04/02/26, care plans for the 30 identified residents were updated to reflect individualized and appropriate fall interventions.

On 04/02/26, change of condition evaluations for the eight identified residents were completed. No additional clinical concerns or adverse outcomes were identified.

On 04/02/26, Temporary Service Plans were implemented and placed in a centralized binder accessible to staff for immediate intervention awareness. All new interventions for falls are documented immediately and placed in a centralized binder by the HSD #213, licensed nurses or designee. All direct care staff (nurses, certified medication aids [CMA] and caregivers) are required to review and acknowledge the interventions at the start of each shift.

On 04/02/26, HSD #213 and Executive Director were educated by the RDHS #951, RDO #955, and VPCO #952 on timely notifications to responsible parties, providers, and hospice, emergency response expectations including 911 activation when indicated, and post-fall intervention implementation and documentation requirements.

On 04/02/26, Alert Charting & Monitoring was re-implemented. Residents are placed on Alert Charting immediately following any fall or significant incident documented on the Community Incident Log by the licensed nurses or designee. Monitoring requirements include routine observation, documentation of resident condition, intervention effectiveness, and reassessment at defined intervals based on the resident's condition and risk level.

On 04/02/26, the notification process was reinforced. Immediate notification of responsible parties, providers, and Hospice required by HSD #213, licensed nurses, CMA, or designee. The Hospice residents requiring emergency services will have 911 activated when indicated, with Hospice notified.

On 04/02/26, the Quality Assurance Performance Improvement (QAPI) was strengthened. Individual root cause analysis is completed by Executive Director, HSD #213 for each incident. This is built into the EHR system and a part of completing the Incident Report. Individual incidents are reviewed through the QAPI processes, and trends are reviewed through the Continuous Quality Improvement (CQI) Committee, which serves as the community's quality oversight body. A monthly global root cause analysis will be conducted through the CQI Committee. The committee consists of Executive Director, HSD #213, Assistant Health Services Director #287, Resident Care Coordinator #221, Business Office Manager (BOM)#266, Maintenance Director #259, Culinary Services Director (CSD) #282.

Beginning on 04/02/26, the Executive Director, HSD #213 or designee will report the findings to the CQI monthly. The CQI committee will review incident trends, identify residents requiring change of condition evaluations and ensure sustained compliance and process improvement.

On 04/02/26, the major Medical Emergencies Policy was reviewed and taken out of use. A new policy titled Accidents, Incidents, and Unusual Occurrence Policy was implemented.

Beginning on 04/02/26, RDHS #951, RDO #955 or designee will audit the timeliness of notifications, implementation of interventions, use of Alert Charting, completion of Temporary Service Plans and accuracy and timeliness of care plan updates.

Although the Real and Present Danger was abated on 04/04/26, the violation remained as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.

Findings include:

Review of medical record for Resident #115 revealed an admission date of 06/25/19. Diagnoses included dementia, hypertension, congestive heart failure (CHF), major depressive disorder, diabetes mellitus type two, and cognitive communication deficit. Resident #115 was transferred to hospital on 02/23/26 and was discharged from the facility on 03/01/26.

Resident #115 had a pattern of falls. Review of an Incident Report for Resident #115 dated 11/17/25 at 11:33 A.M. and authored by LPN #236, revealed Resident #115 was observed sitting on the floor at 6:00 A.M. from an unwitnessed fall. There were no documented interventions to reduce and/or eliminate falls.

Review of Incident Task Note (a post fall note completed by the HSD) dated 11/21/25 and authored by HSD #213, revealed Resident #115 had an unwitnessed fall on 11/17/25. HSD #213 documented numerous fall interventions to be implemented; however, there was no documented evidence of any of the fall interventions being implemented to reduce and/or eliminate falls.

Review of the quarterly Service Plan and Evaluation for Resident #115 dated 11/26/25, revealed Resident #115 had severe cognitive impairment. Resident #115 was at risk for falls, had one to two falls in the last year and had over three chronic conditions.

Review of the Incident Report for Resident #115 dated 12/30/25 at 10:19 A.M. and authored by LPN #236, revealed Resident #115 was observed on her bottom in front of the recliner at 7:30 A.M. from an unwitnessed fall. There were no documented interventions to reduce and/or eliminate falls.

Review of the Incident Task Note for the unwitnessed fall on 12/30/25 and authored by HSD #213 on 01/26/26, revealed Resident #115 had unwitnessed fall. HSD #213 documented numerous fall interventions to be implemented; however, there was no documented evidence of any of the fall interventions being implemented to reduce and/or eliminate falls.

Review of the Incident Report for Resident #115 dated 01/07/26 at 7:00 A.M. and authored by LPN #279, revealed a resident caregiver (RG) called the nurse to Resident #115's room for an unwitnessed fall at 3:42 A.M. Resident #115 had a four cm by two cm hematoma noted on the mid scalp and forehead. There were no documented interventions to reduce and/or eliminate falls.

Review of the Incident Task Note for the unwitnessed fall on 01/07/26 and authored by HSD #213 on 01/21/26, revealed Resident #115 had unwitnessed fall. HSD #213 documented numerous fall interventions to be implemented; however, there was no documented evidence of any of the fall interventions being implemented to reduce and/or eliminate falls.

Review of the Incident Report for Resident #115 dated 02/13/26 at 7:25 A.M. and authored by LPN #279, revealed an RG called the nurse to Resident #115's room for an unwitnessed fall at 2:10 A.M. Resident #115 was found lying face down on the floor in front of her recliner where she was last seen in the reclined position. Resident #115 had a baseball size hematoma to the right forehead which measured five cm by five cm and ice was applied. There were no documented interventions to reduce and/or eliminate falls.

Review of the Hospice Coordination Note for Resident #115 dated 02/13/26, revealed a call was received from LPN #279 on 02/13/26 at 1:40 A.M. reporting Resident #115 had an unwitnessed fall with injuries. LPN #279 reported Resident #115 was found face down in her room with a bigger than a golf ball sized knot on her head and was not following commands.

Review of the Hospice Visit Note for Resident #115 dated 02/13/26 at 2:07 A.M. and authored by Hospice RN #801, revealed a verbal report was received from LPN #279 who stated the resident had an unwitnessed fall and had a large goose egg on the right side of her forehead. Resident #115 appeared pale, frail, and had a large egg-shaped swollen area to the right side of her forehead. There were no recommended interventions to reduce or eliminate falls.

Review of the nurse's progress note for Resident #115 dated 02/13/26 at 7:15 P.M., revealed Resident #115 had a fall overnight and had a lot of bruising to the face with a large hematoma to the right forehead.

Review of the Incident Task Note for the unwitnessed fall on 02/13/26 and authored by HSD #213 on 02/26/26, revealed Resident #115 had an unwitnessed fall. HSD #213 documented numerous fall interventions to be implemented; however, there was no documented evidence of any of the fall interventions being implemented to reduce and/or eliminate falls.

Review of the nurse's progress note for Resident #115 dated 02/14/26 at 11:22 A.M., revealed the nurse spoke with the Hospice nurse for an update on Resident #115's fall. Resident #115 had a knot on the right side of her forehead that was dark purple in color and the resident's right cheek was swollen with a deep purple color and the area was tender.

Review of the Hospice Coordination Note for Resident #115 dated 02/16/26, revealed Hospice LPN #900 visited Resident #115 for a routine visit. Resident #115 had purplish bruising to the right side of her face from a fall and a hematoma to the right side of her forehead.

Review of the Hospice Coordination Note for Resident #115 dated 02/23/26, revealed LPN #279 called Hospice at 2:31 A.M. and reported Resident #115 fell and had a large knot on her head. LPN #279 was requesting an assessment and Hospice RN #850 was notified.

Review of the Hospice Visit Note for Resident #115 dated 02/23/26, revealed RN #850 visited the resident at 3:47 A.M. Hospice RN #850 arrived at the facility and collaborated with LPN #279 and two RGs. The staff reported Resident #115 was found on the floor about two feet away from the bed at about 2:15 A.M. The staff stated Resident #115 appeared to have landed on an existing hematoma on her forehead and her eye from another fall on 02/13/26. Resident #115 was sitting in her geriatric chair in the common area with two RGs sitting nearby. Resident #115's left eye was open and was alert but was non-verbal. Resident #115 guarded the right side of her forehead and face and would not allow palpation or ice to be applied. The surrounding area was dark purple with a moderate amount of bright red drips of blood running down and the resident's face and had small openings above the right eye. Resident #115's lung sounds were clear but diminished to auscultation, respirations were 20 breaths per minute, and the abdomen was soft, round and non-tender to light palpitation. Bowel sounds were active in all four quadrants, and the radial and pedal pulses were palpable with edema. Hospice RN #850 and LPN #279 were unable to control the bleeding from a cantaloupe sized right forehead and eye hematoma with dark purple bruising. Resident #115 was sent to the emergency room by 911 for an evaluation. Hospice RN #850 gave an update with photographs to the physician and updated Resident #115's daughter.

Review of EMS report dated 02/23/26, revealed 911 was contacted at 4:40 A.M. related to a resident who fell with facial injuries. EMS arrived at the facility at 4:47 A.M. and found Resident #115 lying in a chair inside the Memory Care Unit with a large hematoma and ecchymosis (bruising) to the right side of her face. The staff stated the resident had a fall one week ago that caused a softball sized swelling and bruising and was not sent to the hospital. The staff stated the resident fell again on the same place and they could not determine how she fell. The resident presented as being lethargic, had a lacrosse ball sized hematoma to the right side of her face, was black and blue, was unable to open he right eye and had a small amount of blood. The resident's vitals were assessed as blood pressure elevated at 187 over 106 mmHg, pulse elevated at 109 beats per minute and respirations were normal at 16 breaths per minute. The resident was transferred to the emergency room.

Review of the Incident Report for Resident #115 dated 02/23/26 at 9:14 A.M. authored by LPN #279, revealed an RG called the nurse to the resident's room for an unwitnessed fall at 2:30 A.M. Resident #115 was getting out of her recliner and was found lying on the carpeted floor on her left side holding her head halfway between the recliner where she was last seen and the bathroom. The recliner was still in reclined position, and the floor table lamp was knocked over. There was a nine cm by six cm hematoma noted on the right side of the head which was the same location as her injury from a previous fall. There was a small amount of red drainage noted coming from the hematoma. Resident #115 was alert and responsive to her name, but nonverbal and confusion was noted. Pupil sizes could not be assessed due to Resident #115 not wanting to cooperate and the right eye being swollen shut. An assessment was completed and the resident was able to move all four extremities without discomfort, blood pressure was elevated but all other vital signs were within normal limits, and no other injuries were noted. Resident #115 was assisted into the geriatric chair and placed in the common area. An ice pack was applied to the hematoma on the right side of the head. The Hospice nurse came in and assessed the resident. The physician was notified and Resident #115 was sent to the hospital. The Hospice nurse left a message with Resident #115's POA.

Review of the nurse's progress note for Resident #115 dated 02/23/26 at 4:05 P.M., revealed the facility called the hospital to follow up on Resident #115's condition. The nurse reported Resident #115 would be transferring to an inpatient hospice.

Review of the nurse's progress note for Resident #115 dated 03/02/26 at 4:29 P.M., revealed the facility was notified that Resident #115 expired at an inpatient Hospice center on 02/28/26.

Review of the Death Certificate for Resident #115 dated 03/04/26 and certified by Physician #800, revealed the resident's date of death was 02/28/26 at an inpatient Hospice facility. The immediate cause of death listed was blunt force trauma of the head with the approximate interval of time being days. Other significant conditions included atherosclerotic and hypertensive cardiovascular disease. An autopsy was not preformed, and the manner of death was listed as accidental. The location of the injury was listed as being the facility's address and the description of the injury was listed as ground level fall that occurred on 02/23/26.

During an interview on 03/27/26 at 11:50 A.M., the ED and HSD #213 verified Resident #115 had falls on 11/17/25, 12/30/25, 01/07/26, 02/13/26 and 02/23/26 and there was no documented evidence of the fall interventions listed in the Incident Task Notes being implemented to reduce and/or eliminate falls. HSD #213 verified Resident #115 had a fall at the facility on 02/13/26 at 2:10 A.M. and sustained injuries to her head which included a five cm by five cm hematoma noted on her right forehead and Hospice was notified to assess Resident #115's condition. HSD #213 verified the facility did not have any post fall neuro checks or vital signs documented for Resident #115 immediately following the fall on 2/13/26. HSD #213 verified Resident #115 had an unwitnessed fall on 02/23/26 at 2:30 A.M. and was found lying on the floor with a nine cm by six cm hematoma noted on the right side of the head and red drainage coming from the hematoma and Hospice was called in to assess the resident. HSD #213 stated the physician was notified and Resident #115 was sent to the hospital and The Hospice nurse called and left a message with Resident #115's POA

During an interview on 03/27/26 at 11:59 A.M., Hospice LPN #900 stated he saw the resident on 02/16/26 and she had purple bruising and a hematoma on the right side of her face.

Attempted to contact LPN #279 on 03/27/26 at 12:23 P.M. and 03/29/26 at 1:59 P.M. and a voicemail was left requesting a return call. No return call was received.

During an interview on 03/27/26 at 12:28 P.M., the ED stated the facility did not have a policy for completing neuro checks for residents after falls.

During an interview on 03/27/26 at 1:09 P.M., HSD #213 stated she only recorded fall interventions in her Incident Task Notes and there was no other location where they were documented. HSD #213 stated fall interventions were communicated to nurses and caregivers in daily huddles. HSD #213 verified there was no documentation of the fall interventions recorded in her Incident Task Notes for Resident #115 being implemented.

During an interview on 03/27/26 at 1:26 P.M., the ED stated that no resident's fall could be prevented unless the resident had a bedside sitter which the facility did not provide. The ED stated the fall intervention for the fall on 01/07/26 fall was to have the family bring in a new recliner due to it smelling like urine. The ED verified Resident #115 fell at the facility on 02/23/26 at 2:30 A.M. and the Hospice nurse did not arrive at the facility until 3:47 A.M. to assess the resident. The ED stated Resident #115 was a do not resuscitate comfort care (DNRCC) code status and that is why the facility staff called Hospice instead of 911. The ED stated the goal with Hospice being in place was to never send the residents to the hospital.

During a telephone interview on 03/27/26 at 2:08 P.M., Nurse Practitioner (NP) #950 stated she reviewed the note reference to Resident #115's fall on 02/23/26 and stated she would expect the facility to call 911 and send Resident #115 to the hospital instead of calling Hospice services for an assessment.

During an interview on 03/27/26 at 2:17 P.M., the ED and HSD #213 verified the facility the facility had no documentation of the fall interventions listed in the Incident Task Notes being implemented. The ED and HSD #213 verified they did not have any witness statements from the staff following the resident's fall on 11/17/25, 12/30/25, 01/07/26, 02/13/26, and 02/23/26 because the falls were not witnessed. The ED and HSD #213 verified Resident #115's falls on 11/17/25, 12/30/25, 01/07/26, 02/13/26, and 02/23/26 all occurred in Resident #115's room and between 2:10 A.M. and 7:30 A.M. establishing a pattern occurring with Resident #115's falls and no investigation was completed.

During a telephone interview on 03/27/26 at 2:31 P.M., NP #950 stated she assessed Resident #115 at the facility on 02/17/26 and the resident had a hematoma and bruising to the right forehead.

During a telephone interview on 04/01/26 at 4:49 P.M., Hospice RN #850 and Hospice Clinical Director #956 stated Hospice RN #850 was notified on 02/23/26 that Resident #115 fell at the facility and hit her head. Hospice RN #850 stated she was not notified of Resident #115's condition but only notified that Resident #115 needed a visit from Hospice. Hospice RN #850 verified she arrived at the facility on 02/23/26 at about 3:47 A.M. which was approximately one hour and 17 minutes after Resident #115's fall. Hospice RN #850 stated Resident #115 was sitting in the common area in her geriatric chair with two caregivers present when she arrived at the facility. Hospice RN #850 reported the resident had a cantaloupe sized hematoma sticking out from the right side of her forehead with bruising to the right side of the face with blood dripping from the open areas. Hospice RN #850 stated that the nurse and two caregivers were not actively trying to stop the bleeding when she arrived, but the two caregivers told Hospice RN #850 that they tried to apply ice packs. Hospice RN #850 stated she made the decision to send Resident #115 out to the hospital because she did not see any way to control the bleeding and the area was rather large, and she suspected that Resident #115 was bleeding internally based on her observation of the size of the hematoma. Hospice RN #850 stated 911 should have been called immediately based on her assessment of the resident's injuries. Hospice RN #850 stated she contacted Resident #115's POA after she arranged for Resident #115 to be sent to the hospital and the resident's POA stated she had not been contacted by the facility.

Review of the Job Description for HSD revealed the HSD provides leadership for resident care and promotes the health and wellness of the resident population. HSD was responsible for directing each resident's health concerns. The HSD would provide training, supervision and monitoring of caregivers in following the residents' service plans and completing tasks for the assigned services, initiate resident service plans according to the residents individualized needs as prescribed by the ordering healthcare provider. The HSD would ensure caregivers completed daily services and that service plans were updated swiftly when changes in condition are reported and manage the residents' health care status.

Review of the Job Description for LPN, revealed LPNs were responsible for assessing monitoring the health status of the residents, communicating with healthcare professionals and family members, monitoring vital signs and reporting any changes to the healthcare team.

Review of the facility's policy titled Major Medical Emergency and Documentation Policy revised on 05/15/23 and removed from service on 04/02/26, revealed Emergency Medical Services (EMS) would be summoned immediately when a resident at the community showed any signs or symptoms of medical crisis. Any time there is a change in stability of the resident and there appears to be a serious threat to their health or wellbeing, staff would not hesitate to summon EMS. If a resident was receiving Hospice services, staff were to call the resident's Hospice provider first. Examples of signs and symptoms of distress include but are not limited to any fall with suspected head trauma or fall where there is a concern about possible head trauma, trauma such as significant bleeding and any traumatic fall for any resident receiving anticoagulant therapy.

Review of the facility's policy titled Fall Management and Post Fall Investigations Policy dated 05/15/23, revealed communication was provided to the residents, responsible parties and team members on fall interventions. Fall interventions were documented in the resident's individualized service and care plans and the resident's responsible party and physician would be notified of falls. If any of the signs including swelling discoloration of the skin, skin tears, skin abrasions or bleeding, especially from the head were present or if the resident required more than minimal assistance to get up, the staff would call EMS and not move the resident. Staff would not move a resident and call EMS if the resident hit their head or was suspected to have hit their head. An incident report would be completed by the medical team member, licensed nurse team member or the ED and the resident would be placed on Alert Charting. The supervisor in charge would notify the physician and responsible party of the fall. Changes in fall interventions would be communicated to all appropriate community team members, the resident and the responsible party. The medical team members, licensed nurse team members, HSD or the ED would document the fall event in the resident's health record. Falls would be investigated, reported and documented using the incident report and post fall tools. A careful review and analysis of the possible contributing factors to the fall with or without injuries would be completed using the post fall investigation tool. The HSD or designee would analyze the results for trends and patterns in the residents falls to use as a basis for implementation of process improvement.

Review of the facility's policy titled Change in Condition Policy revised 10/21/24, revealed any changes in the resident's physical, mental or emotional condition were promptly recognized, reported, evaluated and addressed by the community. The staff members were responsible for monitoring and reporting changes, and the licensed nurse or their designee was accountable for timely follow up, appropriate interventions and documentation. The licensed nurse or designee would notify the resident's family or responsible party and primary care provider if the change in condition warrants further medical evaluation, treatment or alternations to the resident's evaluation and service plan. Notification details would be documented in the resident health card including the time and method of communication.

This violation represents non-compliance investigated under Complaint Number OH00169947.

Based on staff interview, medical record review, and policy review, the facility failed to timely notify a resident's responsible party of a fall. This affected one (Residents #115) of six residents reviewed for accidents. The facility census was 113.

Findings included:

Review of medical record for Resident #115 revealed an admission date of 06/25/19. Diagnoses included dementia, hypertension, congestive heart failure (CHF), major depressive disorder, diabetes mellitus type two, and cognitive communication deficit. Resident #115 was transferred to hospital on 02/23/26 and was discharged from the facility on 03/01/26.

Review of the quarterly Service Plan and Evaluation for Resident #115 dated 11/26/25, revealed Resident #115 had severe cognitive impairment. Resident #115 was at risk for falls, had one to two falls in the last year and had over three chronic conditions.

Review of the nurse's progress note for Resident #115 dated 02/23/26 at 9:14 A.M. authored by Licensed Practical Nurse (LPN) #279, revealed a resident caregiver (RG) called the nurse to the resident's room for an unwitnessed fall at 2:30 A.M. Resident #115 was getting out of her recliner and was found lying on the carpeted floor on her left side holding her head halfway between the recliner where she was last seen and the bathroom. The recliner was still in reclined position, and the floor table lamp was knocked over. There was a nine cm by six cm hematoma (a localized collection of clotted or partially clotted blood that has leaked from damaged blood vessels into surrounding tissues or body spaces) noted on the right side of the head which was the same location as her injury from a previous fall on 02/13/26. There was a small amount of red drainage noted coming from the hematoma. Resident #115 was alert and responsive to her name, but nonverbal and confusion was noted. Pupil sizes could not be assessed due to Resident #115 not wanting to cooperate and the right eye being swollen shut. An assessment was completed and the resident was able to move all four extremities without discomfort, blood pressure was elevated but all other vital signs were within normal limits, and no other injuries were noted. Resident #115 was assisted into the geriatric chair and placed in the common area. An ice pack was applied to the hematoma on the right side of the head. The Hospice nurse came in and assessed the resident. The physician was notified and Resident #115 was sent to the hospital. The Hospice nurse left a message with Resident #115's power-of-attorney (POA). There was no documented evidence that the residents POA was notified at the time of the fall.

Review of the Hospice Coordination Note for Resident #115 dated 02/23/26, revealed LPN #279 called Hospice at 2:31 A.M. and reported Resident #115 fell and had a large knot on her head. LPN #279 was requesting an assessment and Hospice RN #850 was notified.

Review of the Hospice Visit Note for Resident #115 dated 02/23/26, and authored by Hospice Registered Nurse (RN) #850 revealed she visited the resident at 3:47 A.M. and collaborated with LPN #279 and two RGs. The staff reported Resident #115 was found on the floor about two feet away from the bed at about 2:15 A.M. The staff stated Resident #115 appeared to have landed on an existing hematoma on her forehead and her eye from another fall on 02/13/26. Resident #115 was sitting in her geriatric chair in the common area with two RGs sitting nearby. Resident #115's left eye was open and was alert but was non-verbal. Resident #115 guarded the right side of her forehead and face and would not allow palpation or ice to be applied. The surrounding area was dark purple with a moderate amount of bright red drips of blood running down and the resident's face and had small openings above the right eye. Hospice RN #850 and LPN #279 were unable to control the bleeding from a cantaloupe sized right forehead and eye hematoma with dark purple bruising. Resident #115 was sent to the emergency room by 911 for an evaluation. Hospice RN #850 gave an update with photographs to the hospice physician and updated Resident #115's daughter.

Review of emergency medical services (EMS) report dated 02/23/26, revealed 911 was contacted at 4:40 A.M. related to a resident who fell with facial injuries. EMS arrived at the facility at 4:47 A.M. and found Resident #115 lying in a chair inside the Memory Care Unit with a large hematoma and ecchymosis (bruising) to the right side of her face. The staff stated the resident had a fall one week ago that caused a softball sized swelling and bruising and was not sent to the hospital. The staff stated the resident fell again on the same place and they could not determine how she fell. The resident presented as being lethargic, had a lacrosse ball sized hematoma to the right side of her face, was black and blue, was unable to open he right eye and had a small amount of blood. The residents vitals were assessed as blood pressure elevated at 187 over 106 mmHg, pulse elevated at 109 beats per minute and respirations were normal at 16 breaths per minute. The resident was transferred to the emergency room at 4:57 A.M.

During an interview on 03/27/26 at 1:26 P.M., the Eexecutive Director (ED) verified Resident #115 fell at the facility on 02/23/26 at 2:30 A.M. and the Hospice nurse did not arrive at the facility until 3:47 A.M. to assess the resident. The ED also verified that Resident #115's POA was notified of the fall by Hospice nurse and the facility did not immediately notify Resident #115's POA. The ED stated Resident #115 was a do not resuscitate comfort care (DNRCC) code status and that is why the facility staff called Hospice instead of 911. The ED stated the goal with Hospice being in place was to never send the residents to the hospital.

During a telephone interview on 04/01/26 at 4:49 P.M., Hospice RN #850 and Hospice Clinical Director #956 stated Hospice RN #850 was notified on 02/23/26 that Resident #115 fell at the facility and hit her head. Hospice RN #850 stated she was not notified of Resident #115's condition but only notified that Resident #115 needed a visit from Hospice. Hospice RN #850 verified she arrived at the facility on 02/23/26 at approximately 3:47 A.M., which was approximately one hour and 17 minutes after Resident #115's fall. Hospice RN #850 stated Resident #115 was sitting in the common area in her geriatric chair with two caregivers present when she arrived at the facility. Hospice RN #850 reported the resident had a cantaloupe sized hematoma sticking out from the right side of her forehead with bruising to the right side of the face with blood dripping from the open areas. Hospice RN #850 stated that the nurse and two caregivers were not actively trying to stop the bleeding when she arrived, but the two caregivers told Hospice RN #850 that they tried to apply ice packs. Hospice RN #850 stated she made the decision to send Resident #115 out to the hospital because she did not see any way to control the bleeding and the area was rather large, and she suspected that Resident #115 was bleeding internally based on her observation of the size of the hematoma. Hospice RN #850 stated 911 should have been called immediately based on her assessment of the resident's injuries. Hospice RN #850 stated she contacted Resident #115's POA after she arranged for Resident #115 to be sent to the hospital and the resident's POA stated she had not been contacted by the facility.

Review of the facility's policy titled Major Medical Emergency and Documentation Policy revised on 05/15/23 and removed from service on 04/02/26, revealed Emergency Medical Services (EMS) would be summoned immediately when a resident at the community showed any signs or symptoms of medical crisis. Any time there is a change in stability of the resident and there appears to be a serious threat to their health or wellbeing, staff would not hesitate to summon EMS. If a resident was receiving Hospice services, staff were to call the resident's Hospice provider first. Examples of signs and symptoms of distress include but are not limited to any fall with suspected head trauma or fall where there is a concern about possible head trauma, trauma such as significant bleeding and any traumatic fall for any resident receiving anticoagulant therapy.

Review of the facility's policy titled Change in Condition Policy revised 10/21/24, revealed any changes in the resident's physical, mental or emotional condition were promptly recognized, reported, evaluated and addressed by the community. The staff members were responsible for monitoring and reporting changes, and the licensed nurse or their designee was accountable for timely follow up, appropriate interventions and documentation. The licensed nurse or designee would notify the resident's family or responsible party and primary care provider if the change in condition warrants further medical evaluation, treatment or alternations to the resident's evaluation and service plan. Notification details would be documented in the resident health card including the time and method of communication.

Review of the facility's policy titled Fall Management and Post Fall Investigations Policy dated 05/15/23, revealed communication was provided to the residents, responsible parties and team members on fall interventions. Fall interventions were documented in the resident's individualized service and care plans and the resident's responsible party and physician would be notified of falls. If any of the signs including swelling discoloration of the skin, skin tears, skin abrasions or bleeding, especially from the head were present or if the resident required more than minimal assistance to get up, the staff would call EMS and not move the resident. Staff would not move a resident and call EMS if the resident hit their head or was suspected to have hit their head. An incident report would be completed by the medical team member, licensed nurse team member or the ED and the resident would be placed on Alert Charting. The supervisor in charge would notify the physician and responsible party of the fall. Changes in fall interventions would be communicated to all appropriate community team members, the resident and the responsible party. The medical team members, licensed nurse team members, HSD or the ED would document the fall event in the resident's health record. Falls would be investigated, reported and documented using the incident report and post fall tools. A careful review and analysis of the possible contributing factors to the fall with or without injuries would be completed using the post fall investigation tool. The HSD or designee would analyze the results for trends and patterns in the residents falls to use as a basis for implementation of process improvement.

This violation represents non-compliance investigated under Complaint Number OH00169947.

Based on record review, review of Incident Reports, review of Incident Task Notes, review of Hospice notes, staff and Hospice staff interviews, and policy review, the facility failed to conduct thorough investigations to determine a root cause analysis for residents' falls. This affected one (Resident #115) of the six residents reviewed for accidents. The facility census was 113.

Findings include:

Review of the medical record for Resident #115 revealed an admission date of 06/25/19. Diagnoses included dementia, hypertension, congestive heart failure (CHF), major depressive disorder, diabetes mellitus type two, and cognitive communication deficit. Resident #115 was transferred to hospital on 02/23/26 and was discharged from the facility on 03/01/26.

Review of the facility's Incident Logs from 11/01/25 through 03/27/25, revealed Resident #115 had unwitnessed falls on 11/17/25, 12/30/25, 01/07/26, 02/13/26, and 02/23/26. The facility's Incident log listed a total of 161 falls (witnessed and unwitnessed) with many of the same resident names appearing on the Incident Log.

Review of an Incident Report for Resident #115 dated 11/17/25 at 11:33 A.M. and authored by Licensed Practical Nurse (LPN) #236, revealed Resident #115 was observed sitting on the floor in front of the recliner in her room at 6:00 A.M. Resident #115 had no injuries, vital signs were assessed to be normal, and the resident's power-of-attorney (POA), physician and Hospice were notified. There was no documented evidence of a thorough investigation being completed for the resident's fall.

Review of Incident Task Note (a post fall note completed by the Health Services Director [HSD]) dated 11/21/25 and authored by HSD #213, revealed Resident #115 had an unwitnessed fall on 11/17/25. The staff were to ensure devices were within reach for a visual, ensure check and changes were completed each morning, in between meals and at night, encourage activities, escort the resident to meals, offer hydration, ensure the resident's room was free of clutter, ensure proper footwear was worn and complete frequent safety checks to ensure safety. There was no documented evidence of a thorough investigation being completed for the resident's fall.

Review of the quarterly Service Plan and Evaluation for Resident #115 dated 11/26/25, revealed Resident #115 had severe cognitive impairment. Resident #115 was at risk for falls, had one to two falls in the last year and had over three chronic conditions.

Review of the Incident Report for Resident #115 dated 12/30/25 at 10:19 A.M. and authored by LPN #236, revealed Resident #115 was observed on her bottom in front of the recliner at 7:30 A.M. Resident #115 was wearing gripper socks, had no injuries, range of motion was within normal limits, had no pain, and vital signs were assessed to be normal. Resident #115's POA, nurse practitioner (NP) and Hospice were notified. There was no documented evidence of a thorough investigation being completed for the resident's fall.

Review of the Incident Task Note for the unwitnessed fall on 12/30/25 and authored by HSD #213 on 01/26/26, revealed Resident #115 had unwitnessed fall. The staff were to ensure the resident was positioned properly in the recliner, ensure the recliner was in the lowest position, ensure assistive devices were within reach, ensure check and changes were done in the morning, between meals and at night, escort Resident #115 to meals, offer hydration, ensure the room was free of clutter, ensure proper footwear was worn at all times and frequent safety checks. There was no documented evidence of a thorough investigation being completed for the resident's fall.

Review of the Incident Report for Resident #115 dated 01/07/26 at 7:00 A.M. and authored by LPN #279, revealed a resident caregiver (RG) called the nurse to Resident #115's room for an unwitnessed fall at 3:42 A.M. Resident #115 was sitting with her back up against the footrest of the recliner on the floor. Resident #115 had a four cm by two cm hematoma noted on the mid scalp and forehead. Resident #115 was alert to self but had normal confusion. Resident #115 was unable to explain or remember how she fell, where she hit her head or what she was doing at the time of the fall. Neuro checks were within normal limits, and the resident had full range of motion. Resident #115 was wearing non-skid socks, denied any pain or discomfort and the resident's blood pressure was slightly elevated and all other vital signs were assessed to be within normal limits. Resident #115 was assisted to a standing position and then placed back in the recliner. A wheeled walker was noted across the room away from the recliner where the resident was sitting prior to the fall. Resident #115's Hospice company and physician were made aware. Resident #115's daughter was made aware and was informed for the need of a new recliner. The Hospice Certified Nursing Assistant (CNA) and nurse came to see the resident. There was no documented evidence of a thorough investigation being completed for the resident's fall.

Review of the Incident Task Note for the unwitnessed fall on 01/07/26 and authored by HSD #213 on 01/21/26, revealed Resident #115 had unwitnessed fall. The staff were to ensure Resident #115 was positioned properly when in the recliner, ensure the recliner was in the lowest position, ensure assistive devices were within reach, ensure check and changes were completed in the morning, between meals and at night, encourage activities, escort Resident #115 to meals, offer hydration, ensure the room was free of clutter, ensure proper footwear was worn, encourage, offer and engage in activities and frequent safety checks. There was no documented evidence of a thorough investigation being completed for the resident's fall.

Review of the Incident Report for Resident #115 dated 02/13/26 at 7:25 A.M. and authored by LPN #279, revealed an RG called the nurse to Resident #115's room for an unwitnessed fall at 2:10 A.M. Resident #115 was noted with no socks or shoes on and lying face down on the floor in front of her recliner where she was last seen in the reclined position. Resident #115 had a baseball size hematoma to the right forehead which measured five cm by five cm. Resident #115 was alert but did not respond to staff verbally or by following commands. The staff were unable to assess hand grasps or range of motion. There were no signs of discomfort or acute distress noted. Resident #115's blood pressure was elevated but all other vital signs were within normal limit. Resident #115 was assisted to the bed by two staff members and ice was applied to the right forehead hematoma. Hospice was notified and the on- call Hospice would be in to assess the resident. A message was left with Resident #115's POA and physician. There was no documented evidence of a thorough investigation being completed for the resident's fall.

Review of the Hospice Coordination Note for Resident #115 dated 02/13/26, revealed a call was received from LPN #279 on 02/13/26 at 1:40 A.M. reporting Resident #115 had an unwitnessed fall with injuries. LPN #279 reported Resident #115 was found face down in her room with a bigger than a golf ball sized knot on her head, was not following commands, and her blood pressure was elevated at 204 over 90 millimeters of mercy (mmHg) and no signs of pain were noted. The facility was informed that Hospice Registered Nurse (RN) #801 was notified.

Review of the Hospice Visit Note for Resident #115 dated 02/13/26 at 2:07 A.M. and authored by Hospice RN #801, revealed a verbal report was received from LPN #279 who stated the resident had an unwitnessed fall and had a large goose egg on the right side of her forehead. Resident #115 was in bed with her eyes closed during the visit. Resident #115 appeared pale, frail, and had a large egg-shaped swollen area to the right side of her forehead and the resident was not wearing any non-slip socks or shoes. Resident #115 was assessed with no other injuries and Hospice RN #801 placed gripper socks and slippers on the resident and attempted to wake the resident up multiple times. Resident #115 ate half of a pudding cup and woke up and opened her eyes. Resident #115 was reminded to wait until staff were available to assist her next time she needed to use the bathroom. Hospice RN #801 placed ice on the injury for about 15 minutes and used lotion on Resident #115's hands and face. Resident #115 was resting easy with no furrowed brow and no signs or symptoms of pain or anxiety when Hospice RN #801 departed the facility. The bed was in the lowest position and LPN #279 suggested that a geriatric chair could decrease the amount of falls the resident was having. RN #801 would contact the supplier. There were no recommended interventions to reduce or eliminate falls.

Review of the nurse's progress note for Resident #115 dated 02/13/26 at 7:15 P.M., revealed Resident #115 had a fall overnight, and the medication aide got a report that Resident #115 had a lot of bruising to the face that was black and blue. Resident #115 had a large hematoma to the right forehead and was seen by Hospice with no new orders. Resident #115 was sitting in the chair watching television.

Review of the Incident Task Note for the unwitnessed fall on 02/13/26 and authored by HSD #213 on 02/26/26, revealed Resident #115 had an unwitnessed fall. The staff were to increase observations during waking hours, offer toileting upon rising, between meals and at night, offer hydration, ensure assistive devices were near, prompt and remind the resident, ensure the recliner was in the lowest position when sitting, encourage activities, escort to meals, offer hydration, ensure the room was free of clutter, ensure proper footwear, encourage, offer and engage in activities and frequent safety checks to ensure safety. There was no documentation to support a fall mat was in place at the time of the resident's fall. There was no documented evidence of a thorough investigation being completed for the resident's fall.

Review of the Hospice Coordination Note for Resident #115 dated 02/16/26, revealed Hospice LPN #900 visited Resident #115 for a routine visit. Resident #115 was observed sitting in her recliner with her eyes closed and aroused to verbal stimuli. Resident #115 was alert to self only with confusion and the resident's speech was inappropriate to the situation. Resident #115 had purplish bruising to the right side of her face from a fall and a hematoma to the right side of her forehead. No further signs or symptoms of pain or discomfort were noted during the visit. Resident #115 was able to ambulate to the restroom with a walker and had increased usage of the wheelchair. Resident #115 was sitting in the recliner watching television at the end of the visit.

Review of the Hospice Coordination Note for Resident #115 dated 02/23/26, revealed LPN #279 called Hospice at 2:31 A.M. and reported Resident #115 fell and had a large knot on her head. LPN #279 was requesting an assessment and Hospice RN #850 was notified.

Review of the Hospice Visit Note for Resident #115 dated 02/23/26, revealed RN #850 visited the resident at 3:47 A.M. Hospice RN #850 arrived at the facility and collaborated with LPN #279 and two RGs. The staff reported Resident #115 was found on the floor about two feet away from the bed at about 2:15 A.M. The staff stated Resident #115 appeared to have landed on an existing hematoma on her forehead and her eye from another fall on 02/13/26. Resident #115 was sitting in her geriatric chair in the common area with two RGs sitting nearby. Resident #115's left eye was open and was alert but was non-verbal. Resident #115 guarded the right side of her forehead and face and would not allow palpation or ice to be applied. The surrounding area was dark purple with a moderate amount of bright red drips of blood running down and the resident's face and had small openings above the right eye. Resident #115's lung sounds were clear but diminished to auscultation, respirations were 20 breaths per minute, and the abdomen was soft, round and non-tender to light palpitation. Bowel sounds were active in all four quadrants, and the radial and pedal pulses were palpable with edema. Hospice RN #850 and LPN #279 were unable to control the bleeding from a cantaloupe sized right forehead and eye hematoma with dark purple bruising. Resident #115 was sent to the emergency room by 911 for an evaluation. Hospice RN #850 gave an update with photographs to the physician and updated Resident #115's daughter.

Review of EMS report dated 02/23/26, revealed 911 was contacted at 4:40 A.M. related to a resident who fell with facial injuries. EMS arrived at the facility at 4:47 A.M. and found Resident #115 lying in a chair inside the Memory Care Unit with a large hematoma and ecchymosis (bruising) to the right side of her face. The staff stated the resident had a fall one week ago that caused a softball sized swelling and bruising and was not sent to the hospital. The staff stated the resident fell again on the same place and they could not determine how she fell. The resident presented as being lethargic, had a lacrosse ball sized hematoma to the right side of her face, was black and blue, was unable to open he right eye and had a small amount of blood. The residents vitals were assessed as blood pressure elevated at 187 over 106 mmHg, pulse elevated at 109 beats per minute and respirations were normal at 16 breaths per minute. The resident was transferred to the emergency room.

Review of the Incident Report for Resident #115 dated 02/23/26 at 9:14 A.M. authored by LPN #279, revealed an RG called the nurse to the resident's room for an unwitnessed fall at 2:30 A.M. Resident #115 was getting out of her recliner and was found lying on the carpeted floor on her left side holding her head halfway between the recliner where she was last seen and the bathroom. The recliner was still in reclined position, and the floor table lamp was knocked over. There was a nine cm by six cm hematoma noted on the right side of the head which was the same location as her injury from a previous fall. There was a small amount of red drainage noted coming from the hematoma. Resident #115 was alert and responsive to her name, but nonverbal and confusion was noted. Pupil sizes could not be assessed due to Resident #115 not wanting to cooperate and the right eye being swollen shut. An assessment was completed and the resident was able to move all four extremities without discomfort, blood pressure was elevated but all other vital signs were within normal limits, and no other injuries were noted. Resident #115 was assisted into the geriatric chair and placed in the common area. An ice pack was applied to the hematoma on the right side of the head. The Hospice nurse came in and assessed the resident. The physician was notified and Resident #115 was sent to the hospital. The Hospice nurse left a message with Resident #115's POA. There was no documented evidence of a thorough investigation being completed for the resident's fall.

Review of the nurse's progress note for Resident #115 dated 03/02/26 at 4:29 P.M., revealed the facility was notified that Resident #115 expired at an inpatient Hospice center on 02/28/26.

Review of the Death Certificate for Resident #115 dated 03/04/26 and certified by Physician #800, revealed the resident's date of death was 02/28/26 at an inpatient Hospice facility. The immediate cause of death listed was blunt force trauma of the head with the approximate interval of time being days. Other significant conditions included atherosclerotic and hypertensive cardiovascular disease. An autopsy was not preformed, and the manner of death was listed as accidental. The location of the injury was listed as being the facility's address and the description of the injury was listed as ground level fall that occurred on 02/23/26.

During an interview on 03/27/26 at 11:50 A.M., the ED and HSD #213 verified Resident #115 had falls on 11/17/25, 12/30/25, 01/07/26, 02/13/26 and 02/23/26. HSD #213 verified the resident had an unwitnessed fall at the facility on 01/07/26 and sustained injuries to her mid scalp and forehead which included a four cm by 2 cm hematoma. HSD #213 verified Resident #115 had an unwitnessed fall at the facility on 02/13/26 at 2:10 A.M. and sustained injuries to her head which included a five cm by five cm hematoma noted on her right forehead. HSD #213 stated that Hospice was notified and the on-call nurse assessed Resident #115's condition. HSD #213 verified Resident #115 had another unwitnessed fall on 02/23/26 at 2:30 A.M. and was found lying on the floor with a nine cm by six cm hematoma noted on the right side of the head and red drainage coming from the hematoma and Hospice was called in to assess the resident. HSD #213 stated the physician was notified and Resident #115 was sent to the hospital and The Hospice nurse called and left a message with Resident #115's POA.

During an interview on 03/27/26 at 1:26 P.M., the ED stated that no resident's fall could be prevented unless the resident had a bedside sitter which the facility did not provide. The ED stated Resident #115 was a do not resuscitate comfort care (DNRCC) code status and that is why the facility staff called Hospice instead of 911. The ED stated the goal with Hospice being in place was to never send the residents to the hospital.

During an interview on 03/27/26 at 2:17 P.M., the ED and HSD #213 stated an Incident Report was completed by the nurse and HSD #213 completed an Incident Task Note following a residents fall. ED and HSD #213 stated they did not collect any witness statements from the staff following the resident's fall on 11/17/25, 12/30/25, 01/07/26, 02/13/26, and 02/23/26 because the falls were not witnessed. The ED and HSD #213 verified Resident #115's falls on 11/17/25, 12/30/25, 01/07/26, 02/13/26, and 02/23/26 all occurred in Resident #115's room and between 2:10 A.M. and 7:30 A.M. establishing a pattern occurring with Resident #115's falls. ED and HSD #213 verified thorough investigations were not completed following Resident #115's falls.

During a telephone interview on 04/01/26 at 4:49 P.M., Hospice RN #850 and Hospice Clinical Director #956 stated Hospice RN #850 was notified on 02/23/26 that Resident #115 fell at the facility and hit her head. Hospice RN #850 stated she was not notified of Resident #115's condition but only notified that Resident #115 needed a visit from Hospice. Hospice RN #850 verified she arrived at the facility on 02/23/26 at about 3:47 A.M. which was approximately one hour and 17 minutes after Resident #115's fall. Hospice RN #850 stated Resident #115 was sitting in the common area in her geriatric chair with two caregivers present when she arrived at the facility. Hospice RN #850 reported the resident had a cantaloupe sized hematoma sticking out from the right side of her forehead with bruising to the right side of the face with blood dripping from the open areas. Hospice RN #850 stated that the nurse and two caregivers were not actively trying to stop the bleeding when she arrived, but the two caregivers told Hospice RN #850 that they tried to apply ice packs. Hospice RN #850 stated she made the decision to send Resident #115 out to the hospital because she did not see any way to control the bleeding and the area was rather large, and she suspected that Resident #115 was bleeding internally based on her observation of the size of the hematoma. Hospice RN #850 stated 911 should have been called immediately based on her assessment of the resident's injuries. Hospice RN #850 stated she contacted Resident #115's POA after she arranged for Resident #115 to be sent to the hospital and the resident's POA stated she had not been contacted by the facility.

Review of the undated Job Description for HSD, revealed the HSD provides leadership for resident care, and promotes the health and wellness of the resident population. HSD was responsible for directing each resident's health concerns. The HSD would provide training, supervision and monitoring of caregivers in following the residents' service plans and completing tasks for the assigned services, initiate resident service plans according to the residents individualized needs as prescribed by the ordering healthcare provider. The HSD would ensure caregivers completed daily services and that service plans were updated swiftly when changes in condition are reported and manage the residents' health care status.

Review of the facility's policy titled Fall Management and Post Fall Investigations Policy dated 05/15/23, revealed the medical team members, licensed nurse team members, HSD or the ED would document the fall event in the resident's health record. Falls would be investigated, reported and documented using the incident report and post fall tools. A careful review and analysis of the possible contributing factors to the fall with or without injuries would be completed using the post fall investigation tool. The HSD or designee would analyze the results for trends and patterns in the residents falls to use as a basis for implementation of process improvement.

Review of the facility's policy titled Accidents, Incidents, and Unusual Occurrences Reporting revised on 04/02/26, revealed an incident includes any accident or unusual occurrence that takes place in the course of caring for a particular resident or an unexpected event occurring whether or not an injury to the persons occurred. Any time a resident accident or incident occurs, an accident or incident report will be completed. The ED and/or HSD will investigate and attempt to prevent the accident or incident recurrence and manage the immediate risk. Whenever a resident accident or incident occurs immediate action will be taken to safeguard the resident, provide first aid as necessary, call 911 if the incident results in medical emergency, notify the HSD and ED or designees, notify the resident's primary healthcare provider and the residents responsible party, notify the organization of any sentinel accident or incident, implement measures to prevent accidents or incident recurrence and follow state and local rules regarding notification to authorities or agencies.

This violation represents non-compliance investigated under Complaint Number OH00169947.