Arc At Chillicothe

Based on record review and interview the facility failed to ensure the resident's environment was free of hazards to prevent falls for one of three residents (R1) reviewed for accidents in the sample of five.Findings include:R1's Progress Notes dated 8/16/25 at 12:29 PM and signed by V5 (RN/Registered Nurse) documents, Per (V6/CNA/Certified Nursing Assistant), (V6) tripped in (R1's) room on the air mattress cord and fell, tipping (R1's) wheelchair over. (R1) fell out of her (high back padded wheelchair) and hit her head on the (mechanical lift) machine. (R1) noted to have a small amount of blood present to the right side of (R1's) head.

Area cleansed (and) bleeding stopped. PRN (as needed) Dilaudid and Xanax administered. (V3/R1's Power of Attorney/POA) left voicemail to call facility. On call nurse and hospice notified. (V4/R1's Physician) notified.

Neuro (Neurological) checks initiated.R1's IDT (Inter-Disciplinary Team) Fall Follow-Up Progress Note dated 8/18/25 at 3:06 PM documents, IDT met regarding recent fall (8/16/25). (R1) was tipped out of wheelchair by (CNA/V6).

Root cause: (V6) got wheelchair caught on cord from air mattress and tripped and accidentally tipped wheelchair.

Intervention: Rearrange room for better ease of equipment.On 10/9/25 at 10:02 AM V6 (CNA) stated, On 8/16/5 sometime around noon I was getting (R1) ready. I took (R1) into her room and turned (R1's) chair around.

The cords at the end of the bed were pulled out from under the bed and lying on the floor in front of (R1's) wheelchair. I was just trying to lift the back of (R1's) wheelchair up to get the wheelchair over the cord. I went to push (R1) forward to try to unravel the cord that was wrapped around R1's wheelchair wheel and picked up the back of (R1's) wheelchair.

When I tipped (R1's) wheelchair up, (R1) fell out forward onto the floor. (R1) was sitting up straight and I should have put the back of the wheelchair back to keep (R1) from falling out. (R1) landed on the floor in front of her wheelchair.

The side of (R1's) head was bleeding.On 10/14/25 at 11:00 AM V2 (Director of Nursing) stated V6 should have moved R1's cord out of the way before trying to push R1's wheelchair over the cord to prevent R1 from falling out of the wheelchair. V2 stated V6 should not have lifted the back of R1's wheelchair.The facility's Fall Prevention Program policy dated 10/2024 documents, Purpose: To assure the safety of all residents in the facility, when possible.

The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary.

Programs will monitor the program to assure ongoing effectiveness.

Standards: Fall/safety interventions may include but are not limited to: The resident's environment will be kept of clutter which would affect ambulation and remove hazards.

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.

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