Foundation Park Care Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

straps were still connected and before they could be undone Resident #12 threw himself back and to the left. Resident #12 was laying on his left side with this right leg still strapped in the lift. Resident #12 was released from the strap and wound care finished their assessment of his wound. CNA #283 cleaned and re-dressed Resident #12. It was noted Resident #12 had called out for his mother while on the floor but had not called out in pain. There was no indication of pain or injury at the time. Further review revealed no documentation of notifications being made. Review of the witness statement from Licensed Practical Nurse (LPN) #270 revealed she came into Resident #12's room when requested by CNA #283 to assist with transferring Resident #12 back into his chair after he had a behavior and was lowered to the ground. LPN #270 observed Resident #12 laying on the floor anxiously fidgeting when she entered. This was noted to be normal behavior for Resident #12. LPN #270 and CNA #283 assisted Resident #12 back into his chair. It was noted Resident #12 showed no sign of injury or pain while on the floor, during or after transfer. There were no notifications documented as being made to Resident #12's spouse or hospice provider on 10/16/25. Interview on 11/25/25 at 7:04 A.M. with LPN #270 verified she was called to assist Resident #12

on 10/16/25 after he had been lowered to the ground from his lift. LPN #270 explained Resident #12 had gotten his arm out and under the sling which had been supporting him in the lift. Resident #12 had been caught and lowered to the floor while his legs were still secured in the lift. Resident #12 was then transferred to his wheelchair with the assistance of two staff. LPN #270 stated she had not made notifications of the incident to Resident #12's family or hospice provider on 10/16/25. Interview on 11/25/25 at 8:52 A.M. with RN #238 verified she had been in Resident #12's room with the wound care team on 10/16/25 when Resident #12 got his arm under the lift support sling and was lowered to the ground. RN #238 reported Resident #12 threw himself to the side before they were able to get his legs unstrapped. He had been released and transferred by two staff members back to his chair. RN #238 reported LPN #270 would have made notifications to the family, physician, and hospice, and verified she had not made any notifications regarding the incident on 10/16/25. Interview on 11/25/25 at 9:20 A.M. with Hospice RN #312 verified the facility had not notified Resident #12's hospice provider of the incident when Resident 12 was lowered to the floor on 10/16/25. Review of the facility policy titled, Notify of Changes (Injury/Decline/Room/Etc.), revised January 2023, revealed it was the policy of the facility to notify the resident, physician, and resident representative when there was a change in treatment, accident, significant change in status and or the decision to transfer or discharge the resident. Review of the facility policy titled, Free of Accidents/Hazards/Supervision, Devices, revised May 2024, revealed a fall was defined as unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming force. If a fall occurred the resident was to be assessed for injuries, notify the physician, and provide treatment as necessary and notify the resident representative.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Foundation Park Care Center

1621 S Byrne Rd Toledo, OH 43614

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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

be normal behavior for Resident #12. LPN #270 and CNA #283 assisted Resident #12 back into his chair. It was noted Resident #12 showed no sign of injury or pain while on the floor, during or after transfer.

However, it was noted on 10/17/25 when LPN #270 went back to Resident #12's room to pass medications Resident #12's hospice aide was in the room and reported there was something wrong with Resident #12's leg. LPN #270 assessed Resident #12 and found his right leg was rotated inward. A stat x-ray was completed and revealed the resident had a right femur fracture with severe dislocation and Resident #12 was sent to the hospital for further treatment. Interview on 11/25/25 at 7:04 A.M. with LPN #270 verified she was called to assist Resident #12 on 10/16/25 after he had been lowered to the ground from his lift. LPN #270 explained Resident #12 had gotten his arm out and under the sling which had been supporting him in

the lift. Resident #12 had been caught and lowered to the floor while his legs were still secured in the lift. It was thought Resident #12's leg was broken when he threw himself to the side after being lowered to the ground. LPN #270 stated Resident #12 was assessed by feeling along his legs with her hands and no injury was found at the time. LPN #270 reported there was no bruising at the time and Resident #12's leg was not out of position. Resident #12 was then transferred to his wheelchair with the assistance of two staff members. LPN #270 reported Resident #12 did not bear weight during the transfer and she did not completed range of motion assessment.Interview on 11/25/25 at 7:36 A.M. with the Director of Nursing (DON) verified a range of motion assessment should have been completed following the incident on 10/16/25 when Resident #12 was lowered to the floor from the lift. The DON reported Registered Nurse (RN) #238 had been in the room and witness to the entire situation. The DON was off on the day of the occurrence and RN #238 would have more information on what had been completed.Interview on 11/25/25 at 8:52 A.M. with RN #238 verified she had been in Resident #12's room with the wound care team on 10/16/25 when Resident #12 got his arm under the lift support sling and was lowered to the ground. RN #238 reported she did not completed a range of motion assessment for Resident #12 and stated the resident was transferred by two staff members back to his chair. RN #238 stated she did not think Resident #12 was weight bearing at the time of the transfer and RN #238 reported LPN #270 would have documented any assessment that were completed. Review of the facility policy titled, Free of Accidents/Hazards/Supervision, Devices, revised May 2024, revealed a fall was defined as unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming force. If a fall occurred, the resident was to be assessed for injuries, notify the physician, and provide treatment as necessary and notify the resident representative.

Event ID:

Facility ID:

If continuation sheet