Health inspection·May 28, 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 closed medical record review, observations, mechanical lift users manual, and interviews, the facility failed to properly maintain and inspect mechanical lifts to prevent injuries for residents being transported. This affected one resident (Resident #46) out of four reviewed that required the use of mechanical lifts. The facility census was 78. Findings include: Review of the closed medical record for Resident #46 revealed an admission date of 05/16/24. Diagnoses included cardiomegaly, congestive heart failure, dysphagia, morbid obesity, hypertension, atrial fibrillation, gout, peripheral vascular disease, osteoarthritis, muscle weakness, chronic venous ulcers, low back pain, and cervical stenosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/14/25, revealed the resident had intact cognition. The resident was dependent on staff for bed mobility, transfers, ambulation. Review of physician orders revealed this resident was to be a two-person mechanical lift for all transfers, bathing, and incontinence. Review of the nurses notes dated 04/30/25 at 5:01 P.M. revealed this resident was being transferred by a mechanical lift by two staff when the lift tilted to the right, and the sling bar swung and struck the resident on the forehead. The resident was noted with moderate swelling to his forehead above the nose. The resident voiced no complaints at the time, with all neurological checks being completed with no adverse findings. Review of the nurses notes dated 04/30/25 through 05/10/25 revealed no concerns, complaints, or adverse effects noted from the incident that occurred on 04/30/25. There were no concerns with the ability to properly feed himself. This resident was still able to operate his wheelchair on a daily basis to have lunch with his wife on another hall while he was a resident. Review of progress note dated 05/10/25 revealed Resident #46 had complaints of numbness to bilateral hands and felt like his kidneys were shutting down as this has happened in the past and he knew what it felt like. Review of hospital note dated 05/10/25 revealed Resident #46 was admitted with cervical stenosis, multilevel Degenerative Joint Disease, and central cord syndrome (spinal cord injury). Interview with the Director of Nursing and the Administrator on 05/21/25 at 1:45 P.M. revealed the Page 1 of 2 365178 365178 05/28/2025 Kenwood Terrace Healthcare Center 7450 Keller Road Cincinnati, OH 45243

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few specific lift that was used on 04/30/25 was an Invacare Reliant 450/600 electric panel lift. Both stated after the incident, it was placed out of service until an inspection had taken place by the Maintenance Director. Both stated that upon inspection, it was determined that a mechanical strut had broken on the lift, which caused the floor legs to fold back in and tilt the lift during the incident. Interviews with Certified Nursing Assistants #585 and #590 on 05/21/25 at 2:10 P.M. revealed Resident #46 was being transferred to his wheelchair on 04/30/25 when the lift suddenly tilted forward and to the right, pinning one of them under it. Both stated that the sling bar had swung back and struck the resident on the forehead. The resident did not complain of anything at the time, only checking to see if they were both alright. No complaints of hand numbness or tingling following this incident. Review of the Invacare Reliant 450/600 battery power mechanical lift Users Manual on 05/21/25 at 11:00 A.M. revealed on page 13, all mechanical parts must be inspected at least every six months to determine any extent of wear and tear. If any metal contacts or parts are visibly worn, it must be replaced immediately before use. Interview with Physician #998 on 05/21/25 at 4:45 P.M. verified he had performed surgery on Resident #46 on 05/14/25. He verified this resident had chronic cervical stenosis, and the accident may have had an impact however, he would have needed surgery eventually regardless. Review of mechanical lift inspections could not be provided by the facility as none had been completed for each lift in service. Interview with Certified Nurse Practitioner #999 on 05/22/25 at 11:05 A.M. revealed she had seen Resident #46 via Telehealth appointment after he had requested to go to the hospital. She verified the resident had stated complaints for flank pain and kidney pain as he knows what that feels like. She then provided staff an order to send the resident to the emergency room per request. Interview with the Administrator and Director of Nursing on 05/22/25 at 12:00 P.M. verified they could not provide any evidence that the mechanical lifts had been properly inspected and routine maintenance was completed. This deficiency represents non-compliance under Complaint Number OH00165705. 365178 Page 2 of 2