Inspection·September 28, 2023

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy the facility failed to transfer Resident #30 with the use of a gait belt (a belt used to prevent falls during transfers). This affected one resident (#30) of three residents reviewed for transfers. The facility census was 93. Residents Affected - Few Findings include: Record review for Resident #30 revealed an admission date of 11/09/22. Diagnosis included heart failure, chronic pain, osteoarthritis (OA) right shoulder and knee, age related osteoporosis, difficulty in walking, muscle wasting and atrophy, and history of falls. Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 did not have any communication issues and was cognitively intact. No behaviors or rejection of care was noted. She required extensive assistance from one staff for transfers. She required limited assistance from one staff for ambulation in her room. Balance issues were noted requiring staff assistance to stabilize. She had no falls since her prior assessment. Record review of the fall risk care plan revised 03/02/23 included the intervention dated 05/17/23, for the use of a gait belt for all ambulation and transfers. Impaired mobility care plan revised 03/02/23 also included the use of a gait belt for all transfers and ambulation. That intervention had been in place since 12/01/22. Observation on 09/28/23 at 10:17 A.M. revealed State Tested Nursing Assistant (STNA) #465 transferred Resident #30 from the toilet to a standing position at the grab bar, completed dressing Resident #30 while she was standing, then transferred Resident #30 to her wheelchair. STNA #465 did not use a gait belt while assisting and transferring Resident #30. STNA #465 confirmed she did not have a gait belt with her and did not use one while transferring Resident #30. STNA #465 confirmed she was supposed to use a gait belt on Resident #30 during transfers and revealed her gait belt was in her personal bag somewhere else in the facility. Interview on 09/28/23 at 10:30 A.M. with Resident #30 revealed some STNA's wore gait belts while transferring her and some did not. Interview on 09/28/23 at 1:45 P.M. with the Director of Nursing (DON) revealed all nursing staff were given a gait belt upon hire and needed to use the gait belt on any resident anytime they need to physically lift up on a resident to assist them to stand. Record review of the facility policy titled, Nursing Transfer and Gait Belt Policy dated March 2013 (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 2 Event ID: 365267 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 365267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare Lakewood 13900 Detroit Ave Lakewood, OH 44107 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)