Health inspection·October 20, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, facility policy and procedure review, Self-Reported Incident (SRI) review and facility investigation review, the facility failed to ensure residents were properly transferred, as per their plan of care and/or physician's order to prevent actual injury and/or potential injury. Actual Harm occurred on [DATE] when Resident #125 who was dependent on staff for activities of daily living (ADL) and required a mechanical lift (device used to transfer a person from one place to another) of two staff assist for transfers was transferred by only one staff, State Tested Nursing Assistant (STNA) #614 without a mechanical lift from his bed to his wheelchair. The resident was again transferred on [DATE] by STNA #680 and STNA #685 without a mechanical lift from his wheelchair to his bed. After breakfast on [DATE] STNA #637 pulled back the covers for Resident #125 and noticed he had a large red swollen area to his left hip, purple bruising to his pelvic region and yellow tinted bruising to his left rib cage area. STNA #637 revealed the resident was grunting, clenching his teeth and voiced a sound like ouch displaying signs of significant pain. The resident was transferred to the hospital, and diagnosed with a displaced intertrochanteric fracture to his left femur. The injury was determined to have occurred as a result of not being transferred with the mechanical lift on [DATE]. This affected four residents (#15, #33, #80 and #125) of four residents reviewed for accidents/proper transfers. The facility identified 41 residents (#1, #7, #9, #15, #19, #21, #22, #23, #29, #32, #33 #36, #39, #48, #50, #55, #57, #58, #59, #63, #64, #67, #68, #69, #71, #74, #79, #80 #81, #85, #90, #96, #97, #99, #100, #102, #103, #109, #115, #116 and #125) who were dependent on staff or required (staff) assistance with transfers. The facility census was 119. Findings include: 1. Review of the closed medical record for Resident #125 revealed an admission date of [DATE]. The resident passed away at the facility on [DATE]. Resident #125 had diagnoses including dementia, hypertension, polymyalgia rheumatica (syndrome with pain or stiffness to neck shoulders and extremities), and fracture of head of left femur diagnosed on [DATE]. Review of the care plan dated [DATE] revealed Resident #125 required assistance with activities of daily living (ADL) related to weakness as he required extensive to total staff assistance with ADL. Interventions included a mechanical lift with two staff assist for transfers and monitor and report changes in physical functioning. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #125 was Page 1 of 7 365290 365290 10/20/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0689 cognitively impaired. The assessment revealed the resident was dependent on staff for ADL care including to move from sitting to lying position, and chair to bed/ bed to chair transfers. Level of Harm - Actual harm Residents Affected - Few Review of the undated task bar revealed Resident #125 was to be transferred with a mechanical lift by two staff assist. Review of Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #125 was transferred utilizing only one-person assist on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of [DATE] physician's orders revealed Resident #125 had an order dated [DATE] to be transferred with a mechanical lift with two staff assist. He also had an order for Hospice due to Alzheimer's disease dated [DATE]. Review of weight record revealed on [DATE] Resident #125's weight was recorded as 159.6 pounds. Review of nursing note dated [DATE] at 7:12 A.M. and completed by Licensed Practical Nurse (LPN) #629 revealed Resident #125 had purple areas to his left foot near his great toe measuring three centimeters (cm) in length by four cm in width and another area measured two cm in length by one cm in width. The note revealed both areas were blanchable, and the areas were cleansed with normal saline and covered. Primary Care Physician (PCP) #900 was called and a message was left. Review of nursing note dated [DATE] at 9:20 A.M. completed by Registered Nurse (RN) #689 revealed staff had called her to Resident #125's room due to reddened area to his left hip, left pelvis, and left rib cage area. The note revealed the resident was in pain. PCP #900 was notified and ordered to obtain x-rays of the areas. Review of the Bath/ Shower Skin Inspection Sheet dated [DATE] and completed by RN #689 revealed Resident #125 had bruises to his left hip, left side of his pelvis, left side of his ribs, right foot, and right great toe. Review of facility SRI, tracking number 239869 and dated [DATE] revealed the Administrator submitted an SRI for injury of unknown source. The SRI noted on [DATE] Resident #125 had redness near his leg hip, rib, and pelvis area and that he was dependent on staff with mobility. Resident #125 was found to have a closed displaced intertrochanteric fracture of his left hip. The SRI revealed during the investigation the facility concluded the resident was possibly not transferred correctly per care plan, but abuse was not suspected. The facility unsubstantiated the SRI. Review of the nursing note dated [DATE] at 11:01 A.M. and completed by RN #689 revealed the x-ray company was unable to obtain x-rays and PCP #900 was notified and ordered to send Resident #125 to the hospital emergency room. Review of the After Visit Summary dated [DATE] revealed emergency room (ER) Physician #708 had evaluated Resident #125 and noted in the summary the reason of the visit was due to a fall. The resident had a closed displaced intertrochanteric fracture of his left femur. He was to follow up with Physician #709 and received orders for pain medications. Review of the nursing note dated [DATE] at 6:49 A.M. completed by LPN #704 revealed at approximately 8:00 P.M. the hospital called and reported Resident #125 was returning to the facility with a new 365290 Page 2 of 7 365290 10/20/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0689 Level of Harm - Actual harm diagnosis of left femur fracture. The note revealed no intervention would be done because the resident was contracted per the orthopedic physician at the hospital. The note revealed Resident #125 was nonverbal throughout the night but grimaced in pain while transferring from gurney to bed. PCP #900 was notified and ordered pain medication, and his family was notified. Residents Affected - Few Review of the Skin Observation Tool dated [DATE] and completed by RN #670 revealed Resident #125 had bruising to his left trochanter area that measured 16 cm in length by 5.2 cm in width. The area was described as redness noted with dark purple area to center of his boney prominence. Review of the nursing notes dated [DATE] at 11:28 A.M. and completed by Social Service Director (SSD) #622 revealed Resident #125's daughter had spoken with PCP #900 and they both agreed to have Hospice services initiated due to his decline in health. Review of the Witness Statement dated [DATE] and completed by STNA #680 revealed she had come on duty on [DATE] at approximately 8:30 P.M. to 9:00 P.M. and STNA #685 asked for assistance to transfer Resident #125 to his bed as he was not on a Hoyer sling (designed to be suspended from a swivel bar on a mechanical lift to transfer a person) in his wheelchair. The statement revealed that this had happened several times. The statement revealed the only available Hoyer sling was not suitable for the current mechanical lift. The statement revealed she and STNA #685 armed and leg him into his bed and then she left the room. Review of the Witness Statement dated [DATE] and completed by STNA #615 revealed she had gotten Resident #125 up on [DATE] and that she was not aware he was to be transferred with a mechanical lift. Review of nursing notes dated [DATE] at 8:15 A.M. and completed by RN #670 revealed Resident #125 had expired at the facility. Interview on [DATE] at 2:39 P.M. with RN #689 revealed (on [DATE]) at approximately 9:00 A.M. STNA #637 notified her Resident #125 had something on his left hip. She revealed she immediately evaluated and noted a softball size red hard area to his left hip over his boney prominence. She revealed he also had bruising to his left pelvic area, and on his left rib cage. She revealed she notified PCP #900, and he ordered an in-house x-ray, but the x-ray company was unable to obtain good imaging due to the resident's contractures. She revealed PCP #900 ordered the resident to be sent to the hospital for an evaluation. Interview on [DATE] at 2:44 P.M. with STNA #630 revealed she worked day shift on [DATE] and had observed Resident #125 was sitting up in his wheelchair without a Hoyer sling underneath him. Interview on [DATE] at 3:05 P.M. with STNA #665 revealed she had worked on [DATE] on day shift and had observed Resident #125 was sitting up in his wheelchair without a Hoyer sling underneath him. She revealed she had seen this happen a few times before as well. She revealed Resident #125 was to be transferred by a mechanical lift and did not know how staff were transferring him without use of a mechanical lift as he was contracted, heavy, and not able to assist by bearing any weight. Interview on [DATE] at 3:20 P.M. with STNA #685 revealed on [DATE] she had worked 7:00 P.M. to 7:00 A.M. and when she came in, Resident #125 was sitting in his wheelchair without a Hoyer sling underneath him. She revealed she told LPN #629 the resident was not on a Hoyer sling as this had happened several times before. She revealed LPN #629 stated that she would communicate again that staff were still getting him up without a Hoyer sling. She revealed she and STNA #680 got on each side of him 365290 Page 3 of 7 365290 10/20/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0689 Level of Harm - Actual harm Residents Affected - Few and transferred him by getting under his arms and grabbing the back of his pants. She revealed she felt the transfer was completed in a safe manner. She revealed he already had a gown on and that she just removed his sweat pants. She revealed since he had a urinary catheter and was not incontinent of bowel that she did not remove his incontinent product and/or lift his gown. She revealed she did not notice any bruising. Attempts to interview STNA #615 on [DATE] at 3:36 P.M. and on [DATE] at 8:42 A.M. were unsuccessful as she did not return the calls. Interview on [DATE] at 3:38 P.M. with STNA #680 revealed on [DATE] she came in at 7:00 P.M. and noticed Resident #125 was not on a Hoyer sling. She revealed she went to laundry to retrieve a sling to place underneath him, but there was only one available. She verified she had not notify LPN #629 that he was not on a Hoyer sling and that she was unable to locate a sling to transfer him with. She revealed she and STNA #685 were strong and transferred him under his arms and grabbed his pants. She verified she did not utilize a gait belt during the transfer. She revealed she left the room after the transfer but felt the transfer was done in a gentle manner. During the interview, she revealed first shift staff continued to get up residents , including Resident #81 and #119 without a mechanical lift as she frequently came in and they did not have a Hoyer sling underneath them despite orders to be transferred with a mechanical lift. Interview on [DATE] at 3:42 P.M. with LPN #629 revealed she was the nurse on duty [DATE] from 7:00 P.M. to 7:30 A.M. but was not notified by the staff that Resident #125 did not have a Hoyer sling underneath him and/or that they transferred him without a mechanical lift. She revealed on [DATE] she was completing the treatment on his foot and noticed he had new dark purple areas to the inside of his right foot. She revealed she did not know if the areas were pressure and/or bruise and passed on the areas in report. Interview on [DATE] at 3:48 P.M. with STNA #637 revealed she worked on [DATE] and after breakfast she pulled back Resident #125's covers and noticed he had a large red swollen area to his left hip, purple bruising to his pelvic region, and yellow tinted bruising to his left rib cage area. She revealed he was grunting, clenching his teeth together, and voicing a sound like ouch showing he was in significant pain. She revealed RN #689 was notified. She revealed she had worked on [DATE] and felt STNA #615 had gotten Resident #125 up all by herself as she was working the same hall as her, and she had not asked her to help transfer him. Interview on [DATE] at 4:12 P.M. with [NAME] President (VP) of Clinical Services #711 verified STNA #615 revealed during the investigation that she had gotten Resident #125 up by herself without a mechanical lift on [DATE]. She also verified that the facility only had a policy regarding transfer with a mechanical lift but did not have a policy regarding one or two persons transfer assistance. Interview on [DATE] at 10:40 A.M. with the Administrator, Director of Nursing, and VP of Clinical Services #711 verified the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #125 was transferred utilizing only one-person assist on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. They verified Resident #125 was to be transferred with a mechanical lift with two staff assist per his physician order dated [DATE]. Also, they verified on [DATE] STNA #615 had transferred him by herself without the use of a mechanical lift from his bed to his wheelchair and on [DATE] STNA #680 and #685 had transferred him without a mechanical lift from his chair to his bed. They verified per STNA #680's witness statement she had stated the only available Hoyer sling was not suitable for the mechanical lift so they armed and leg 365290 Page 4 of 7 365290 10/20/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0689 transferred him. Level of Harm - Actual harm 2. Review of the medical record for Resident #33 revealed an admission date of [DATE] with diagnoses including congestive heart failure, lymphedema, and morbid obesity. Residents Affected - Few Review of the care plan dated [DATE] revealed Resident #33 required assistance with ADL related to weakness and morbid obesity. Interventions included he was to be transferred by use of mechanical lift and two staff assist. Review of the Medicare Five-Day MDS assessment dated [DATE] revealed Resident #33 was cognitively impaired as his Brief Interview for Mental Status Score (BIMS) was a 12. Review of the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #33 was transferred utilizing only one-person assist on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the [DATE] Physician Orders revealed no orders regarding utilizing a mechanical lift to transfer. Review of the weight record revealed on [DATE] Resident #33's weight was 335.2 pounds. Review of the Kardex as of [DATE] revealed Resident #33 was to utilize a mechanical lift with two staff assist with transfers. Interview on [DATE] at 7:38 A.M. with Resident #33 revealed he was to be transferred with a mechanical lift in and out of bed but that it was hard as sometimes staff would not transfer him back into bed when he wanted as there was not enough staff. He revealed this caused him to sit up in his wheelchair for a long time causing his legs and buttocks to hurt. He revealed staff sometimes had no choice but to only use one staff to transfer him back to bed as he stated there were not enough staff. He revealed there was one aide and described the aide: African American and that she had told him she was [AGE] years old but could not remember her name had gotten him up and put him back to bed with the mechanical lift by herself on several occasions. He revealed it was not her fault as there just were not enough staff. Interview on [DATE] at 10:40 A.M. with the Administrator, Director of Nursing, and VP of Clinical Services #711 verified the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #33 was transferred utilizing only one-person assist on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. They verified Resident #33 was to be transferred utilizing a mechanical lift with two staff. 3. Review of medical record for Resident #15 revealed an admission date of [DATE] with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease, and major depression. Review of the care plan dated [DATE] revealed Resident #15 was at risk for falls related to impaired mobility. Interventions included transfer by use of a mechanical lift and two staff assistance. Review of the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #15 was transferred utilizing only one-person assist on all the above days except [DATE] and [DATE]. 365290 Page 5 of 7 365290 10/20/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0689 Review of annual MDS assessment dated [DATE] revealed Resident #15 had significant cognitive impairment. Level of Harm - Actual harm Residents Affected - Few Review of the [DATE] physician orders revealed Resident #15 had an order dated [DATE] to be transferred with a mechanical lift by two staff. Review of the Kardex dated as of [DATE] revealed Resident #15 was to be transferred using a mechanical lift and two staff assist. Observation on [DATE] at 7:26 A.M. revealed STNA #600 and STNA #710 transferred Resident #15 with a mechanical lift with no concerns. She was unable to be interviewed due to cognitive ability. Interview on [DATE] at 10:40 A.M. with the Administrator, Director of Nursing, and VP of Clinical Services #711 verified the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #15 was transferred utilizing only one-person assist on all the above days except [DATE] and [DATE]. 4. Review of the medical record for Resident #80 revealed an admission date of [DATE] with diagnoses including unspecified psychosis, abnormalities with gait and mobility, osteoporosis, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed she was cognitively intact and required extensive assist of two staff with transfers. Review of the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #80 was transferred utilizing only one-person assist on all the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Interview on [DATE] at 3:09 P.M. with Resident #80 revealed she was unsure how and how many staff usually assisted in transferring her to her bed to chair and/or her chair to her bed. Review of the Kardex dated [DATE] Resident #80 was to be transferred with two staff assist. Observation on [DATE] at 10:02 A.M. revealed STNA #632, and STNA #665 transferred Resident #80 with no issues. Interview on [DATE] at 10:40 A.M. with the Administrator, Director of Nursing, and VP of Clinical Services #711 verified the Task- Transferring documentation from [DATE] to [DATE] revealed staff documented Resident #80 was transferred utilizing only one-person assist on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the facility policy labeled; Mechanical Lift, dated [DATE], revealed the purpose of the policy was to transfer a dependent resident safely. The policy revealed to confirm a mechanical lift was to be used. There was nothing in the policy regarding how many staff were to assist during a transfer with a mechanical lift. Review of the undated policy labeled, Freedom from Abuse and Neglect revealed neglect was the 365290 Page 6 of 7 365290 10/20/2023 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0689 failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, and emotional stress. Level of Harm - Actual harm This deficiency represents non-compliance investigated under Complaint Number OH00147411. Residents Affected - Few This deficiency is an example of continued non-compliance from the survey completed on [DATE]. 365290 Page 7 of 7