Inspection·January 22, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record review, review of Joerns Hoyer user instruction manual and Invacare patient slings operator's manual, review of the facility's Self-Reported Incident (SRI) and investigation including witness statements, review of the emergency medical services (EMS) report, review of hospital documentation, review of the facility policies on transfer, mechanical lifts, and the mechanical lift checklist, the facility failed to ensure a resident requiring transfers with a mechanical lift was transferred safely. This resulted in Immediate Jeopardy when Resident #15 experienced serious life-threatening injuries during an avoidable fall from a mechanical lift when the lift pad was incorrectly placed on the Hoyer lift and only one-person assisted in the transfer, resulting in a head injury, and severe fractures of the left lower leg which subsequently required an above the knee amputation of the left lower leg. This affected one (Resident #15) of three residents reviewed for utilization of a mechanical lift for transfers and placed an additional 14 current residents (#101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, and #114), identified by the facility as requiring the use of a mechanical lift for transfers, at risk for potential serious injuries and/or negative health outcomes as the facility was utilizing Invacare slings for the two Joerns Hoyer lifts for the 14 current residents. The facility census was 69. On 01/09/24 at 10:02 A.M., the Administrator and Chief Executive Officer (CEO) #200 were notified Immediate Jeopardy began on 12/25/23 at 10:40 A.M., when Nursing Assistant (NA) #20 transferred Resident #15 from her bed to the wheelchair using a mechanical lift without another staff member present. NA #20 utilized the wrong color-coded sling loops and positioned them incorrectly on the Hoyer lift, resulting in Resident #15 sliding out of the Hoyer lift while it was suspended five feet in the air and her head hitting the ground first and her left leg getting tangled up in the lift. The facility policy and Resident #15's plan of care required two staff members to be present when completing a mechanical lift transfer. Resident #15 was sent to a trauma level one hospital via EMS where she was diagnosed with comminuted fracture (a bone that is broken into more than two pieces) of the proximal left tibia, open fracture (a broken bone that causes an open wound in the skin) of left fibula, hemorrhagic shock requiring a blood transfusion, head contusion and multiple hematomas throughout the body. Surgical treatment of the left leg resulted in an above the knee amputation due to the severity of the traumatic wound and catastrophic fractures sustained to both the left tibia and fibula. On 01/08/24, interviews and observations revealed the facility was utilizing Invacare slings for the two Joerns Hoyer lifts for 14 current residents. Invacare manufacturer instructions state not to intermix slings and lifts of different manufacturers for the safety of the patient. The Immediate Jeopardy was removed on 01/12/24 when the facility implemented the following corrective actions: (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 7 Event ID: 365362 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 365362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Hills Center 6557 US 68 South West Liberty, OH 43357 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)