Health inspection·May 30, 2023

F 0689 Level of Harm - Actual harm Residents Affected - Few Resident #10's room on 04/07/23. Resident #10 was found in front of the recliner, with the sit-to-stand foot tray and legs under her. The nurse noted the sit-to-stand sling was connected properly. While attempting to move Resident #10, she began hollering and complained of bilateral lower extremity pain and wished to go to the hospital. Upon investigation, when staff went to use the lift, Resident #10 began to slide out of the recliner and fell on top of the legs/foot tray. Resident #10 had a cushion on the chair with a pillowcase over it, intervention was to remove the cushion to prevent sliding. Review of Hospital #1's emergency documentation dated 04/07/23 revealed Resident #10 was nonambulatory and was sitting in a chair when attempting to be readjusted with a lift, slipped and landed on her right hip. X-radiation (X-ray) results revealed obvious bilateral intertrochanteric femur fractures. Resident #10 required hospitalization and surgical intervention/repair for the bilateral femur fractures. Interview on 05/17/23 at 12:12 P.M. with the Director of Nursing (DON) and Administrator regarding the incident revealed STNA's #29 and #30 assisted Resident #10 with the sit-to-stand lift on 04/07/23. Resident #10's lift chair was at its highest position when the pillow she was sitting on caused her to slip off the seat. The DON and Administrator alleged it was the pillow, not the lift that caused Resident #10's fall. The Administrator shared STNA #30 was an agency staff member who had only worked at the facility the evening of the incident and was placed on the do not return list. When the decision was questioned, the Administrator answered it had nothing to do with Resident #10's transfer, just the situation itself. The DON and Administrator denied either STNA (#29 and #30) were interviewed during the fall investigation, because they had a statement from LPN #27. Interview on 05/17/23 at 1:02 P.M. with LPN #27 revealed on the morning of 04/07/23, STNA #30 came out to the nurse's station and asked for assistance with the sit-to-stand lift. LPN #27 stated STNA #29 was coming down the hall at the same time and LPN #27 requested he assist STNA #30. LPN #27 stated a short time later STNA #29 came to the nurse's station and informed her Resident #10 had fallen. LPN #27 stated upon entering the room, Resident #10 was found on the floor in front of the recliner. LPN #27 believed Resident #10 was sitting too far forward on the recliner when she slipped off the seat. LPN #27 shared the upper strap was in place, but there was no lower strap. LPN #27 also verified Resident #10's chair was a recliner, not a lift chair. LPN #27 was unable to answer if both STNA's #29 and #30 operated the lift prior to transferring Resident #10, she only observed STNA #29 and #30 were both in the room when she entered after the fall. LPN #27 stated she believed she got a statement from STNA #29 regarding the fall, but STNA #30 was employed by an agency and that day was the only time she was there. Interview on 05/22/23 at 11:30 A.M. with STNA #29 revealed he worked on 04/07/23 when he was approached by STNA #30 to assist with using the sit-to-stand lift with Resident #10. STNA #29 shared he was helping a resident at the time and when he finished, he went to Resident #10's room to find STNA #30 present and Resident #10 on the floor. STNA #29 stated he left the room to inform LPN #27 of the situation. STNA #29 shared he did not assist STNA #30 with the transfer and did not enter the room after contacting LPN #27. STNA #29 stated he had a conversation with the Administrator regarding the incident and denied telling her he assisted with the transfer, he also denied LPN #27 asked him about the fall. Interview on 05/22/23 at 12:18 P.M. with STNA #30 revealed on the morning of 04/07/23, she went in to check on Resident #10 and the resident was frustrated because she was usually up by that time and was also upset STNA #30 was not her usual STNA. STNA #30 stated Resident #10 needed incontinence (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365374 If continuation sheet Page 2 of 3 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 365374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beavercreek Post Acute 1974 North Fairfield Road Dayton, OH 45432 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 - Actual harm Residents Affected - Few care and the pads under her changed, so she went to get assistance from another staff member and to retrieve the sit-to-stand lift. STNA #30 stated she asked the nurse for assistance and returned to Resident #10's room to start to set up the lift. STNA #30 stated she attached the upper strap, but could not use the lower strap because of the size of Resident #10's legs. STNA #30 stated no staff member came to assist and Resident #10 was crying because she was upset and wanted up. STNA #30 then lifted Resident #10 slightly from the seated position, the resident pushed back from the lift instead of standing with it. STNA #30 then requested assistance a second time from the nurse before going back to Resident #10's room. STNA #30 stated she did not try to transfer Resident #10, she just wanted to lift her enough to get her cleaned up. STNA #30 stated when she lifted Resident #10 from the sitting position, she began to slide and slid onto the floor. STNA #30 stated STNA #29 came to the door and saw Resident #10 on the floor and got the nurse. STNA #30 stated STNA #29 never entered the room and did not assist with lifting Resident #10. When LPN #27 arrived they removed the strap, put a pillow in between Resident #10 and the chair and called EMS. STNA #30 shared that she did write a statement regarding the incident and gave it to LPN #27 prior to leaving. Review of a facility policy titled Mechanical Lift last revised 06/08/22 revealed to safely lifting and transfers of residents required assistance of two individuals. This deficiency represents non-compliance investigated under Complaint Number OH00142703. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365374 If continuation sheet Page 3 of 3