Health inspection·May 21, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interview and facility policy review, the facility failed to ensure Resident #10 was transferred in a safe manner and as per the resident's plan of care and facility policy with two staff via a mechanical (Hoyer) lift to prevent a potential accident. This affected one resident (#10) of four residents reviewed for accident hazards. The facility census was 59. Findings include: Review of the medical record for Resident #10 revealed an admission date of 07/12/2023 with diagnoses including chronic obstructive pulmonary disease, spinal stenosis lumbar region, and dementia. Review of the plan of care dated 07/26/2023 revealed Resident #10 had an activity of daily living (ADL), self-care performance deficit related to decreased mobility, weakness, memory loss/confusion, and required assistance for ADLs and mobility needs. Interventions included providing two staff assist with transfers using a Hoyer (mechanical) lift. Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08 out of 15 indicating a moderately impaired cognition for daily decision-making abilities. Resident #10 was noted to be free from bilateral upper and/or lower extremity impairment and required a wheelchair for mobility. The assessment noted the resident was dependent on staff with all transfers. Review of the Fall Risk Assessment completed for Resident #10 dated 04/28/2024 revealed resident was alert only with one to two falls in the past three months. Resident #10 was noted to be chair bound and was noted to require the use of assistive devices for gait and balance. Interview on 05/08/2024 at 2:00 P.M. with the Administrator revealed there was a staff member, State Tested Nursing Assistant (STNA) #335 who was still in training who transferred Resident #10 (on 05/06/24) by himself with the use of a mechanical lift. The Administrator revealed the management team was made aware of the incident by Resident #8's daughter. Interview on 05/08/24 at 4:30 P.M. with the daughter of Resident #8 revealed she was concerned an STNA (STNA #335) was transferring Resident #10 via a Hoyer lift by himself, without a second person present on 05/06/24. The daughter indicated she asked the STNA if he needed a spotter since she stated she was aware he was a new employee. The daughter indicated the STNA replied to her he had 25 (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: 365399 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 365399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerwood Rehabilitation 5757 Ponderosa Drive Columbus, OH 43231 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)